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Claims Submission and Reimbursement

You are required to:

Send claims to us for your Horizon BCBSNJ and BlueCard program 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.

Accept our allowance for eligible services as payment in full.

You are expected to bill members for the appropriate member liability (deductible and/or coinsurance), as indicated on the Explanation of Payment (EOP) you receive.

Horizon BCBSNJ will reimburse the lesser of your billed charge or our fee schedule amount, less applicable copayment, coinsurance or deductible amounts. For more information on your responsibilities and obligations, see the Policies, Procedures and General Guidelines section.

For physicians or other health care professionals 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.
  • Reimbursement will be calculated at the PPO OON allowance.
  • Members are liable only for copayment amounts, coinsurance and/or deductible amounts indicated on the EOP.
  • You cannot bill members for amounts in excess of the member liability as indicated on our Explanation of Payment (EOP).

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

For physicians or other health care professionals 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:

  • Claims will be processed according to the member’s out-of-network (OON) benefits.
  • Reimbursement will be calculated at the Centers for Medicare & Medicaid Services (CMS) allowance.
  • Members enrolled in Medicare Advantage plans are liable only up to the legally allowed amounts as determined by CMS.
  • Please note that participating PPO physicians/other health care professionals 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.

For physicians or other health care professionals participating only in our Horizon PPO network who treat a member enrolled in a Horizon BCBSNJ managed care plan that DOES NOT include out-of-network benefits, for example, Horizon HMO, Horizon EPO and Horizon Medicare Blue Value (HMO):

  • Claims will be denied (except for services that were authorized or provided in emergent situations).
  • Reimbursement will not be made.
  • Members (except those enrolled in Medicare Advantage plans) are liable up to your total billed amount.
  • Members enrolled in Medicare Advantage plans are liable up to the legally allowed amounts as determined by CMS.

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:

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

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 (i.e., a minimum of 30 days).

We encourage you to inform our members of your billing practices before member liabilities will not paid in a timely manner.

NATIONAL PROVIDER IDENTIFIER (NPI)

In accordance with Centers for Medicare & Medicaid Services (CMS) regulations, physicians and other health care professionals 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

Horizon BCBSNJ requires all physicians to have a unique NPI. If you have not yet applied for a NPI, visit https://nppes.cms.hhs.gov/NPPES/welcome.do.

Registering Your NPI

To reimburse you correctly, your NPI(s) must be registered with Horizon BCBSNJ. 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, do so immediately.

To register by fax:

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

NPI and Group Tax ID Number Affiliation

Ensure that your NPI is linked/associated with your Group Tax ID number (TIN) and correctly registered in our files. A group NPI that is incorrectly associated to an individual physician’s TIN or Social Security Number may cause claims to be incorrectly processed. If your group practice NPI is incorrectly associated with an individual physician, visit CMS at CMS.gov to request a correction to the NPI. Once CMS has corrected its records, fax the updated information 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.

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, 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 login orapply for an NPI.
  • Click Login following the heading,Want to View or Update your NPI data?

To download a NPI update form, visit cms.gov/cmsforms and:

  • Click CMS Forms in the left navigation.
  • Click CMS 10114 to display the NATIONAL PROVIDER IDENTIFIER (NPI) APPLICATION/UPDATEFORM.

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

Horizon BCBSNJ also requests that if you update, add or change your NPI information/tax ID, fax the information to 1-973-274-4416.

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. Submit this NPI information on all claim submissions.

Electronic Submissions

Electronic claims submissions help speed our reimbursement to you. You must submit claims to us electronically.

Horizon BCBSNJ’s electronic Payor ID is 22099.

Our EDI Service Desk is available to discuss:

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

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

Behavioral Health Care Claims

Behavioral health claims should be submitted electronically. If you must submit printed claims, mail claims to:

Horizon BCBSNJ

Horizon Behavioral Health

PO Box 10191

Newark, NJ 07101-3189

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

  • Ask for the patient’s ID card at each visit to have the most current enrollment information available. Always copy both sides of the ID card for your files.
  • 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.
  • Use the subscriber’s and/or patient’s full name. Avoid nicknames or initials.
  • Complete the patient’s date of birth.
  • 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 group number field on the claim form when it appears on the ID card.
  • When you treat a patient due to an injury, be sure to include the date the injury occurred.
  • When appropriate, be sure to include the date of onset for the illness you are treating.
  • Include rendering, referring and admitting physician NPI information on all appropriate claim submissions.
  • When submitting claims under your NPI, remember that your tax ID number is also required.
  • Clearly itemize your charges and date(s) of service.

