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Claims Requiring Additional Documentation

Reimbursement Policy:
Claims Requiring Additional Documentation

Effective Date:
October 1, 2019

Occasionally, Horizon BCBSNJ will conduct post service claim reviews on a prepayment basis. Claim reviews are conducted in order to confirm the healthcare services or supplies within the submitted claim were delivered consistent with the plan of treatment as well as ensuring general industry standard claim processing and billing standards and guidelines and relevant regulations were followed.

In such cases, Horizon or its designee may request supporting information and/or documentation from the rendering provider. This may include information and/or documentation substantiating the treatment rendered or the health service provided or the delivery of supplies that are noted within the claim(s) submission. (Such requested information and/or documentation may include, but is not limited to, more detailed or itemized bills, office notes, operative reports, medical record progress notes, and/or diagnostic test results reports.) The requested information, when received, will assist Horizon in determining whether the claim(s) are eligible for payment and what amount of reimbursement is due and owing on the claim(s).

This policy documents Horizon’s policy with respect to claims requiring supporting information/documentation, Horizon’s expectations with regard to the provider’s compliance with the request for information/documentation and how Horizon will treat such claims in instances where the requested information/documentation are not received.

All products and claims are included, except

  • Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).
  • COB claims
  • FEP
  • Claims under review by Special Investigations

Upon request from Horizon or its designee, providers will be requested to submit supporting information/documentation for claims identified for post-service, prepayment review. Claims that may be subject to such requests may include, but are not limited to, the following:

  • Claims with unlisted surgical codes.
  • Claims for services that due to their nature require supporting clinical and/or other information/documentation to be submitted in order to determine whether they are payable.
  • Claims requesting an extension of benefits (ie. therapies).
  • Appealed claims where supporting documentation may be necessary for determination of payment.
  • Claims where documentation may be required by other entities such as the Centers for Medicare and Medicaid Services (CMS) or under relevant state or federal regulations.
  • Documentation of claims for durable medical equipment, prosthetics, orthotics, and supplies, rehabilitation services, and home health care.

This policy will not supersede state or federal laws, rules and regulations or provider contract provisions. Horizon will follow the below procedures for determining such claims that are subjected to requests for supporting information/documentation as part of the above-described post-service prepayment review process.

Horizon will follow the below procedures in connection with claims where supporting information/documentation is requested as part of the post service prepayment review process:

  1. Upon confirmation of the healthcare provider’s or facility’s address, a letter requesting the specific supporting information/documentation needed to determine the claim will be sent, which will include the time frame in which the request must be responded to by the rendering provider.

  2. If a response from the provider is not received within the prescribed time frame; 25 days for non-BlueCard claims and 10 days for BlueCard claims, Horizon will issue a claim denial with EOB/EOP messaging as described below. Appeal rights will accompany the claim determination.

  3. If a timely submission is received, the claim will be determined based upon a review of the information/documentation received.

If the requested information/documentation is received after the claim has been denied for failure to submit the requested documentation as described herein, Horizon will review the claim for payment determination as an initial review and not as an appeal provided that the claim with the requested information/documentation has been submitted and received by Horizon within the applicable timely claims filing requirements given the member’s line of business coverage documentation.

Limitations and Exclusions:
In addition to Horizon’s receipt of relevant requested information/documentation, payment determinations are also subject to, but not limited to:

  • Group or Individual benefit contract provisions
  • Provider Participation Agreement terms and conditions
  • Routine and industry standard claim editing logic, including but not limited to incidental or mutually exclusive logic
  • State and federal laws, rules and regulations and/or mandated benefits and requirements will always supersede other requirements or criteria.

09/23/2019: Policy Approved