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Horizon Fee Schedule Updates based on Third Party Sources

Reimbursement Policy:
Horizon fee schedule updates based on third party sources

Effective Date:
January 1, 2022

To provide a reasonable timeframe to implement new pricing changes and minimize claim adjustments

All products are included, except

  • Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).
  • COB

To the extent any rates set forth in a provider contract that are based on a Medicare, Medicaid, or other third-party fee schedule, Horizon shall implement any changes to such fee schedule(s) within 90 days from the date on which Horizon first receives notice of the fee schedule change.  Unless applicable Law or a Governmental Authority requires otherwise, Horizon shall implement such changes on a prospective basis only, and payments will remain at the existing rate(s) until such time as Horizon’s payment system is updated with the changes.

Horizon shall use existing operational processes/procedures to update fee schedules.

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.

11/22/2021: Policy approved