Provider Outlier Program Frequently Asked Questions

A. Only fully insured plans/programs are included in the audit. The following categories are excluded from this process:

• The New Jersey State Health Benefits Program (SHBP) and the School Employees’ Health Benefits Program (SEHBP)
• The Federal Employee Program ® (FEP ®)
• BlueCard
• Medigap claims and secondary claims

A. The following criteria are subject to the audit:

• All high-level Evaluation and Management (E&M) services billed with or without a modifier
• Prolonged services and time-based E&M codes
• Modifiers associated with E&M services including, but not limited to, modifier 25
• Modifier 59 (XE, XS, XP and XU)
• Observation codes
• Telephone E&M services

A. Yes. Providers must continue to submit claims electronically or to the appropriate mailing address.

Only copies of the medical records should be mailed to:

• Horizon BCBSNJ
• PO Box 140
• Newark, NJ 07101-0140

Providers should send the supporting medical records within a week of submitting the claim electronically. If the documentation is not provided, a denial for no medical records will be generated two weeks after the claim is received.

A. The provider should mail corrected claims/appeals and/or additional information clearly marked together with the Horizon BCBSNJ Inquiry and Adjustment Form #579, found online at HorizonBlue.com/form579, to:

• Horizon BCBSNJ
• PO Box 140
• Newark, NJ 07101-0140

The provider may attach an Explanation of Payment (EOP) form, which can be found on NaviNet®, with the claim noted on a cover sheet.

A. This information must be included in the medical record:

• Member's ID number
• Patient's name
• Date of service
• Physician group name
• Tax Identification Number (TIN)

Please include the patient’s name and identification number on all pages of the medical record.

A. Claims that are part of this audit will have the following claim denials:

• X945: Illegible record; missing information; code undocumented in medical record
• X946: No medical record provided = unsubstantiated services
• X947: Inappropriate use of override modifier
• X948: Medical record does not support CPT code billed

Other denial codes not listed above are not associated with the audit and should be resolved by calling Provider Services at 1-800-624-1110, weekdays, from 8 a.m. to 5 p.m., Eastern Time (ET).

A. The audit may be in process. If the provider has sent the medical record to the address above in A.4., they may call Provider Services at 1-800-624-1110 two weeks after the medical record was sent to verify if it was received. An adjustment to the X946 decline is initiated based on the review of the received medical record.

A. No. Providers should submit one claim for all services performed for the patient on the same day.

A. The whole claim is reviewed during this audit. Documentation for every line of the claim needs to be included. The provider is required to send in all documentation for all services billed on that claim for that date of service.

A. A provider is in prepayment audit until less than 25 percent of the claims submitted contain errors for three consecutive months. This is not a 90-day audit.

A. The error rate is based on the number of claims and accompanying medical records submitted in a month that is reviewed by Horizon BCBSNJ. This includes claims submitted with medical records which pass the audit as well as those which receive X945, X947 and X948 denials.

The denial code X946 is not included in the error rate calculation since an audit has not yet been completed.

A. Claims that are not included in the error rate are:

• X946 declines for no medical records
• Claims for excluded plans/programs including SHBP, SEHBP, FEP and BlueCard
• Medigap
• Secondary claims

A. It is not a medical necessity audit. This prepayment audit is only a coding audit. Providers must submit medical documentation that supports each CPT®/HCPCS code billed.

A. You may exercise your right to a Health Claims Authoriazaiton, Processing and Payment Act (HCAPPA) appeal.