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Frequency of G0179

Reimbursement Policy:
Frequency of G0179

Effective Date:
February 25, 2019

Purpose:
Provide guidelines for the application of home care visit code G0179 when appropriately billed by professional providers.

Scope:
All products are included, except

  • Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).
  • COB
  • ITS Home In-Network
  • FEP
  • SHBP non MA

All Insured Individual, Commercial medical plans, and Medicare Advantage Plans, are included.

ASO accounts will be included as an Opt-In option for additional claims editing on an account-by-account basis

Policy:
Horizon BCBSNJ shall allow reimbursement of G0179 only once every two months.

Procedure:
Horizon BCBSNJ shall reimburse physician recertification for home health services (G0179) once every two months at the applicable Horizon BCBSNJ fee schedule amount.

Horizon BCBSNJ shall deny physician recertification for home health services (G0179) when billed more than once every two months

No additional reimbursement shall be made if the provider is capitated or the reimbursement structure for that provider is a global fee.

In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.

In instances where the provider is not participating, member liability shall be up to the provider’s charge.

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

  • Group or Individual benefit
  • Provider Participation Agreement
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
  • Mandated or legislative required criteria will always supersede.

History:
10/25/2017: Policy approved

Policy 108_v1.0_10252017