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Claims Submissions and Reimbursement

You are required to:

Send claims to us before billing your Horizon BCBSNJ patients.

We will process your claims and send you reimbursement for all eligible services. An Explanation of Payment (EOP) will be sent to you outlining patient liability. In some cases, we may reimburse our full allowance; however, some services or products may require a copayment, or be subject to a deductible or coinsurance.

If your patient asks for a copy of his/her bill, please explain that you will file the claim with Horizon BCBSNJ first. We hope to discourage patients from sending claims that you have already submitted. This will help us avoid processing the same claim twice and generating two notifications, confusing your office or facility and the member.

Copayments, coinsurance or deductibles may be collected in advance but not as a condition for the provision of services.

Please do not bill your Horizon BCBSNJ patients at the time of service for any amounts except for applicable copayments.

Accept our allowance for eligible services as payment in full.

Horizon BCBSNJ will reimburse the lesser of your billed charge or our contracted rates, less applicable copayment, coinsurance or deductible amounts.

For ancillary providers participating only in our Horizon Managed Care Network who treat a member enrolled in a Horizon PPO or Horizon BCBSNJ Indemnity plan:

Claims will be processed according to the member’s out-of-network (OON) benefits.

  • You cannot bill members for amounts in excess of the member liability as indicated on our EOP.
  • Members are liable only for copayment amounts, coinsurance and/or deductible amounts indicated on the EOP.
  • Reimbursement will be calculated at the PPO allowance.

For ancillary providers participating only in our Horizon PPO Network who treat a member enrolled in a Horizon BCBSNJ managed care plan that includes out-of-network benefits, for example, Horizon POS, Horizon Direct Access or NJ DIRECT:

Claims will be processed according to the member’s out-of-network (OON) benefits.

  • Members are liable for copayment, coinsurance and/or deductible amounts indicated on the EOP.
  • Reimbursement will be calculated at the PPO rate.

For ancillary providers participating only in our Horizon PPO Network who treat a member enrolled in a Horizon BCBSNJ Medicare Advantage plan that includes out-of-network benefits, for example, Horizon Medicare Blue PPO or members enrolled in other Blue Cross and/or Blue Shield MA PPO Plans who reside or travel in our service area:

  • Note that participating PPO ancillary providers who have opted out of, or who are excluded from, Medicare are not eligible to receive reimbursement for services rendered to a Medicare Advantage member.
  • Members enrolled in Medicare Advantage plans are liable only up to the legally allowed amounts as determined by CMS.
  • Reimbursement will be calculated at the Centers for Medicare & Medicaid Services (CMS) allowance.
  • Claims will be processed according to the member’s out-of-network (OON) benefits.

COLLECTION OF MEMBER RESPONSIBILITY AMOUNTS AT THE TIME OF SERVICE

Although we prefer that participating practices submit claims and wait for our Explanation of Payment (EOP) prior to collecting any member liability amounts other than copayments, we understand the financial challenges that many practices are facing in regard to the collection of patient responsibility amounts. In addition to the collection of member copayment amounts, participating practices may make arrangements with members at the time services are provided for the payment of amounts that will be applied toward their deductibles.

Participating practices may NOT seek amounts that will be applied to member deductibles at the time of service from:

  • Collection of coinsurance amounts at the time of service.
  • Members enrolled in high-deductible health insurance plans that work in conjunction with an employer-sponsored Health Reimbursement Arrangement (HRA).
  • Members enrolled in Horizon BCBSNJ Medicare Advantage plans.

In no case shall treatment be refused to a Horizon BCBSNJ member if he or she is not able to pay a requested amount at the time of service.

Collection Fees/Interest

To protect our members, Horizon BCBSNJ forbids participating physicians and other health care professionals from adding a collection fee, interest or other amount to the member liability until the member has had a reasonable opportunity to pay (e.g., a minimum of 30 days).

We encourage you to inform our members in advance of your billing practices for the collection of member liability and of any fees or interest that you charge when member liabilities are not paid in a timely manner.