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.

  • Always use accurate five-digit CPT-4 or HCPC codes.
  • Please use valid, compliant codes for the date on which services were rendered.
  • When the patient’s primary insurance is traditional Medicare, claims are sent to Horizon BCBSNJ from 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.
  • If the patient has any other insurance, please record the patient’s Coordination of Benefits (COB) information on the claim form.

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. Claims incomplete and/or illegible in these areas may be delayed.

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

  • Always use an original CMS 1500 form for hard copy claim submissions. Do not use photocopies of the CMS1500 form.
  • Make sure the print on your CMS 1500 form is clear and dark, and that characters are centered in each box.
  • All characters on the 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.
  • Do not highlight or circle information or apply extraneous stamps or verbiage to the forms. Highlighting, circling and stamps may prevent our scanners from correctly identifying characters.
  • Include rendering, referring and admitting physician NPI information on all appropriate claim submissions.
  • For information omitted from computer-prepared forms, use typewritten instead of handwritten data.
  • Do not staple any submitted documents.
  • Avoid duplicate claim submissions:

EDI TRANSACTION INVESTIGATION

From time to time, you may 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, have the Horizon EDI Gateway Receipt Number or Carrier Reference Receipt Number available to provide to the EDI Service Desk Representative.

  • Professional claims
  • Eligibility status
  • Claim status

Remittance Advice

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

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

You may reach the EDI Service Desk at 1-888-334-9242, weekdays, between 7 a.m. and 6 p.m., Eastern Time, or by emailing 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:

  • Local claims (including SHBP and FEP).
  • BlueCard claims¹.

BlueCard 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, NJ07754-1301

Contact the vendor or clearinghouse for information about 837 transactions.

For additional information, contact the Horizon BCBSNJ EDI Service Desk at 1-888-334-9242,

weekdays from 7 a.m. to 6 p.m., Eastern Time, or via email at HorizonEDI@HorizonBlue.com.

How to indicate that your 837 transaction is an adjustment request

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).

Share this information with your vendor or clearinghouse to ensure that electronic transactions are submitted correctly.

ERROR REPORT 999 OR 277CA

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

What the reports show

The 999 report shows:

  • Claims with incomplete information
  • Invalid codes
  • Non-compliance with the 837 implementation guide

The 277CA report will show:

  • Claims with invalid ID/member not found
  • Dependent coverage rejections
  • Duplicate claims

When you receive an error report you must:

  • Review the report to see why your claim(s) was rejected
  • Work with your clearinghouse to resolve any errors
  • Correct the claim and resubmit for processing

Submitting claims

To be sure a claim is accepted when submitted, always include the patient and insured’s names and addresses, and the ICD-10 diagnosis codes.

If you must submit a professional claim on paper, please use the standard, government approved red-lined CMS 1500 claim form. To help expedite your hard copy claim submissions:

  • Do not use black and white, or photocopies of the CMS 1500 claim form.
  • Do not handwrite your claims.
  • Use a laser printer instead of a dot-matrix type printer to ensure better quality.

You will receive a letter for any paper claims that are unable to be entered into the claims processing system. Please review the letter carefully and submit a new claim with all of the required fields necessary for processing.

It’s important to review the claim report, or the Horizon BCBSNJ-issued letter, with your clearinghouse first before calling.

CORRECTED CLAIMS AND INQUIRIES

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

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

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 is on HorizonBlue.com/form579.

OBSERVATION CARE AND PLACE OF SERVICE CODES

Horizon BCBSNJ recognizes that either place of service code 23 (ER hospital) or place of service code 22 (outpatient hospital) meets the requirements for billing the appropriate place of service when submitting professional claims for services provided to members in an observation care status.

Please note the following:

Consistent with our current policies and procedures, services billed with place of service code 23 do not require a prior authorization.

  • Horizon BCBSNJ’s prior authorization requirements remain unchanged for specific services rendered in the outpatient setting and billed with place of service code 22. As a reminder, it is the ordering physician’s responsibility to obtain this prior authorization.

