Claims Submissions and Reimbursement
Claims Submissions and Reimbursement
Paper Claims Submissions
We require that all paper claim submissions are printed on an original, government-approved UB-04 claim form. Claim submissions that we receive on photocopies of the UB-04 claim form or on another carrier’s claim submission forms will not be processed.
Always fill out UB-04 forms completely and accurately. Pay close attention to required fields to minimize processing delays. With the exception of the dedicated service teams listed below, one central area routes your claims to the appropriate processing location. Mail your claims to the appropriate address.
- BlueCard® claims:
Horizon BCBSNJ BlueCard Claims
PO Box 1301
Neptune, NJ 07754-1301
- Federal Employee Plan (FEP) claims (Plan ID numbers begin with a single R):
PO Box 656
Newark, NJ 07101-0656
- For all other claims:
PO Box 25
Newark, NJ 07101-0025
Behavioral Health Care Claims
When providing behavioral health care, check the patient’s ID card for information on the behavioral health and substance use disorder care administrator.
Substance Use Disorder Claims and Information
Providers that treat or diagnose patients for Substance Use Disorders or refer patients for Substance Use Disorder treatment may be subject to the Confidentiality of Substance Use Disorder Patient Records Rule (42 C.F.R. Part 2) as a Part 2 Program. These providers must comply with the Consent and Notice provisions below with respect to any claim or other communication it submits through the Horizon Behavioral Health program that contains Patient Identifying Information (PII). You must comply with these requirements in order to be reimbursed for claims.
For purposes of this section, the capitalized terms “Part 2 Program,” “Patient Identifying Information,” and “Substance Use Disorder” shall have the meanings provided in 42 C.F.R. ¨ 2.11. Consent. Providers are prohibited by law from disclosing PII without obtaining the patient’s consent. Your patient must consent to releasing their PII before you submit any claim (or other record) that contains PII.
Notice. When PII is included with a claim or other record submission, you must include a specific statement that the information is subject to Substance Use Disorder confidentiality restrictions (the “Part 2 Disclaimer”). Horizon Behavioral Health program may deny payment of any claim (and refuse to process other information) if you do not comply with these Consent and Notice provisions.
Audits and Evaluations. Upon request, you may be required to provide PII to Horizon Behavioral Health in order for Horizon BCBSNJ to perform evaluations and audits, including, utilization review, quality assessment and improvement activities (such as collection of HEDIS data), and reviewing qualifications of health care professionals.
HELPFUL HINTS FOR PAPER CLAIM 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 manually processing paper claims. However, the efficiency of processing paper claims through OCR depends on your legible, compliant and complete claim submission.
To maximize the benefits of OCR, we recommend the following when submitting your UB-04 form:
- Use an original red-lined form instead of a black and white photocopy.
- Use dark ink (black ink is recommended).
- All characters on the UB-04 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 claim processing delays. Use a laser printer for best results.
- Center characters in each box on the UB-04 form.
- Use a standard Sans Serif font and select a font size that fits comfortably within the boxes.
- Do not apply extraneous stamps or verbiage to the forms.
- Do not circle or highlight information, as it may cover other data and cause it to become illegible.
- For information omitted from computer prepared forms, use typewritten instead of handwritten data.
- When submitting a claim for secondary carrier payment, please ensure the primary carrier’s corresponding Explanation of Benefits (EOB) is included with the UB-04 claim form (patient name, procedures and dates of service must coincide).
- Do not staple any submitted documents.
HELPFUL HINTS FOR ALL CLAIM SUBMISSIONS
- Ask for the patient’s current ID card during the inpatient or outpatient admission process. Always photocopy both sides of the ID card for your files.
- Use the subscriber’s and/or patient’s full name. Avoid nicknames or initials.
- Date(s) of birth for the subscriber and the patient, if different, are important.
- If the patient has any other insurance coverage, be sure that we have complete information when you submit your claim. If another carrier is primary and incomplete information is received, it will result in a delay or denial of payment.
- Complete the patient information on your claim as it relates to the person being treated. The patient may or may not be the subscriber.
- Claims must include the entire ID number. Always use the prefixes associated with the ID number.
- Complete the group number field when that information appears on the ID card.
- Clearly itemize services provided, your charges and date(s) of service.
- 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 the onset of illness.
- Provide the referral or authorization number in Box 63 on the UB-04 form, when applicable.
