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Prepayment Coding Audit Review

  • Which products are included or not included in the audit?

    Only fully insured plans/programs are included in the audit. The following products are not included:

    • The New Jersey State Health Benefits Program (SHBP) and the School Employees’ Health Benefits Program (SEHBP)
    • The Federal Employee Program® (FEP®)
    • BlueCard
    • Medigap claims and secondary claims
  • Which claims are included in the audit?

    The following criteria are subject to the audit:

    • All high-level Evaluation and Management (E&M) services billed with or without a modifier
    • Prolonged services and time-based E&M codes
    • Modifiers associated with E&M services including, but not limited to, modifier 25
    • Modifier 59 (XE, XS, XP and XU)
    • Observation codes
    • Telephone E&M services
  • Can I submit the claims and medical records electronically?

    Yes. You must continue to submit claims electronically or to the appropriate mailing address you currently send to.

    Only copies of the medical records should be mailed to:

    Horizon BCBSNJ
    PO Box 140
    Newark, NJ 07101-0140

    Or send via fax to: 1-732-938-1407

    You should mail or fax the supporting medical records within a week of submitting the claim electronically. If the documentation is not provided, a denial for no medical records will be generated two weeks after the claim is received.

  • How should I send in additional information/corrected claims/appeals?

    You should mail corrected claims/appeals and/or additional information clearly marked together with the Horizon BCBSNJ Inquiry and Adjustment Form #579, found online at, to:

    Horizon BCBSNJ
    PO Box 140
    Newark, NJ 07101-0140

    Or send via fax to: 1-732-938-1407

    You may attach an Explanation of Payment (EOP) form, which can be found on NaviNet®, with the claim noted on a cover sheet.

  • What information must be included in the medical record?

    This information must be included in the medical record:

    • Member’s ID number
    • Patient name
    • Date of service
    • Physician group name
    • Tax Identification Number (TIN)

    Please ensure that each service is electronically/manually signed and dated. Unsigned medical records will not be considered finalized and therefore will not be considered in a pre-payment audit review. Notes should ALWAYS be accompanied by a transcription if handwriting is illegible. This allows a Certified Professional Coder to review the services more accurately. Medical records amended outside of the acceptable industry standard will not be considered valid as their authenticity cannot be validated (e.g., Service Date 4/2/20, Amendment Date 11/19/20)

  • How can I identify claim denials from the audit?

    Claims that are part of this audit will have the following claim denials:

    X945: Illegible record; missing information; code undocumented in medical record
    X946: No medical record provided = unsubstantiated services
    X947: Inappropriate use of override modifier
    X948: Medical record does not support CPT code billed

    Other denial codes not listed above are not associated with the audit and should be resolved by calling Provider Services at 1-800-624-1110, weekdays, from 8 a.m. to 5 p.m., Eastern Time (ET).

  • What if a provider has already sent in the medical record, but receives an X946 decline for medical records?

    The audit may be in process. If the provider has sent the medical record to the address above in A.4., they may call Provider Services at 1-800-624-1110 two weeks after the medical record was sent to verify if it was received. An adjustment to the X946 decline is initiated based on the review of the received medical record.

  • Can a provider submit more than one claim for services performed for a patient on the same day (split claims)?

    No. Providers should submit one claim for all services performed for the patient on the same day.

  • What is reviewed when a claim is identified for audit?

    The whole claim is reviewed during this audit. Documentation for every line of the claim needs to be included. The provider is required to send in all documentation for all services billed on that claim for that date of service.

  • How long is a provider in the prepayment audit?

    A provider is in prepayment audit until less than 25 percent of the claims submitted contain errors for three consecutive months. This is not a 90-day audit.

  • How is the error rate calculated?

    The error rate is based on the number of claims and accompanying medical records submitted in a month that is reviewed by Horizon. This includes claims submitted with medical records which pass the audit as well as those which receive X945, X947 and X948 denials.

    The denial code X946 is not included in the error rate calculation since an audit has not yet been completed.

  • What claims are not included in the error rate?

    Claims that are not included in the error rate are:

    • X946 declines for no medical records
    • Claims for excluded plans/programs including SHBP, SEHBP, FEP and BlueCard
    • Medigap
    • Secondary claims
  • Does this review include medical necessity?

    It is not a medical necessity audit. This prepayment audit is only a coding audit. Providers must submit medical documentation that supports each CPT®/HCPCS code billed.

  • What if I disagree with the final audit determination?

    You may exercise your right to a Health Claims Authorization, Processing and Payment Act (HCAPPA) appeal.