CHIROPRACTIC CLAIMS

Please use the Chiropractic Manipulative Treatment (CMT) codes listed below when submitting chiropractic claims to us. 98940 CMT; spinal, one or two regions. 98941 CMT; spinal, three or four regions. 98942 CMT; spinal, five regions. 98943 CMT; extra spinal, one or more regions.

Include Rendering/Referring NPI Info Chiropractic claims must include rendering and referring practitioner NPI information on all claim submissions as appropriate.

E&M Services and PT Modalities

In compliance with New Jersey Department of Banking and Insurance (DOBI) Order A09-113, Horizon BCBSNJ considers Evaluation and Management (E&M) services and physical therapy (PT) modalities for reimbursement separate from the reimbursement of CMT codes.

This impacts all participating and nonparticipating New Jersey chiropractors.

Chiropractic Order Number A09-113 does not apply to Federal Employee Program®(FEP®) members, Horizon Medicare Advantage members or Medigap members.

Evaluation of E&M services and PT modalities may require the submission of medical records to support the appropriateness of the services being billed.

The eligible CPT-4 codes are listed below. However, reimbursement of codes is subject to Horizon BCBSNJ policies and the member’s benefits.

  • Evaluation and Management Codes

For initial patient – 99201 through 99205.

For established patient – 99211 through 99215.

  • Physical Therapy Modality Codes

97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, 97110, 97112, 97113, 97116, 97124, 07139, 97140, 97530, 97550, G0283

  • Chiropractic Manipulative Therapy Codes 98940 through 98943.

Benefit Maximums

A common standard benefit is to cover a maximum of 30 visits per benefit year. However, some groups have other benefit maximums or elect not to cover chiropractic services.

Depending on the member’s contract, maximums may also apply to physical therapy modalities.

Please call the service number on your patient’s ID card to verify chiropractic and physical therapy modality benefits.

CLAIMS FOR HOT OR COLD PACKS

Horizon BCBSNJ does not provide reimbursement for CPT® code 97010.

The denial of this service as not eligible for reimbursement aligns our approach to 97010 with the Centers for Medicare & Medicaid Services (CMS) and standard business practice.

According to the terms of your participating Agreements with us, you may not bill or seek reimbursement from a Horizon BCBSNJ member for these denied services whether billed in conjunction with other medical services or alone.

Administrative Services Only (ASO) plans and self-funded employer groups may or may not provide this benefit to their covered employees.

PHYSICAL THERAPY AND OCCUPATIONAL THERAPY CLAIMS

Reimbursement for physical therapy and occupational therapy services is made on a maximum per-visit basis and covers all medically necessary treatment provided to a patient in a single visit.

Significant, separately identifiable Evaluation & Management (E&M) services may be eligible for separate reimbursement if:

  • The appropriate level of E&M service is billed.
  • The appropriate modifier is appended to the E&M service, which is above and beyond the other services provided.
  • The reason for the E&M service is clearly documented in the member’s medical record and this documentation supports that the member’s condition required the significantly, separate E&M service.
  • The services in question have not been specifically identified as part of an impacted code pair combination in our claim processing logic that prevent separate reimbursement (even if the E&M code is appended with a modifier).

Include Rendering/Referring NPI Info

PT/OT practitioner claims must include rendering and referring practitioner NPI information on all claim submissions as appropriate.

Online Authorizations

Participating health care professionals can use NaviNet to obtain online authorizations for short-term outpatient physical therapy and occupational therapy services for enrolled Horizon BCBSNJ members.

The online Utilization Management Request Tool should be used to submit submit and/or check the status of authorization and predetermination requests, access the online Utilization Management Request Tool.

To access this tool, log on to NaviNet.net, select Horizon BCBSNJ within the My Health Plans menu and:

  • Under Workflows for this Plan, mouse over Referrals and Authorizations.
  • Click Utilization Management Requests.

Online Training

Online training tutorials are available. Log on to NaviNet and select Horizon BCBSNJ from the My Health Plans menu, mouse over References and Resources and click Provider Reference Materials. Mouse over Resources, click Training, and then click Education.

