Noncovered Related Services

Reimbursement Policy:
Noncovered Related Services

Effective Date:
March 23, 2015

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

Scope:
All plans, products and accounts are included, except

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

  • Coordination Of Benefits (COB) situations when Horizon BCSNJ is not the primary carrier

  • BlueCard® program products where member enrollment is through a Blue Cross and Blue Shield Plan other than Horizon BCSBNJ, including Medicare Advantage

  • Federal Employee Program (FEP) 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

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

Procedure:
Phase 1: Denial of all services deemed to be related, based on any submitted diagnosis, to a noncovered surgical service:

  • billed by the same or a different provider

  • on the same or a 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

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.

Policy 079_v2.0