Pre-Payment Documentation Requests : Facility Claims

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

Policy:
Upon request from Horizon BCBSNJ or its designee, facilities are required to submit the requested documentation (i.e. itemized bill and/or medical record) within 30 calendar days from the date of the request for claims identified for pre-payment review.

Applicable types of claim reviews include, but are not limited to:

• Validation of the correct diagnosis related group (DRG) assignment/payment (DRG validation audits)
• Validation that items and services billed are properly documented in a) the medical record and/or b) in an itemized bill for hospital bill audits, and in either case are items that are eligible to be separately billed.
• Verification that services billed do not conflict with eligible benefits for covered persons
• Services billed that are reimbursable at a percent of invoiced amount.

Procedure:
Upon pre-payment process claim review, if a medical record, itemized bill or sign off sheet (on an audit referral) or other supporting documentation is needed to complete that review/audit, a request will be made to the facility indicating they have 30 calendar days to submit the requested information.

In the event the requested records or itemized bills are not received by Horizon BCBSNJ within the thirty (30) calendar days of the request, the claim or claims involved shall be denied for failure to submit the requested documentation for the claim or claims identified for pre-payment review/audit. Any denial of claim payments will be performed in accordance with the applicable provisions within the HCAPPA law.

• In instances where the facility is participating, the member shall be held harmless for any such claims payment denials based on the failure of the facility to submit the requested supporting documentation and the relevant hold harmless provisions within the Provider Participation Agreement.

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:
08/25/2020:     Policy Approved

Policy138_v1.0_08252020