NATIONAL PROVIDER IDENTIFIER (NPI)

In accordance with the Centers for Medicare & Medicaid Services (CMS) regulations, ancillary providers who conduct electronic transactions or submit claims to us through a third-party vendor are required to use a NPI. To avoid claim rejection, include NPI information on your standard transactions.

Apply for NPI

If you have not yet applied for an NPI, please visit https://nppes.cms.hhs.gov/NPPES/Welcome.do.

  • Members enrolled in Medicare Advantage plans are liable up to the legally allowed amounts as determined by CMS.
  • Members (except those enrolled in Medicare Advantage plans) are liable up to your total billed amount.
  • Note: Participating PPO ancillary providers who have opted out of, or who are excluded from, Medicare are not eligible to receive reimbursement for services rendered to a Medicare Advantage member.

Registering Your NPI

Your NPI(s) must be registered with Horizon BCBSNJ for you to be reimbursed correctly. Registration ensures that our internal systems accurately reflect your NPI information and prevents reimbursement delays. If you haven’t registered your NPI information with us, please do so immediately.

To register by fax:

  • Visit HorizonBlue.com/individual NPI or HorizonBlue.com/groupNPI
  • Complete the form and fax it to 1-973-274-4416.

What to do if you move to a new location

You must notify the National Plan and Provider Enumeration System (NPPES) of your new location within 30 days of the effective date of the move. The CMS encourages health care professionals who were assigned a NPI and who are not covered entities, to do the same.

To submit your address change to NPPES, please visit https://nppes.cms.hhs.gov and:

  • Click the link within the statement: If you are a Health Care Provider, you must click on National Provider Identifier(NPI) to log in or apply for an NPI.
  • Click Login following the heading, Want to View or Update your NPI data?

To download a paper NPI update form, please visit:

  • cms.gov/cmsforms.
  • Click CMS Forms in the left navigation.
  • Click CMS 10114 to display the NATIONAL PROVIDER IDENTIFIER (NPI) APPLICATION/UPDATE FORM.

If you need to request a form, please call the NPI E numerator at 1-800-465-3203.

Horizon BCBSNJ also requests that if you update, add or change your NPI information/tax ID, please fax the information to your Ancillary Contracting Specialist or Ancillary Reimbursement Analyst at 1-973-274-4202.

CLAIM ADJUDICATION POLICIES

Horizon BCBSNJ adjudicates claims according to our claim editing policy and medical policy guidelines.

Ancillary providers are required to accurately report the services rendered to a member with the correct revenue, diagnosis, CPT and/or HCPCS codes, and for appending the applicable modifiers, when appropriate. The code(s) and modifiers(s) must be active for the date of service reported, and describe the services provided during the patient’s encounter.

If our claim processing system does not recognize information on a claim, the claim is manually reviewed. The claim is then reviewed for medical eligibility based on our medical policy guidelines. Our claim policy department will review all required medical documentation from the facility and will determine if further review from the Medical Advisor’s Office is necessary.

To access Horizon BCBSNJ’s Claim Editing Policies, please sign in to NaviNet.net, access Provider ReferenceMaterials and:

  • Click Reimbursement and Billing.
  • Click Claim Editing Policies.

For more information on our claim adjudication policies, please call your Ancillary Contracting Specialist.

CLAIMS SUBMISSIONS

Claims are a vital link between your office and Horizon BCBSNJ. Generally, claims must be submitted within 180 days of the date of service. Helpful Hints are provided in this section for your reference.

Rendering, referring and admitting NPI information on claims

Horizon BCBSNJ requires that your claim submissions include National Provider Identifier (NPI) information to identify referring and admitting physicians. Please submit this NPI information on all claim submissions.

Electronic Submissions

Electronic claims submissions help speed our reimbursement to you. We require all ancillary providers to submit claims to us electronically.

Horizon BCBSNJ’s electronic payor ID is 22099.

Our EDI Service Desk is available to discuss:

  • Enhancing your current practice management system with specifications for electronic submission to us.
  • Your electronic claim submission options.

For more information on submitting your claims electronically, contact the EDI Service Desk at 1-888-334-9242, or via email at HorizonEDI@HorizonBlue.com.