Helpful Hints for Physical Therapy Claims

  • Standard benefit is to cover a maximum of 30 visits per benefit year. However, some large groups can elect other benefit maximums.
  • Call the Member Services phone number on the patient’s ID card to verify his or her physical therapy benefits.
  • Submit all claims using current CPT-4 codes that accurately reflect your services.
  • Certain groups may require services to be reviewed for medical necessity at specific intervals.
  • Medical records may be requested to confirm the medical necessity for care.

Note: Reimbursement may vary by county.

CLINICAL LABORATORY CLAIMS

Participating physicians are required, according to their Physician 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 Physician Agreement(s) may result in your termination from the Horizon BCBSNJ networks.

Managed Care Laboratory Network

Horizon BCBSNJ’s Managed Care laboratory network includes 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 Medicare Advantage plans, including Braven Health plans).

PPO Laboratory Network

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

As a reminder, our networks also include a number of participating laboratories that can provide a variety of specialized laboratory services, although our participating national laboratories provide a full menu of services including most 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.

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 Managed Care Network use requirements.

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. That Policy requires, among other things, that you have your patient sign an Out of Network Referral Consent Form.

Note: Certain self-insured employer groups for whom Horizon BCBSNJ administers 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.

ELECTRONIC FUNDS TRANSFER

Horizon BCBSNJ requires all participating physicians and other health care professionals to register for Electronic Funds Transfer (EFT) upon joining our networks.

Horizon BCBSNJ reserves the right to re-evaluate the participation status of physicians and other health care professionals who do not comply with this requirement.

The benefits of EFT include:

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

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.

Reimbursements generated from our dental claim processing system will still be made via paper check, even for those who sign up for EFT. We will keep you apprised of our progress toward generating EFTs from our dental claim processing system in our Blue Review newsletter.

Horizon BCBSNJ no longer makes payments using checks. If providers are not already registered for EFT, future payments will default to a single use card (known as a 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

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 noncontract 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, self-funded businesses we work with as Administrative Services Only (ASO) accounts.

If you have questions about identifying the members to whom Prompt Pay applies, call 1-800-624-1110.

Clean Claim

“Clean claim means one that can be processed without obtaining additional information from the provider of the service or from a third party. It does not include a claim from a provider who is under investigation for fraud or abuse or a claim under review for medical necessity.” Under the New Jersey Health Claims Authorization, Processing and Payment Act, claims must also meet the following criteria:

(a) the health care provider is eligible at the date of service

(b) the person who received the health care service was covered on the date of service

(c) the claim is for a service or supply covered under

(d) the claim is submitted with all the information requested by the payor on the claim form or in other instructions that were distributed in advance to the health care provider or covered person in accordance with the provisions of section 4 of P.L.2005, c.352 (C.17B:30-51)

(e) the payor has no reason to believe that the claim has been submitted fraudulently

Additional Interest Payments

Horizon BCBSNJ issues additional interest payments on claims (for certain lines of business) to MDs and DOs. 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 Explanation of Payment (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:

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

REIMBURSEMENT REQUESTS FOR UNDER- AND OVERPAYMENTS

The Health Claims Authorization, Processing and Payment Act (HCAPPA) affects physicians, other health care professionals and facilities. 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 a physician or health care professional 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 COB.

Recapture of overpayments by a health insurer may be offset against a physician’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 a physician or health care professional 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 a physician’s or health care professional’s prior written consent, or if a physician or health care professional 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 physician or other health care professional 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 physician or other health care professional may seek more than one reimbursement for underpayment of a particular claim.

QUALIFIED MEDICARE BENEFICIARIES’ COST SHARING RESPONSIBILITIES

According to CMS guidelines, Qualified Medicare Beneficiaries (QMB) program members are not responsible for copayments or other cost sharing for Medicare-covered services and items. These enrollees include members who are enrolled in both a Horizon BCBSNJ Medicare Advantage (MA) plan and the New Jersey state Medicaid program.

You may bill the appropriate state source for those amounts. We encourage you to establish processes to identify the Medicaid status of your Horizon BCBSNJ MA plan or Medicare patients prior to billing for items and services.

Reference:

Centers for Medicare & Medicaid Services. (2017, February). Dual Eligible Beneficiaries under the Medicare and Medicaid Programs. Retrieved October 11, 2017, from https://www.cms.gov/ Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/ Medicare_Beneficiaries_Dual_Eligibles_At_a_Glance.pdf

CAPITATION

Capitation is a predetermined monthly rate paid to the physician for each member enrolled on a physician's panel regardless of the actual services rendered to members in certain Horizon BCBSNJ managed care plans. The payment is reviewed periodically to reflect changes in utilization, medical technology or the cost of medical goods and services.