- Always use the most current codes as identified in the UB-04 Data Elements Specifications Manual as developed by the National Uniform Committee of the American Hospital Association.
- Ensure paper and electronic UB-04 submissions have the correct revenue codes and charges for services rendered.
- All characters on paper claims must be intact and printed clearly. Missing tops or bottoms of letters or numbers will result in processing delays.
- Be sure to supply the name, address and National Provider Identifier (NPI) of your hospital.
- Prior to submitting the claim for reimbursement, verify that all listed services were provided.
- Be sure to correct errors in your claim submission reports in a timely manner prior to resubmission.
- To avoid adjustments for late charges, ensure that submitted bills reflect all services rendered to the patient during a given hospital stay.
- When treating patients with out-of-state Blue Cross and/or Blue Shield Plan coverage, submit your claim either electronically or as a printed copy to Horizon BCBSNJ. We will forward claims information to the other Plan on your behalf.
- With every Coordination of Benefits (COB) claim, send a completed UB-04. When Horizon BCBSNJ is secondary, also provide information on how the primary carrier processed the claim.
- 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.
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.
- Facility claims
- Eligibility status
- Claim status
If you need help with a Remittance Advice/835 investigation, please also have the following information available:
- Provider NPI or Medicare Provider ID
- Check date
- Check amount
- Check number
You may contact the EDI Service Desk at 1-888-334-9242, via email at HorizonEDI@HorizonBlue.com or by fax at 1-973-274-4353.
ELECTRONIC FUNDS TRANSFER (EFT)
Horizon BCBSNJ requires all network hospitals to register for Electronic Funds Transfer (EFT). 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. Enrolling in EFT requires that you receive online Explanations of Payment (EOPs) in place of paper statements.
We will perform two test deposits into the bank account you indicate. You must confirm test deposits within 30 days to complete your EFT registration. Once you confirm that the tests were successful, it takes only two to four business days before EFTs begin.
As of 2020, 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. If you have questions about EFT or EFT registration, call our EDI Service Desk at 1-888-777-5075. You can also email questions to Provider_Portal@HorizonBlue.com.
If you are not registered with NaviNet, visit NaviNet.net and click Sign up. If you have questions about NaviNet registration, call NaviNet at 1-888-482-8057.
Rounding of Claim Bill Lines
Based on our claim processing system configuration, the allowances calculated for claim lines submitted by hospitals that are reimbursed by certain payment methodologies (e.g., APC, DRG), may be rounded either up or down by a de minimis amount (a few pennies). 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 and payments generated.
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.
REIMBURSEMENT REQUESTS FOR UNDERAND OVERPAYMENT
The New Jersey state law known as 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).
Health insurers may only seek reimbursement for overpayment of a claim from a facility or other 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, a facility or other health care professional with a “pattern” of inappropriate billing submits the claim, or the claim is subject to COB.
Recapture of overpayments by a health insurer may be offset against a facility’s future claims if a 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 facility 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.
Note: Horizon BCBSNJ will not recapture an overpayment made on claims processed for members enrolled in insured groups and individual plans covered under HCAPPA until the expiration of the 45-day notice period (except with a facility’s prior written consent, or if a facility 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.
The 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®).
In the event that Horizon BCBSNJ determines that an overpayment is the result of fraud and reports 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.
Under HCAPPA, no facility 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 facility may seek more than one reimbursement for underpayment of a particular claim.
CHECKING CLAIMS STATUS
Interactive Voice Response (IVR) System
You may call our Interactive Voice Response (IVR) system at 1-888-666-2535 to obtain information on enrollment, benefits and claims for most patients. For patients with the prefixes listed below, call the dedicated teams listed below:
Prefixes Phone Numbers
FEP (R) 1-800-624-5078
DEH, DMM, DTP, NGM (General Motors/ Delphi Auto) 1-800-456-9336
Registered users of NaviNet can check a patient’s enrollment and claim status information at NaviNet.net.
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.
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
CLAIM ADJUSTMENTS REQUEST FORM
You can also request claim adjustments, claim status or a recapture of an overpayment using our Inquiry Request and Adjustment Form (579). The following tips help ensure that our investigation and adjustment of your claim inquiries are not slowed by requests for additional information:
- Be as specific as possible when describing what it is that you are asking us to do. For example, if you send in a corrected claim form, specify the changes made relative to the original claim submission (revenue codes, late charges added, etc.).
- Attach all required supporting documentation (e.g., UB-04 claim form, a Medicare or other carrier Explanation of Benefits [EOB], etc.).