Paper Claims Submissions

If paper claims are necessary, we require that all paper claim submissions are printed on original, government-approved UB-04 or CMS 1500 claim forms. Claim submissions that we receive on photocopies of the UB-04 or CMS 1500 claim forms or on another carrier’s claim submission forms will not be processed.

Always fill out UB-04 or CMS 1500 forms completely and accurately. Pay close attention to required fields to minimize processing delays.

Mail your claims to the appropriate address listed below.

Medical claims:

  • BlueCard claims:
    • Horizon BCBSNJ
      BlueCard Claims
      PO Box1301
      Neptune, NJ 07754-1301
  • Federal Employee Plan®(FEP®) claims (Plan ID numbers begin with a single R):
    • Horizon BCBSNJ
      PO Box 656
      Newark, N J07101-0656

For all other medical claims:

  • Facilities:
    • Horizon BCBSNJ
      PO Box 25
      Newark, NJ 07101-0025
  • Professionals:
    • Horizon BCBSNJ
      PO Box 1609
      Newark, NJ 07101-1609

Behavioral health claims:

  • BlueCard claims:
    • Horizon BCBSNJ
      Horizon Behavioral  Health
      PO Box 1301
      Neptune, NJ 07754-1301
  • FEP claims:
    • Horizon  BCBSNJ
      Horizon Behavioral Health
      PO Box 656
      Newark, NJ 07101-0656

For all other behavioral health claims:

  • Horizon BCBSNJ
    Horizon Behavioral Health
    PO Box 10191
    Newark, NJ 07101-3189

HELPFUL HINTS FOR CLAIMS SUBMISSIONS

To assist us with the timely and accurate processing of your claims:

  • If the patient has any other insurance, please record the patient’s Coordination of Benefits (COB) information on the claim form.
  • When the patient’s primary insurance is traditional Medicare, claims are sent to Horizon BCBSNJ from the Centers for Medicare and Medicaid Services (CMS) national crossover contractor, the Benefits Coordination & Recovery Center (BCRC). Claims are transmitted after the Medicare Payment Floor (14 days) is reached, regardless of when you receive a remittance advice. If you do not receive a payment summary from us, submit the claim 30 days after you receive the Medicare Remittance along with a copy of the Medicare Provider Summary.
  • Please use valid, compliant codes for the date on which services were rendered.
  • Always use accurate five-digit CPT-4 or HCPD codes.
  • Use accurate and specific ICD diagnosis codes for each condition you are treating. List the primary diagnosis first. To report multiple ICD-10 codes (our systems can handle up to four), list each one with the corresponding procedure by numbers 1, 2 or 3.
  • Clearly itemize your charges and date(s) of service.
  • When submitting claims under your NPI, please remember that your tax ID number is also required.
  • Include rendering, referring and admitting physician NPI information on all appropriate submissions.
  • When appropriate, be sure to include the date of onset for the illness you are treating.
  • When you treat a patient due to an injury, be sure to include the date the injury occurred.
  • Complete the group number field on the claim form when it appears on the ID card.
  • Claims must include the entire ID number. Always use the prefixes or suffixes that surround the ID number. The only exceptions are Federal Employee Program® (FEP®) products. For FEP, disregard any characters after the eighth numeric character following the R prefix.
  • Complete the patient’s date of birth.
  • Use the subscriber’s and/or patient’s full name. Avoid nick names or initials.
  • Don’t confuse the subscriber with your patient. The patient is always the person you treat. Complete the patient information on your claim as it relates to the person being treated.
  • Ask for the patient’s ID card at each visit to have the most current enrollment information available.

HELPFUL HINTS FOR PAPER CLAIMS SUBMISSIONS

If you submit paper claims, your claim submissions may be processed through Optical Character Recognition (OCR). Our enhanced OCR processing provides faster and more efficient adjudication and reimbursement than the traditional methods of manually processed paper claims. The efficiency of processing paper claims through OCR depends on your legible, compliant and complete claim submission. Incomplete and/or illegible claims may be delayed.