Horizon Managed Care Network Primary Care Physicians (PCPs) who have a capitated payment arrangement will be reimbursed monthly as such for members enrolled in Horizon HMO, Horizon POS, Horizon Medicare Blue Value (HMO), Horizon Medicare Blue Access Group (HMO-POS), Horizon Medicare Blue Advantage (HMO), Horizon Medicare Blue Select (HMO POS), and Horizon Medicare Blue Choice w/Rx (HMO) plans.

Reimbursements for Horizon HMO Access members are through capitation only if the member has made a valid preselection of the treating PCP. If not, fee-for-service reimbursement applies.

Requests to amend your current reimbursement methodology may be made, in writing, to your Network Specialist. Please include:

  • Your practice name and address.
  • Your tax ID number and NPI.
  • A detailed explanation of your request.

Your request will be reviewed by a Network Management Representative and a notification of the implementation date of your new reimbursement methodology will be sent to your office. Allow 60 days from the date of your request for notification.

Base Monthly Capitation

The Base Monthly Capitation amount is defined as the amount of dollars prepaid to you or your group for all members on your or your group’s panel who are considered active with your office as recorded in Horizon BCBSNJ’s enrollment system when the monthly capitation is generated.

The Base Monthly Capitation is sent directly to the PCP by the 15th day of each month. Group practices receive a single capitation check.

If you are paid on a capitation basis, capitation payments for additions to your panel will be made as follows:

  • You will receive 100 percent capitation amount for persons covered by a plan requiring PCPs to be paid on a capitation basis who are added to your panel on or before the 15th day of the month.
  • You will receive 50 percent of the capitation amount for persons covered by a plan requiring PCPs to be paid on a capitation basis who are added to your panel after the 15th day of the month.

Capitation Liaison

A Horizon BCBSNJ Capitation Liaison is available at capitation_liaison@HorizonBlue.comto respond to your capitation-related issues, including concerns and questions about:

  • Your Horizon BCBSNJ capitation payment.
  • The members of your Horizon BCBSNJ patient panel.
  • The services that are included in the capitation payment.
  • The correct application of copayments on your capitation report.

To expedite our investigation and response, please include the following information in your email:

  • Name of your practice.
  • Office address.
  • Tax ID Number (TIN) and/or NPI.
  • Detailed description of the issue.
  • Any applicable member ID numbers.

Capitation Adjustment Request Forms Capitation adjustment request forms are available online. To access this information:

  • Visit HorizonBlue.com/Providers.
  • Mouse over Forms.
  • Select Forms by Type, then Inquiry/Request and select Request Form – Adjustment to Capitation for Multiple People or Request Form – Adjustment to Capitation for OnePerson.

Fax completed capitation adjustment request forms to 1-973-274-4530.

Bulk Move of Members

We will initiate a bulk move of members for a terminating PCP to another PCP affiliated with the same tax identification number (TIN). The PCP must be terminating from our network(s) due to death, retirement or leaving the service area. The request to move members must be submitted in writing along with the termination request.

Reconciliation of Additions and Deletions to Panel

Horizon BCBSNJ will make periodic adjustments to the Base Monthly Capitation due to changes in your panel, but will not honor requests for adjustments that date more than 12 months back from the date Horizon BCBSNJ receives the initial request. Changes to your panel may occur for the following reasons:

  • Newborn enrollment (ADD) – Most of our members’ accounts require applications for newborns to be received by the employer group within 30 days from the date of birth. The application must then be forwarded to Horizon BCBSNJ for enrollment processing.
  • Retroactive enrollment, change of an employer group to the plan or individual member to an employer group (ADD/DELETE).
  • PCP changes made or processed after capitation checks have been generated (ADD/DELETE).
  • Change in PCP group practice affiliation (ADD/DELETE) – Horizon BCBSNJ must be notified in writing within 10 business days of such changes.

Positive adjustments processed by Horizon BCBSNJ prior to the generation of the current Base Monthly Capitation will generate extra payments to you or your group and will be paid in the current month’s Base Monthly Capitation payment. Those adjustments processed after the generation of the current Base Monthly Capitation cycle will be included in the subsequent month’s Base Monthly Capitation payment.

