- HEDIS® Resources
- Claim Submission & BillingClaim Submission & Billing
- Claim Editing Policies
- Claim Submission Claim Submission
- Electronic Claim Adjustments
- Explanation of Payment
- PCP Billable Lists
- Pre-payment Correct Coding Reviews
- Prompt Pay Guidelines
- Demographic UpdatesDemographic Updates
- The Importance of Demographic Updates
- Provider Directory Management Policy
- CMS Audits to Validate Directory Information
- Updating Your Directory Information
- TIN Changes and Termination Letters
- Nonparticipating Provider Demographic Information
- Inquiries, Complaints & AppealsInquiries, Complaints & Appeals
- Inquiries
- Complaints
- Time Limits for Filing Inquiries/Complaints
- Resolving Inquiries/Complaints
- Appeals of Non-Utilization Management Determinations
- Appeals of Utilization Management/Medical Management Determinations
- Appeals of Post Service Medical Necessity Determinations
- PoliciesPolicies
- Medical Policies Medical Policies
- Administrative Policies Administrative Policies
- Allowable Practice Locations for Pathologists
- Appointment Availability Access Standards for Primary Care-Type Providers, ObGyns and Specialists
- Behavioral Health Providers Access Standards
- Credentialing and Recredentialing Policy for Ancillary and Managed Long Term Support Service (MLTSS) Providers
- Credentialing and Recredentialing Policy for Participating Physicians and Healthcare Professionals
- EDI and NaviNet Claims Submission Requirement
- Electronic Funds Transfer (EFT)
- Material Adverse Change (MAC) Notification Policy
- Medical Records Documentation Standards
- Medicare Advantage Readmission
- Never Events
- Out-of-Network Referral Policy
- Physician and Healthcare Professional Counseling and Termination Policy - Professional Competency
- Participation Status in Products that Utilize Tiering and/or Subset of an Existing Horizon Network
- Practitioner Office Site Quality and Medical Record Keeping Standards
- Provider Directory Management
- Retainer Based Medicine
- Tier Awareness Policy
- Use of Horizon Hospital Network Performance Data
- Use of Practitioner Performance Data
- BlueCard® Medical Policies
- Reimbursement Policies & Guidelines Reimbursement Policies & Guidelines
- After-hours and Weekend Care
- Ambulatory Electrocardiographic Monitoring
- Anesthesia Reimbursement Guidelines
- ASC Multiple Procedure Methodology
- Assistant at Surgery
- Balloon Sinuplasty
- Bariatric Surgery Billed With Hiatal Hernia Repair
- Bilateral Procedures
- Billing Guidelines for Maternity Services
- Cardiac Event Detection
- Cardiovascular Implant Device Monitoring Services
- Chemotherapy Administration
- Chronic Care Management Services
- Claim Editing Policies
- ClaimsXten Editing Rules
- Clinical Trials Support Program
- Co-Surgeon Reimbursement
- Colonoscopy with Modifier 59
- Conscious Sedation
- Consultation Services Payment
- Consumable Medical Supplies
- Continuous Positive Airway Pressure or Bi-level Positive airway Pressure (CPAP/BiPAP) Supplies
- Daily Management of Epidural or Subarachnoid Continuous Drug Administration
- Daily Maximum Units for Surgical Pathology and Microscopic Examination
- Determination of Refractive State
- Diabetic Screening Services
- Diabetic Supplies
- Distinct Procedural Service Modifiers
- DME Rent to Purchase
- Drug and Immunization Pricing
- Duplex Scanning
- Drug Wastage – Modifier JW
- Duplicate Claim Logic for Independent Laboratory Services
- Enhancement to CMS Always Bundled Edit
- Evaluation and Management Services with Chiropractic Manipulative Treatment
- Evaluation and Management Services with Osteopathic Manipulative Treatment
- Evaluation and Management Services billed with Global Radiology, Stress Test, Stress Echo, Myocardial Profusion Imaging
- Frequency of Care Coordination Services and ESRD Procedures
- Frequency of G0179
- Hip Arthroscopy
- Hot or Cold Pack Therapy
- Inpatient Consultations
- Knee Arthroscopy
- Lab Panel Rebundling
- Laboratory Services Billed by Physicians
- Maternity Reimbursement
- Modifier 25
- Modifier 50 Bilateral Guidelines
- Modifier 52
- Modifier 53
- Modifier 54
- Modifier 55
- Modifier 56
- Modifier 57
- Modifier 76
- Modifier 77
- Modifier 78
- Modifier SU
- Multiple Procedure Payment Reduction (MPPR) for Endoscopies
- Multiple Procedure Reductions
- Mutually and Non-Mutually Exclusive NCCI Supplemental Edits
- Non-ESRD ESA Level Reporting
- Noncovered Related Services
- Outpatient Consultations
- Outpatient Laboratory Claims: Referring Practitioner Required
- Outpatient Therapy Daily Maximum
- Physician Extenders Non-Surgical Services
- Pre-Admission Testing
- Pulmonary Diagnostic Procedures when billed with E&M Codes
- Radiology, Preliminary and Double Reads
- Radiopharmaceuticals
- Reimbursement and Billing Guidelines for Anesthesia Claims
- Removal of Impacted Cerumen Requiring Instrumentation
- Screening and Diagnostic Mammography & 3D Tomosynthesis
- Site of Service Differential
- Smoking Cessation
- Status N Codes
- Telemedicine Services
- Ulcer Debridement and Ulcer Stages
- Urinalysis with Evaluation and Management (E&M) Services
- Urine Drug Screening/Testing
- Utilization ManagementUtilization Management
- Clinical Practice Guidelines
- PT/OT Outpatient Prior Authorization for Horizon Medicare Advantage Plans
- Services Requiring Prior Authorization Services Requiring Prior Authorization
- Prior Authorization Procedure Search Tool
- BlueCard® Members
- Medicare Advantage
- OMNIA Health Plans
- SHBP/SEHBP
- Unite Here Health
- Utilization Management Request Tool