To maximize the benefits of OCR, we recommend the following when submitting your UB-04 form or CMS 1500 form:

Always use an original UB-04 form or CMS 1500 form for hard copy claim submissions. Always use an original CMS 1500 form for hard copy claim submissions. Do not use photocopies of the CMS 1500 form.

  • Include rendering, referring and admitting physician NPI information on all appropriate claim submissions.
  • Do not highlight or circle information or apply extraneous stamps or verbiage to the forms. Highlighting, circling and applying stamps may prevent our scanners from correctly identifying characters.
  • All characters on the UB-04 form or CMS 1500 form need to be intact. We use OCR equipment that recognizes full characters only. If the characters are missing tops or bottoms of the letters, the OCR equipment will not function properly, causing claims processing delays. Use a laser printer for best results.
  • Make sure the print on your UB-04 form or CMS1500 form is clear and dark, and that characters are centered in each box.

For information omitted from computer-prepared forms, use typewritten instead of handwritten data.

  • Avoid duplicate claim submissions:
  • Do not staple any submitted documents.

1-888-482-8057.

  • When submitting a claim for secondary carrier payment, please ensure the primary carrier’s corresponding EOP is included with the UB-04 form or CMS 1500 form claim form (patient name, procedures and dates of service must coincide).

EDI TRANSACTION INVESTIGATION

From time to time, you might experience Electronic Data Interchange (EDI) transaction rejections. Different from a claim denial, an EDI transaction rejection is not forwarded to our claim processing systems for adjudication.

The following information will help to expedite any transaction rejection investigations you may need to conduct with the EDI Service Desk.

Information Required for EDI Investigation

If you need help with EDI rejection messages for any of the transactions listed below, please have the Horizon EDI Gateway Receipt Number or Carrier Reference Receipt Number available to provide to the EDI Service Desk Representative.

  • Claim status.
  • Eligibility status.
  • Professional or Facility claims.

Remittance Advice

If you need help with a Remittance Advice/835 investigation, please also have the following information available:

  • Check number.
  • Check amount.
  • Check date.
  • Provider NPI and tax ID.

You may call the EDI Service Desk at 1-888-334-9242, Monday through Friday, between 7 a.m. and 6 p.m., Eastern Time (ET), or email HorizonEDI@HorizonBlue.com.

CLAIM ADJUSTMENT REQUESTS

Horizon BCBSNJ encourages all practices to submit claim adjustment requests electronically using the standard HIPAA 837P transaction, as appropriate. Submitting electronic claim adjustment requests simplifies the claim adjustment process and helps to speed adjudication and the payment to providers.

Providers may electronically submit any adjustments that DO NOT require the submission of additional supporting documentation (e.g, medical record, etc) for:

  • BlueCard claims.¹
  • Local claims (including SHBP and FEP).

¹BlueCard claim adjustment requests to change subscriber ID, provider Tax ID number or provider suffix cannot be submitted electronically.

Please mail these claim adjustment requests to:

BlueCard Claims
PO Box 1301
Neptune, NJ 07754-1301

Contact the vendor or clearing house for information about 837 transactions.

For additional information, please contact Horizon BCBSNJ eService Desk at 1-888-334-9242or via email at Horizon EDI@HorizonBlue.com. Representatives are available weekdays from 7 a.m. to 6 p.m., ET.

How to indicate that your 837 transaction is an adjustment request

To indicate that the 837 transaction is an adjustment request, simply include the following required information within the 837 transaction.

  1. Frequency code: The frequency code (values 7 or 8) associated with the place of service indicates that this transaction is an adjustment.
  2. Adjustment reason: The adjustment reason and narrative explaining why the claim is being adjusted. For example, the adjustment reason could be “number of units” and additional narrative could be “units billed incorrectly, changed units from 010 to 001.”
  3. Original reference number: Claim number of the originally adjudicated claim found on remittance advice (the ICN/DCN of the claim to be adjusted).

IF YOUR CLAIM IS REJECTED: ERROR REPORT 999 OR 277CA

If a claim is rejected, you will receive an error report, either the 999 or the 277CA Claim Acknowledgement Report, that explains why the claim was rejected.

