72 Hour Rule

Clarification: Radiology/imaging guidelines for reimbursement of procedures billed within 72 hours of initial service

Horizon follows industry standards with incorporating the 72-hour rule. The 72-hour rule applies to a procedure done on one day (initial date of service) that is followed by a second or combination procedure performed up to 72 hours after the initial date of service.

These procedures would then have the correct coding or bundling rules applied. The 72-hour rule applies to the codes and combination of codes found on the “Radiology Bundling Rules” document and the “Radiology Rules Bank” document.

Documentation must support any delay in performing services post-72 hours when final determination of diagnosis is pending these services. In addition, Horizon may request an audit of the member’s chart to ensure timely performance of any radiology/imaging procedures.

This rule does not apply to hospital in-patient care.