BlueCard Medical Policy/Pre-Certification Info
Access Medical Policy and Pre-Certification/Pre-Authorization information for your BlueCard patients who are enrolled through other BCBS plans.
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- HEDIS Resources
- Claim Submission & BillingClaim Submission & Billing
- Billable Service Exceptions Billable Service Exceptions
- Claim Editing Policies
- Claim Reimbursement
- Claim Submission Claim Submission
- Electronic Claim Adjustments
- Explanation of Payment
- PCP Billable Lists
- Pre-payment Correct Coding Reviews
- Prompt Pay Guidelines
- Demographic UpdatesDemographic Updates
- The Importance of Demographic Updates
- Provider Directory Management Policy
- CMS Audits to Validate Directory Information
- Initiating Demographic Updates: Participating Providers Initiating Demographic Updates: Participating Providers
- Supporting Documentation Requirements for Practice-level Demographic Updates
- Supporting Documentation Requirements for Practitioner Demographic Updates
- Supporting Documentation for Ancillary Provider Demographic Updates
- Initiating Demographic Updates: Nonparticipating Providers
- Inquiries, Complaints & AppealsInquiries, Complaints & Appeals
- Inquiries
- Complaints
- Time Limits for Filing Inquiries/Complaints
- Resolving Inquiries/Complaints
- Appeals of Non-Utilization Management Determinations
- Appeals of Utilization Management/Medical Management Determinations
- Appeals of Post Service Medical Necessity Determinations
- PoliciesPolicies
- Medical Policies Medical Policies
- Allied Health
- DME
- Drugs
- Introduction
- Medicine
- Obstetrics
- Pathology
- Radiology
- Surgery
- Treatment
- MCG Care Guidelines
- Documentation Submission Guidelines
- Administrative Policies Administrative Policies
- Allowable Practice Locations for Pathologists
- Appointment Availability Access Standards for Primary Care-Type Providers, ObGyns, Specialists and Behavioral Health Providers
- Credentialing and Recredentialing Policy for Ancillary and Managed Long Term Support Service (MLTSS) Providers
- Credentialing and Recredentialing Policy for Participating Physicians and Healthcare Professionals
- Diagnostic Imaging Privileging by Participating Provider Practice Specialty
- Digital Member ID Card Policy
- EDI and NaviNet Claims Submission Requirement
- Electronic Funds Transfer (EFT)
- Material Adverse Change (MAC) Notification Policy
- Medical Records Documentation Standards
- Medicare Advantage Readmission
- Never Events
- Out-of-Network Referral Policy
- Outlier Audit Programs: Post Payment and Pre-Payment
- Physician and Healthcare Professional Counseling and Termination Policy - Professional Competency
- Participation Status in Products that Utilize Tiering and/or Subset of an Existing Horizon Network
- Pass Through Billing (Modifier 90)
- Practice Location Reinstatements
- Practice Locations Limit
- Practitioner Office Site Quality and Medical/Behavioral Health Record Keeping Standards
- Provider Directory Management
- Provider Outlier Program Frequently Asked Questions
- Retainer Based Medicine
- SHBP/SEHBP Inpatient Readmission Reimbursement
- Standards for All Types of Medical and Dental Diagnostic Radiology and Imaging Facilities
- Tier Awareness Policy
- Use of Horizon Hospital Network Performance Data
- Use of Practitioner Performance Data
- BlueCard Medical Policies
- Reimbursement Policies & Guidelines Reimbursement Policies & Guidelines
- Add-on Payment for COVID-19 Diagnostic Testing Run on High Throughput Technology (U0005)
- After-hours and Weekend Care
- Ambulance Services
- Ambulatory Electrocardiographic Monitoring
- Anesthesia Reimbursement Guidelines
- ASC Multiple Procedure Methodology
- Assistant at Surgery
- Balloon Sinuplasty
- Bariatric Surgery Billed With Hiatal Hernia Repair
- Bilateral Procedures
- Billing Guidelines for Maternity Services
- Biologics Correct Coding
- Cardiac Event Detection