What the reports show

The 999 report shows:

  1. Non-compliance with the 837 implementation guide
  2. Invalid codes
  3. Claims with incomplete information

The 277CA report shows:

  1. Duplicate claims
  2. Dependent coverage rejections
  3. Claims with invalid ID/member not found

When you receive an error report you must:

  1. Correct the claim and resubmit for processing
  2. Work with your clearing house to resolve any errors
  3. Review the report to see why your claim(s) was rejected

CORRECTED CLAIMS AND INQUIRIES

Corrected or adjusted claims may be submitted electronically in most cases. Provider Physician Service Representatives can also accept missing or corrected claim information over the phone.

You are no longer required to submit the information in writing for most corrected claim situations. However, ITS and Fund Accounts must submit corrected claims using Form 579, Inquiry Request and Adjustment Form.

For corrected claims processed by eviCore healthcare for radiology services, use Form 579 to add multiple bill lines not included in the original claim submission.

If there are circumstances that prevent an electronic claim submission, please complete Form 579 or risk denial of your paper claim submission as a duplicate claim.

Ensure the following is included:

  1. All pertinent information requiring data correction (“Details of Request” within the Subscriber/Patient information section).
  2. The original claim # (“Claim #” within the Subscriber/Patient Information section).
  3. Identification of the corrected claim at the top of the page (“Request for…”).

If the form is not received with the corrected claim submission, the claim may not be processed as a corrected claim and may be identified as a duplicate. Form 579 can be found at HorizonBlue.com/providers. Simply mouse over Forms and select Forms by Type.

Then select Inquiry/Request and select Request Form–Inquiry,Adjustment,Issue Resolution.

CLINICAL LABORATORY CLAIMS

You are required, according to your Ancillary Provider Agreement(s), to refer Horizon BCBSNJ patients and/or send Horizon BCBSNJ patients’ testing samples to participating clinical laboratories. Failure to comply with the terms of your Ancillary Provider Agreement(s) may result in your termination from the Horizon BCBSNJ networks.

Managed Care Laboratory Network

Horizon BCBSNJ’s managed care laboratory network expanded to include Quest Diagnostics in addition to Laboratory Corporation of America®(LabCorp®). LabCorp and Quest provide national in-network clinical laboratory services to your Horizon BCBSNJ managed care patients (i.e., members enrolled in Horizon HMO, Horizon EPO, Horizon Direct Access, Horizon POS, OMNIA℠ Health Plans, NJ DIRECT, Horizon BCBSNJ Medicare Advantage and Braven Health plans).

You may refer members enrolled in Horizon PPO and Indemnity plans (and/or send their testing samples) to one of our participating clinical laboratories including LabCorp, Quest and BioReference Laboratories, Inc. or to hospital outpatient laboratories at network hospitals).

As a reminder, our networks include a number of participating laboratories that can provide a variety of specialized laboratory services. Please visit our Online Doctor & Hospital Finder to locate participating laboratories.

To view a list of our participating clinical laboratories, visit HorizonBlue.com/doctorfinder. Within the Other Healthcare Services tab, select Laboratory – Patient Centers or Laboratory – (Physician Access Only) under the Service Type dropdown menu and click Search.

You may refer a Horizon BCBSNJ patient who has out-of-network benefits (or send his or her testing sample) to a nonparticipating clinical laboratory, if that patient chooses to use his or her out-of-network benefits and you follow the guidelines in our Out-of-Network Referral Policy.

Pathology services provided in a hospital setting to members enrolled in Horizon BCBSNJ managed care plans by a practice that participates in the Horizon Managed Care Network are allowed as an exception to the above-described LabCorp/Quest network use requirements.

Laboratory providers who are only contracted provide services to members with PPO/Non-Managed Care plans will not be reimbursed for services rendered to managed care members.

Note: Certain self-insured employer groups for whom we administer health care benefits have established special benefit arrangements that allow their enrolled members to use the nonparticipating clinical laboratory affiliated with each employer group as exceptions to the guidelines of our Out-of-Network Consent Policy. These special benefit arrangements apply ONLY to members/dependents enrolled in these employer group plans.