Likewise, negative adjustments processed by Horizon BCBSNJ prior to the generation of the current Base Monthly Capitation will be an offset against other adjustments or against your Base Monthly Capitation amount in the current month’s Base Monthly Capitation payment. Those negative adjustments processed after the generation of the current Base Monthly Capitation will be applied to the subsequent month’s Base Monthly Capitation payments.

All adjustments are reflected on the monthly Capitation Report within the guidelines mentioned on the previous page and will be indicated as an ADD or DELETE next to the member’s name.

All adjustments, offsets or payments are made by the end of the 12-month period.

Under no circumstances will adjustments be made beyond 12 months for members who join or leave your panel. If eligible claims incurred on a date of service more than 12 months prior to Horizon BCBSNJ’s receipt of request for addition of that individual to a panel, the claims will be reimbursed

on a fee-for-service basis and not through an adjustment or reconciliation to a capitation payment, unless we have agreed otherwise with the employer group.

Services reimbursed to you or your group which should have been considered under capitation may be netted against future claim payments.

Lastly, Horizon BCBSNJ will not make adjustments to panels beyond the 12 months when notification for a physician group affiliation change is not sent timely to Horizon BCBSNJ. However, timely filed claims for eligible billable services, as listed, will be considered for fee-for-service reimbursement.

Under no circumstances will Horizon BCBSNJ reimburse claims incurred beyond 12 months from the date of the initial request.

CAPITATED SERVICES

Services in the following categories are included in capitation:

  • Evaluation and Management Services1
  • Physicals and Routine Office Visits
  • Consultations with Your Own Patient
  • Routine Hospital Care, excluding ICU
  • Electrocardiogram (EKG) and/or Rhythm Strip
  • Urinalysis, Routine only
  • Hemoglobin and Hematocrit
  • Spirometry
  • Tympanograms/Hearing/Speech/Vision Screens2

¹Special services are billable under Billable Services for Capitated PCPs

²Additional testing should be referred to the appropriate specialist.

BILLABLE SERVICES FOR CAPITATED PCPS

In addition to capitation, PCPs may bill for some special services. You will receive fee-for-service reimbursement for these services.

Primary Care Physicians (PCPs) may access a current list of billable services online. Our Billable Services for Capitated PCPs identifies the special services and immunizations that capitated PCPs may bill for and receive fee-for-service reimbursement, in addition to their capitation payment from HorizonBlue.com/pcplists.

If you have questions, contact your Network Specialist.

BILLABLE SERVICES FOR FEE-FOR-SERVICE PCPS

PCPs in solo or group practices who receive fee-for-service reimbursement for services provided to members enrolled in Horizon BCBSNJ managed care plans, may bill for and receive

fee-for-service reimbursement for all current procedure codes appropriate for their specialty.

All reimbursements for services provided to Horizon BCBSNJ members are subject to the limits imposed by the physician’s contract and the member’s benefits.

This information may be subject to change. Physicians will be notified of any changes.

FEE INFORMATION AVAILABLE ONLINE

You can access our Fee Schedule information online. Our managed care and PPO fee schedules are based primarily on Resource-Based Relative Value Scale (RBRVS) methodology and the Centers for Medicare & Medicaid Services (CMS) fee schedule.

Please note that our Fee Schedule information is subject to change upon notice. Fee information is not a guarantee of the reimbursement amount for a particular service. Claim reimbursement is subject to member eligibility, the applicable fee schedule in effect when Horizon BCBSNJ processes the claim, and all member and group benefit limitations, conditions and exclusions. Payments are subject to contract limitations and can only be determined upon receipt of a claim.

To access our fee information – including Injectable Medication Fee Schedule information – registered NaviNet users should:

  • Log on to NaviNet.net and select Horizon BCBSNJ from the My Health Plansmenu.
  • Mouse over Claim Management and select
  • Fee Schedule Inquiry.
  • On the Fee Schedule Inquiry page, select your Billing (Tax) ID number, County and Specialty.
  • Then, based on the information you’re seeking, you may either:

Injectable Medication Fee Schedule Information Updates

Horizon BCBSNJ updates our Injectable Medication Fee Schedule information on a quarterly basis (on or around the first day of February, May, August and November).

