Pre-Payment Coding Reviews Documentation Requests

Reimbursement Policy:

Effective Date:

March 1, 2023

Purpose:

To provide pre-payment coding validation review requirements for professional and all outpatient facility claims. This policy applies to participating and nonparticipating providers.

Products:

All products are included, except

Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).
COB
ITS Home
ITS Host
FEP
SHBP/SEHBP
ASO

All Insured Individual, Commercial medical plans, 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 or its designee may conduct a pre-payment coding validation review of services provided to our members. Horizon BCBSNJ or its designee may request medical records during the pre-payment coding validation review to help ensure accuracy in our processing of claims.

Providers are required to submit the requested medical records within 25 calendar days from the date of the request for the services identified for pre-payment review. In the event the requested records are not received by Horizon BCBSNJ or its designee within the twenty five (25) calendar days of the request, the services shall not be considered for reimbursement for failure to submit the requested medical records.

Types of claim reviews that may require documentation include, but are not limited to:

National Correct Coding Initiative (NCCI) Modifiers
Modifiers appended to Physician and Outpatient Hospital Medicare and Medicaid claims that bypass code pair edits designed to prevent payment for inappropriate coding combinations.
Global Surgical Package Modifiers
Modifiers appended to surgical procedure codes that bypass a specified post-surgical period during which certain services related to a surgical procedure, furnished by the physician who performed the surgery, are to be included in the payment of the surgical procedure code.
Add-On Procedure Codes
Procedure codes that are not eligible for reimbursement that are billed without the primary procedure.
Cross Provider Duplicates
Cross-Provider Duplicates occur when more than one provider has submitted a claim for the same service on the same day for the same patient.
Unbundled Code Combination Modifiers
Modifiers appended to procedure codes that bypass edits related to the appropriate billing of code combinations.
Evaluation and Management Codes billed with Modifier-25
Appending Modifier -25 to an Evaluation and Management procedure code bypasses claim edits that allow only one E&M code to be considered for reimbursement on a single day by the same practitioner or provider.

Procedure:

Horizon BCBSNJ or its designee will submit a written request for medical records (when applicable) indicating the provider has twenty five (25) calendar days to provide the requested documentation.

Horizon BCBSNJ will deny the service(s) when the requested medical records are not received within twenty five (25) calendar days of the written request.

Horizon BCBSNJ will deny the service(s) when the medical records do not support the services billed.

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:

10/7/2022: Policy approved

Policy 157_v1.0_10072022