SPECIALTY PHARMACY CLAIMS

When you use the Horizon BCBSNJ Specialty Pharmaceutical Program you’ll obtain specialty pharmaceuticals directly from a specialty pharmacy.

Under this program, your office or facility should not submit claims for specialty medications when obtained from our specialty pharmacy providers. These contracted specialty pharmacy providers will bill Horizon BCBSNJ directly for the cost of the medication.

Specialty pharmacy claims must be sent to the Blue Plan in the service area where the ordering physician is located. The claim will process according to the pharmacy’s relationship with that Blue Plan. For example, if the ordering physician is located in New Jersey, send the claim to Horizon BCBSNJ and the claim will process according to the pharmacy’s participating status with Horizon BCBSNJ.

However, if the ordering physician is located in Pennsylvania, the claim must be sent to the Blue Plan in Pennsylvania and will process according to the pharmacy’s contractual relationship with the Pennsylvania Blue Plan and consistent with the member’s Home Plan benefits.

ELECTRONIC FUNDS TRANSFER

Horizon BCBSNJ requires all ancillary providers to register for Electronic Funds Transfer (EFT) upon joining our networks.

Horizon BCBSNJ reserves the right to re-evaluate the participation status of ancillary providers who do not comply with this requirement.

The benefits of EFT include:

  1. Elimination of bank fees for check deposits.
  2. Improved cash flow by eliminating mail time and check float.
  3. Quicker reimbursement into one or more designated bank accounts.
  4. Reduction in the opportunity for error/theft.
  5. Reduction in paperwork and administrative costs.
  6. Elimination of paper checks to track and deposit.

Note: EFT will only be used by Horizon BCBSNJ to make deposits into your designated accounts. We will not withdraw any amounts from these designated accounts.

Enrolling in EFT requires that you receive online Explanation of Payments (EOPs) in place of paper statements.

Please Submit Claims through EFT

Horizon BCBSNJ no longer makes payments using checks. If providers are not already registered for EFT, payments will be made with a Single Use Account (SUA) card payable in the exact amount owed.

The SUA cards include a high level of security: a unique 16-digit SUA card number created for each payment, receipt of an image of a SUA card (which will be sent by mail) and more.

Find out how to register for EFT and more

ROUNDING OF CLAIM BILL LINES

Based on our claim processing system configuration, the allowance calculated for claim bill lines submitted by ancillary providers that are reimbursed by certain payment methodologies (e.g., Percent of charges, Top of Range) may be rounded either up or down by a de minimis amount.

When multiple claim bill lines are aggregated, the total amount of our allowance may not be equal to the exact reimbursement expected.

These rounding calculations should not materially affect claim allowances or payments generated.

PROMPT PAY

All New Jersey insurance companies, health, hospital, medical and dental services corporations, HMOs and dental provider organizations and their agents for payment (all known as payers) must process claims in a timely manner, as required by New Jersey law (Prompt Pay Law).

Prompt Pay Law also requires that carriers pay clean claims within 30 calendar days of receipt for electronic claims and 40 calendar days of receipt for paper claims. Claims that are not paid must be denied or disputed within the same 30- or 40-day time frames.

Note: According to CMS guidelines, a Medicare health plan must pay clean claims from non contract providers within 30 calendar days of the request, and pay or deny all other claims within 60 calendar days of the request.

In addition, the Health Claims Authorization, Processing and Payment Act (HCAPPA), where it applies, requires any claim paid beyond the above time frames to be paid with interest at the rate of 12 percent per annum. As such, interest calculation begins on the 31st day for electronic claims and the 41st day for paper claims (when applicable).

Prompt pay requirements do not apply to certain lines of business. For example, we provide Administrative Services Only (ASO) for self-funded businesses.

If you have questions about identifying the members to whom Prompt Pay applies, please call Physician Services at 1-800-624-1110 (CMS 1500 submitters) or an Institutional Services Representative(UB-04 submitters) at 1-888-666-2535, Monday through Friday, between 8 a.m. and 5 p.m., ET.