Revised information will be available online following the implementation of each quarterly update.

ANESTHESIA REIMBURSEMENT GUIDELINES

Below are some reimbursement guidelines for eligible anesthesia services for participating and nonparticipating physicians. The overall anesthesia service(s) performed during a given procedure will not exceed 100 percent of the contracted benefit. Eligible anesthesia services provided by a physician or a Certified Registered Nurse Anesthetist (CRNA) will be reimbursed as follows:

 

Modifier Description of service Services are:
AA Anesthesia services performed personally by the anesthesiologist. Reimbursed at 100 percent of the applicable Horizon BCBSNJ fee schedule.
AD Medical supervision by a physician for more than four concurrent anesthesia procedures. Reimbursed at 50 percent of the applicable Horizon BCBSNJ fee schedule.
QK Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals. Reimbursed at 50 percent of the applicable Horizon BCBSNJ fee schedule.
QY Medical direction of one CRNA by an anesthesiologist. Reimbursed at 50 percent of the applicable Horizon BCBSNJ fee schedule.
QX CRNA service with medical direction by a physician. Reimbursed at 50 percent of the applicable Horizon BCBSNJ fee schedule.
QZ CRNA service without medical direction by a physician. Not eligible and will be denied. Some Medicare products are excluded from the QZ denial per CMS guidelines.

Include the above-listed modifiers in the first position to ensure correct reimbursement.

ANESTHESIA REIMBURSEMENT CALCULATION

Horizon BCBSNJ reimburses for anesthesia services based on the following formula:

Base Value Units + Time Units x Conversion Factor = Reimbursement

TIME AND ANESTHESIA CLAIMS

When submitting anesthesia claims electronically, please be sure to include the information in the table below.

Loop Element Description
2300 NTE02 ADD
2300 NTE03 Anesthesia start to stop time in military time separated by a dash with no spaces (e.g., HH:MM - HH:MM)
2400 SV104 Total number of minutes that anesthesia was provided
2400 SV103 MJ qualifier

When submitting anesthesia claims on a CMS 1500 form, be sure to include the anesthesia start-to-stop time in military time separated by a dash with no spaces (e.g., HH:MM - HH:MM) in the supplemental information section in Box 24 (shaded upper row).

TIME AND ANESTHESIA CLAIMS (continued)

Our claims processing system calculates time units based on the total time that anesthesia was provided. Time units are calculated in 15-minute intervals. Our system will round additional time greater than eight minutes up to the next unit. Our system will round down additional time seven and fewer minutes.

For example:

  • 30 minutes of anesthesia is equal to two units (30=15+15)
  • 38 minutes of anesthesia is rounded up to three units (38=15+15+8)
  • 37 minutes of anesthesia is rounded down to two units (37=15+15+7)

ANESTHESIA FOR VAGINAL AND CESAREAN SECTION DELIVERIES

Anesthesia for deliveries may follow unique rules, based on the type of delivery performed.

  • Anesthesia for normal vaginal delivery is reimbursed based on a flat case rate (rates vary by geographic region).
  • Cesarean section delivery is reimbursed based on a time calculation.
  • A normal vaginal delivery that becomes a cesarean section delivery is reimbursed at a special rate that combines both a case rate plus a time calculation.

Horizon BCBSNJ reserves the right to change our obstetric reimbursement methodology.

CERTIFIED REGISTERED NURSE ANESTHETIST (CRNA)

Anesthesia services provided by a CRNA are eligible for reimbursement provided that the CRNA is employed by, or under the supervision of, an anesthesiologist.

When billing Horizon BCBSNJ for services rendered, submit your full charges for the applicable CPT-4 codes on both the CRNA claim line and the anesthesiologist claim line. Do not split the total charge between the CRNA and the anesthesiologist. Our systems will adjudicate the claim lines to calculate 50 percent of our allowance for both the CRNA and the supervising anesthesiologist for the service provided.

Please also append the claim lines with the appropriate modifier as indicated in the table below:

To view our anesthesia guidelines online, log in to NaviNet.netand:

  • Mouse over References and Resources and click Provider Reference Materials.
  • Click Reimbursement and Billing.
  • Click Reimbursement and Billing Guidelines for Anesthesia Claims.