- Cardiovascular Implant Device Monitoring Services
- Casting, Strapping and Splints
- Chemotherapy Administration
- Chronic Care Management Services
- Claim Editing Policies
- Claims Requiring Additional Documentation
- ClaimsXten Editing Rules
- Clinical Trials Support Program
- Co-Surgeon Reimbursement
- Collaborative Care Management Services
- Colonoscopy with Modifier 59
- Conscious Sedation
- Consultation Services Payment
- Consumable Medical Supplies
- Continuous Positive Airway Pressure or Bi-level Positive airway Pressure (CPAP/BiPAP) Supplies
- COVID 19 Antibody Testing
- COVID-19 Testing and Testing Related Services
- Daily Management of Epidural or Subarachnoid Continuous Drug Administration
- Daily Maximum Units for Surgical Pathology and Microscopic Examination
- Determination of Refractive State
- Diabetic Screening Services
- Diabetic Supplies
- Distinct Procedural Service Modifiers (59, XE, XP, XS, XU)
- DME Rent to Purchase
- Drug and Immunization Pricing
- Duplex Scanning
- Drug Wastage – Modifier JW
- Duplicate Claim Logic for Independent Laboratory Services
- Evaluation and Management Services with Chiropractic Manipulative Treatment
- Evaluation and Management Services with Osteopathic Manipulative Treatment
- Evaluation and Management Services billed with Global Radiology, Stress Test, Stress Echo, Myocardial Profusion Imaging
- False Claims
- Free Flap Breast Reconstruction
- Frequency of Care Coordination Services and ESRD Procedures
- Frequency of G0179
- Hip Arthroscopy
- Horizon Fee Schedule Updates based on Third Party Sources
- Hospital Non-Patient Laboratory Services Hospital Non-Patient Laboratory Services
- Hot or Cold Pack Therapy
- Inpatient Consultations
- Knee Arthroscopy
- Lab Panel Rebundling
- Laboratory Services Billed by Physicians
- Laser Treatment of Psoriasis or Parapsoriasis
- Maternity Reimbursement
- Maximum Units for Anesthesia
- Medical Nutrition Therapy (MNT)
- Medicare Advantage Hospital Sequestration Reimbursement
- Microsurgery and Robotic Surgery
- Modifier 25
- Modifier 50 Bilateral Guidelines
- Modifier 52
- Modifier 53
- Modifier 54
- Modifier 55
- Modifier 56
- Modifier 57
- Modifier 76
- Modifier 77
- Modifier 78
- Modifier SU
- Modifiers CQ/CO
- Multiple Procedure Reductions
- Mutually and Non-Mutually Exclusive NCCI Supplemental Edits
- Non-ESRD ESA Level Reporting
- Noncovered Related Services
- Outpatient Consultations
- Outpatient Facility Code Edits: Bundling and Revenue Codes Outpatient Facility Code Edits: Bundling and Revenue Codes
- Bundled Services
- Lab codes when billed with other services
- Revenue Codes Requiring HCPCS Codes
- Typically packaged codes
- Outpatient Laboratory Claims: Referring Practitioner Required
- Outpatient Therapy Daily Maximum
- Physician Extenders Non-Surgical Services
- Pre-Admission Testing
- Pre-Payment Coding Reviews Documentation Requests
- Pre-Payment Documentation Requests: Facility Claims
- Post Payment Documentation Requests: Facility Claims
- Pulmonary Diagnostic Procedures when billed with E&M Codes
- Radiology, Preliminary and Double Reads
- Radiopharmaceuticals
- Reimbursement and Billing Guidelines for Anesthesia Claims
- Removal of Impacted Cerumen Requiring Instrumentation
- Screening and Diagnostic Mammography & 3D Tomosynthesis
- Site of Service Differential
- Smoking Cessation
- Status N Codes
- Telemedicine Services Telemedicine Services
- Telemedicine Services Reimbursement Policy: Temporary Addendum for Horizon BCBSNJ Commercial/ASO plans and products
- Telemedicine Services Reimbursement Policy: Temporary Addendum for Horizon Medicare Advantage
- Ulcer Debridement and Ulcer Stages
- Urgent Care Center Billing Requirements
- Urinalysis with Evaluation and Management (E&M) Services
- Urine Drug Screening/Testing
- Vascular Correct Coding
- Vitamin D Testing
- Utilization ManagementUtilization Management
COVID-19
Stay informed.
Get the latest information on COVID-19.
Get the latest information on COVID-19.