Additional Interest Payments

Horizon BCBSNJ issues additional interest payments on claims (for certain lines of business) to ancillary providers. Interest will be paid at a rate of 8 percent per annum on balances due from the 20th calendar day after Horizon BCBSNJ receives a complete, electronically submitted claim to the earlier of the date that:

  1. Horizon BCBSNJ directs issuance of payment, or
  2. Interest becomes payable under New Jersey law.

These additional interest payments will be noted on your EOP, which will separately identify interest payments required by New Jersey law and interest payments resulting from the settlement.

Claims eligible for this additional interest are limited to certain lines of business and exclude, for example, claims of members enrolled in the Federal Employee Program (FEP), certain national account groups managed outside of New Jersey and Medicare or Medicaid programs. Other limitations include:

  1. Claims payable during a major disruption in services for which claims processing is excused or delayed as a result of that event.
  2. Claims reimbursed to a member.
  3. Claims from a physician who balance bills a Horizon BCBSNJ member in violation of their network participation Agreement.
  4. Claims that include a defect or error that prevents them from being systemically processed.
  5. Duplicate claims submitted within 30 days of the original claim submission.

REQUESTS FOR UNDER- AND OVERPAYMENTS

The Health Claims Authorization, Processing and Payment Act (HCAPPA) affects ancillary providers. This law applies to all insured New Jersey group and individual business.

HCAPPA requirements do not apply to certain lines of business, such as self-funded business, including Administrative Services Only (ASO) accounts such as the New Jersey State Health Benefits Program (SHBP) and School Employees’ Health Benefits Program (SEHBP).

Overpayment

Health insurers may only seek reimbursement for overpayment of a claim from an ancillary provider within 18 months after the date the first payment on the claim was made. There can only be one reimbursement sought for overpayment of a particular claim. However, recapture of an overpayment, beyond the 18-month period, is permitted if there is evidence of fraud, if a physician or health care professional with a pattern of inappropriate billing submits the claim, or if the claim is subject to Coordination of Benefits (COB).

Recapture of overpayments by a health insurer may be offset against an ancillary provider’s future claims if notice of account receivable is provided at least 45 calendar days in advance of the recapture, and all appeal rights under HCAPPA are exhausted. An offset will be stayed pending an internal appeal and state-sponsored binding arbitration. However, with prior written consent, Horizon BCBSNJ will honor requests for the recapture prior to the expiration of the 45-day period. If an ancillary provider prefers to make payment directly to Horizon BCBSNJ rather than permit an offset against future claims, the 45-day notice letter will include an address to remit payment.

Horizon BCBSNJ may extend the notice period up to 90 days. The decision to offer an extended notice period is made on a case-by-case basis.

Note: Horizon BCBSNJ will not recapture an overpayment made on claims processed for members enrolled in insured group and individual plans covered under HCAPPA until the expiration of the 45-day notice period (except with an ancillary provider’s prior written consent, or if an ancillary provider remits payment directly to Horizon BCBSNJ). Both the paper voucher and the electronic (HIPAA standard 835 transaction) version of the voucher, if applicable, will reflect the adjustment as soon as it is recorded.¹

In the event that Horizon BCBSNJ has determined that an overpayment is the result of fraud and has reported the matter to the Office of the Insurance Fraud Prosecutor, HCAPPA allows a recapture of that overpayment to occur without the 45-day notice period.

¹The overpayment recapture guidelines noted above do not pertain to overpayments made on claims processed through the BlueCard program for members enrolled in other Blue Cross and/or Blue Shield Plans or for members enrolled in the Federal Employee Program (FEP).

Underpayment

Under HCAPPA, no ancillary provider may seek reimbursement from a member/patient or health insurer for underpayment of a claim submitted later than 18 months from the date the first payment on the claim was made, except if the claim is the subject of an HCAPPA appeal submitted or the claim is subject to continual claims submission.

No ancillary provider may seek more than one reimbursement for underpayment of a particular claim.