Status N Codes

Reimbursement Policy:
Status N Codes (Non-Covered Services)

Effective Date:
October 19, 2016

Purpose:
Provide reimbursement policy that clearly articulates which services are considered non-covered services and treated as Plan General Exclusions under standard Horizon BCBSNJ benefit contract exclusions. Such non-covered services shall include, but shall not be limited to, services assigned Status N codes by CMS.

Scope:
All products are included, except

  • Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).
  • COB
  • FEP
  • Flex Link
  • ITS Home In-Network
  • ITS Host MA Non-PPO
  • ITS Host MA PPO Non-Par
  • MPL

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

Policy:
Horizon BCBSNJ shall not separately reimburse for certain codes that CMS has identified as status N codes (Non-Covered Service). This policy will apply to professional providers.

In accordance with CMS guidelines, status N codes are not considered for reimbursement. Such items and services are typically excluded from most plans, and include convenience and consumer items and non-medical services. Examples include:

  • Exercise equipment
  • Reaching/grabbing device
  • Automatic blood pressure machine
  • Ear piercing
  • Autopsy
  • Medical testimony

The CPT codes and nomenclature used in this policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the policy is reviewed and updated to reflect the new or amended coding.

Procedure:
Horizon BCBSNJ may deny procedure codes identified by CMS as Status N (Non-covered Service) when billed. Under specific circumstances, some services may be covered depending upon group and/or product benefits.

In denied instances where the provider is participating, there shall be no member liability.

In denied instances where the provider is non-participating, the member’s 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:
10/19/2016:     Policy Approved

Policy 101_v1.0_10192016