Access our Inquiry Request and Adjustment Form (579) at HorizonBlue.com/form579. You can complete the required fields online and then print the form for submission. This method allows us to quickly and accurately process your forms. Or, if you prefer, you can print a blank form and type or handwrite your content.
Mail the completed form along with all supporting documentation (e.g., the corrected CMS 1500 or UB-04 claim form, a Medicare or other carrier Explanation of Benefits [EOB], etc.) to:
Hospital and institutional physician inquiries:
PO Box 1770
Newark, NJ 07101-1770
Federal Employee Program (FEP) inquiries:
PO Box 656
Newark, NJ 07101-0656
PO Box 1301
Neptune, NJ 07754-1301
If our claim investigation results in a change to the claim reimbursement amount, Horizon BCBSNJ will send an Explanation of Payment (EOP) to the billing address we have on file. If the claim adjustment does not result in a change in the claim payment amount, we will respond by letter to the name and address provided to us on the 579 form.
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
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.
Facility payment vouchers are documents detailing payment information about your processed claims. This section of the manual includes an example of each statement along with brief descriptions for your reference.
FACILITY PAYMENT VOUCHER
- Patient’s Name – Your patient’s name.
- Claim Number – Horizon BCBSNJ’s internal control number.
- From-Thru Date – First date of service through last date of service.
- Qty – Number of units.
- Patient Control # – Your internal control number; only appears if supplied when submitting your claim.
- Rev – Procedures performed as indicated by revenue code.
- Prov Charges – Your total charges.
- Coverage – Patient’s type of coverage (e.g., Horizon HMO, Horizon POS, NJ DIRECT).
- Other Ins Pd – Any reimbursement already made by another carrier.
- Not Covered – Amount of your charges ineligible under the patient’s contract.
- Amt Allowed – Amount of your charges eligible under the patient’s contract.
- Customer’s Name – Subscriber’s name.
- Customer’s ID # – The customer’s ID number, which appears on his/her ID card.
- Deductible – Amount of eligible charges applied to the patient’s deductible.
- Coins/Copay – Represents coinsurance, copayment or managed care penalty amounts.
- Ps – Payment status. See the list in the upper right-hand corner of the voucher for the payment status legend.
- Net Payment – Amount of eligible charges paid.
- Message Codes – Alpha numeric message code; defined on the second to last page of your summary.
UNIVERSAL PAYMENT SYSTEM (UPS) VOUCHER
A – Payment Summary This section summarizes the total charges and payments for the submitted claims. In this section, you will find special announcements of general interest.
Gross claim amount – Total charges for the claims processed on this voucher.
Late interest – Amount paid if the claim was not finalized in a timely manner.
A/Rs applied – Total dollars taken from this voucher to satisfy outstanding account receivables.
Check amount – Total dollars paid on this voucher.
B – Check or ACH Voucher
If you receive a paper check, it will be attached here. If you receive an automatic clearing house (ACH) deposit, the receipt will be attached here.
C – Outpatient Section
This section provides claim details for outpatient claims. They are grouped by product type. In this section, you will find the patient’s account/control number, dates of service, billed and allowed amounts and explanatory codes, such as Remark and Reason Codes, which describe how the claim was processed. Your patient’s liability is listed in the column labeled Customer Liability.
Outpatient totals – Total number of claims and total amount of dollars paid for the outpatient claims listed on this voucher.
D – Remark Codes
This is a list of the claim level/service line level codes and definitions explaining how the claims were processed.
E – Inquiry Address
Mail your inquiries to the address listed on the voucher.
F – Inpatient Section
This section provides claim details for inpatient claims. They are sorted by product type. In this section, you will find the patient’s account/control number, dates of service, billed and allowed amounts and explanatory codes, such as Remark and Reason Codes, which describe how the claim was processed. Your patient’s liability is listed in the column labeled Customer Liability.
Inpatient totals – Total number of claims and total amount of dollars paid for the inpatient claims listed on this voucher.
G – Account Receivable Summary
This section summarizes information on monies due to Horizon BCBSNJ. Listed are details on outstanding Account Receivables, liens, etc., including when they were created and what amounts have been taken to satisfy them as of the current voucher date. Entries in this section will appear as long as there are outstanding balances due to Horizon BCBSNJ. The field marked “SS-Claim”, refers to the claims Source System, and is for Horizon BCBSNJ’s internal reference.