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Noncovered Related Services

Reimbursement Policy:

Noncovered Related Services

Effective Date:

March 15, 2022

Last Reviewed Date:

March 23, 2023

Purpose:

To provide guidelines for the reimbursement of services related to certain noncovered services. This policy applies to outpatient facility, ancillary and professional providers.

Scope:

All products are included, except

  • Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).
  • COB
  • ITS Home PAR
  • ITS Host, including ITS Host Medicare Advantage
  • FEP Non-par

All Insured and Administrative Services Only (ASO) accounts are included.

Policy:

Phase I: Certain surgical services are deemed to be noncovered by Horizon BCBSNJ based on our medical and/or payment policies. Services deemed to be related, based on any submitted diagnosis, to a noncovered surgical service will not be eligible for reimbursement when billed:

  • by the same or different provider
  • on the same or different claim
  • one day prior to the noncovered surgical service
  • on the same day as the noncovered surgical service
  • within five days after the noncovered surgical service

Phase II: In addition, the following services deemed to be related to the noncovered surgical services will also not be eligible for reimbursement when billed in the circumstances described below:

Anesthesia related services:

  • Anesthesia claim must be a professional claim
  • Anesthesia claim must be the same date of service as the noncovered surgical service
  • Provider ID billed on the anesthesia claim is not required to match the provider ID billed on the noncovered claim
  • Procedure code billed on the anesthesia claim must be in the anesthesia category

Assistant Surgeon related services:

  • Assistant surgery claim lines must contain modifiers 80-82 and AS
  • Assistant surgery claim must be a professional claim
  • Date of service on the assistant surgery claim must match the date of service billed on the noncovered service claim line

Evaluation & Management related services:

  • Date of service billed on the E&M claim must be the same day, 10 days prior or 7 days after the noncovered service claim line
  • Provider ID billed on the E&M claim must match the provider ID billed on the noncovered claim
  • There is at least one matching diagnosis code between the E&M claim and the noncovered service claim line
  • Procedure code billed on the E&M claim must be a code that falls within the E&M category
  • If another eligible covered service (major procedure) is found on the same date of service as the noncovered service then it is assumed that the related service(s) are associated with the covered service and consequently should not be denied.

Outpatient facility related services:

  • The outpatient facility claim must have the same date of service as the noncovered surgical service
  • The provider ID billed on the outpatient claim is not required to match the provider ID billed on the noncovered claim
  • Outpatient claim must be a facility claim
  • If another eligible covered service (major procedure) is found on the same date of service as the noncovered service then it is assumed that the related service(s) are associated with the covered service and consequently should not be denied

Pathology related services:

  • Date of service on the pathology claim must match the date of service billed on the noncovered service claim line
  • Provider ID billed on the pathology claim is not required to match the provider ID billed on the noncovered claim
  • There is at least one matching diagnosis code between the pathology claim and the noncovered service claim line
  • Procedure code billed on the pathology claim must be a code that falls within the pathology category
  • If another eligible covered service (major procedure) is found on the same date of service as the noncovered service then it is assumed that the related service(s) are associated with the covered service and consequently should not be denied

Pre-operative testing related services:

  • Date of service billed on the pre-operative claim must be 7 days prior to the date of service billed on the noncovered service claim line
  • Provider ID billed on the pre-operative claim is not required to match the provider ID billed on the noncovered claim
  • There is at least one matching diagnosis code between the pre-operative testing claim and the noncovered service claim line
  • Procedure code billed on the pre-operative claim must be a code that falls within the pre-operative category
  • If another eligible covered service (major procedure) is found on the same date of service as the noncovered service then it is assumed that the related service(s) are associated with the covered service and consequently should not be denied

Radiology related services:

  • Date of service on the radiology claim must match the date of service billed on the noncovered service claim line
  • Provider ID billed on the radiology claim is not required to match the provider ID billed on the noncovered claim
  • There is at least one matching diagnosis code between the radiology claim and the noncovered service claim line
  • Procedure code billed on the radiology claim must be a code that falls within the radiology category
  • If another eligible covered service (major procedure) is found on the same date of service as the noncovered service then it is assumed that the related service(s) are associated with the covered service and consequently should not be denied

Same Day-Same Procedure related services:

  • The same day procedure must have the same date of service as the noncovered surgical service
  • Provider ID billed on the same day procedure claim is not required to match the provider ID billed on the noncovered claim
  • Procedure code billed on the same day procedure claim should match the procedure billed on the noncovered claim line
  • The diagnosis billed on the same day surgery claim does not need to match the diagnosis billed on the noncovered service claim line
  • If another eligible covered service (major procedure) is found on the same date of service as the noncovered service then it is assumed that the related service(s) are associated with the covered service and consequently should not be denied

This policy will be applied to related services submitted on both professional and outpatient facility claim types, regardless of how the original noncovered surgical service was submitted.

Procedure:

Horizon BCBSNJ shall deny services deemed to be related to a noncovered surgical service, based on the criteria outlined above.

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:

  • 10/2/2014: Policy Approved
  • 03/15/2016: Updated into new online policy template
  • 02/13/2018: Added enhanced related services to policy (Assistant Surgeon, Pre-operative Testing, Radiology, Pathology, Same Day Same Procedure
  • 03/16/2022: Revised Scope

Policy 079_v5.0_03232023