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Inquiries, Complaints and Appeals

Claim Appeals Process

Horizon BCBSNJ maintains an internal claims review procedure that is intended to provide you with a prompt, fair and full investigation and resolution of your inquiries and complaints regarding the payment of claims.  We encourage all physicians, hospitals and other health care professionals to use our automated telephone features or to speak with our Health Care Professional Representatives to resolve your claim inquiries and complaints.

Our physicians and other healthcare professionals may call 1-800-624-1110. Our hospitals and facilities may call
1-888-666-2535. Our service staff is often able to immediately resolve such questions at the point of contact. Please continue to contact the appropriate service teams to have inquiries and complaints addressed prior to pursuing a Claim Appeal.

There are now enhanced procedures available to physicians, hospitals and other health care professionals that wish to dispute formally matters relating to the payment of claims or are dissatisfied with a Horizon BCBSNJ Claim Payment Determination.

Physicians, hospitals and other health care professionals may file a claim appeal as described herein. The process includes a secondary, binding external review mechanism administered through the NJ Program for Independent Claims Payment Arbitration.  As described below, this process is available for claims arising from services rendered on or after July 11, 2006 that physicians, hospitals and other health care professionals continue to dispute after pursuing their appeal through Horizon Blue Cross Blue Shield of New Jersey's internal appeals processes.

Written Claim Appeals*
If your complaint involves the payment of claims or a specific Claim Payment Determination that does not relate to your treatment of an ASO, Medicare or BlueCard® member or covered person (or other member or covered person to whom the Claim Appeal process does not apply) and you are dissatisfied with the outcome resulting from the complaint process, you have the right to pursue a written Claim Appeal as described in the next section.

What is a Claim Appeal?*
A Claim Appeal is a written request made on the New Jersey Department of Banking and Insurance (DOBI) prescribed application form by a physician, hospital or other health care professional asking for a formal review by Horizon BCBSNJ of a dispute relating to the payment of claims or capitation. This includes, but is not limited to, a request for a formal review of a Horizon BCBSNJ Claim Payment Determination as described below.

Note: Utilization Management matters are not included in the Claim Appeals process. For information on Utilization Management Appeals, click HERE.

What is a Claim Payment Determination?
A Claim Payment Determination is a decision on a submitted claim or a claims-related inquiry or complaint. Claim Payment Determinations may also involve recurring payments, such as a base monthly capitation payment, made to a participating physician pursuant to the terms of the physician's contract.

What about utilization management matters?
A claims dispute or decision that is based on a utilization management determination, where the services in question are reviewed for medical necessity (or whether the services are experimental or investigational, or are dental services as opposed to medical services) in order to determine coverage under the benefits plan, may not be appealed under the Claim Appeal process. Adverse utilization management determinations may be appealed by a physician, hospital or other health care professional, with the consent of and on behalf of a member/covered person, under Horizon BCBSNJ's Member Medical Appeals process.

To whom does the Claim Appeals process apply?
This Claim Appeals process is available to all physicians, hospitals or other health care professionals who wish to appeal disputes relating to the payment of claims for services rendered to members/covered persons in Horizon BCBSNJ's and its subsidiaries and affiliates following insured lines of business, issued in the State of New Jersey:

  • Horizon HMO
  • Horizon POS
  • Horizon Direct Access
  • Horizon PPO/Indemnity
  • Horizon MyWay

*The written Claim Appeal process is consistent with the requirements currently set forth within the Health Claims Authorization, Processing and Payment Act. This process is subject to change as a result of any subsequent revision of that law, or by regulation issued by the New Jersey Department of Banking and Insurance.

This Appeal Process is not available for claims related disputes involving the delivery of services to individuals covered under:

  • Horizon NJ Health (Claim related disputes or appeals for Horizon NJ Health members may be submitted to Horizon NJ Health in accordance with that entity's policy on Claim Appeals)
  • Horizon Casualty Services
  • Any Medicare products
  • Administrative Services Only (ASO) and self-insured accounts, including the State Health Benefits Plan (SHBP), and the Federal Employee Health Benefits Program (FEHBP)
  • Other Blue Cross and/or Blue Shield plans utilizing the services of participating providers through the BlueCard program
  • Any other plans not within the scope of the this Claim Appeal process**

In order to be eligible for appeal through state's Program for Independent Claims Payment Arbitration, Claims Appeals must be submitted in writing on the NJ State DOBI prescribed application form.  

Note: Claims for services rendered prior to July 11, 2006 are not eligible for review through this process.

The form must be submitted with all information requested on the form and must be received by Horizon BCBSNJ within 90 days of the later of:

a) The date Horizon BCBSNJ's voucher was issued describing the Claim Payment Determination;

b) The date of Horizon BCBSNJ's electronic claims payment advice or

c) The date the physician, hospital or other health care professional can reasonably demonstrate being notified of the specific dispute being appealed.

Horizon BCBSNJ may require some or all of the following information in connection with any inquiry, complaint or Claim Appeal:

  • Name and address of the physician, hospital or other health care professional and the group practice name, if applicable
  • Taxpayer Identification Number
  • The member/covered person's name and ID number involved in the claim
  • Date(s) of service, the service(s) rendered and charges billed for the specific claim in question
  • A clear description regarding the claim in question
  • A copy of any and all voucher(s) relating to the claim appealed
  • The specific basis or rationale for the Claim Appeal
  • The specific remedy or relief sought and if the amount due on the claim is in question, the specific amount believed to be due and the basis, rationale and supporting documentation for such view
  • Other documentation that supports the rationale for the Claim Appeal, if necessary. Examples of documents that may be helpful include claims records, prior correspondence, payment vouchers, printouts of electronic claims systems transactions and any other documentation to adequately support the rationale for the Claim Appeal

Click  HERE to obtain a copy of the Health Care Provider Application to Appeal a Claims Determination for use in filing Horizon BCBSNJ Claims Appeals.  Copies of the generic state form are also available on the state's website. 

** Members/covered persons in certain plans are not within the scope of the Health Claims Authorization, Processing and Payment Act, and the Claim Appeal process does not apply to claims for services rendered to such members/covered persons. If your Claim Appeal is not within the scope of the Claim Appeal process, you will be so informed. Some of such claims may be covered by a different appeal process.

If the Claim Appeal does not involve a Claims Payment Determination (for example, a capitation payment) , you should supply a detailed description of the subject matter of the appeal, along with copies of all supporting documentation relevant to the Claim Appeal, including all applicable items listed above.

Click here for a list of the addresses for submission of appeals.

Horizon BCBSNJ
Appeals Unit - Physicians and other Healthcare Professionals
P.O. Box 10129
Three Penn Plaza East
Newark, NJ 07101-2200

Horizon BCBSNJ
Facility/Hospital Appeals Unit
P.O. Box 1770
Three Penn Plaza East
Newark
, NJ 07101-2200

To file a mental health related Claim Appeal, this information must be sent to:

Magellan Behavioral Health
Participating Provider Appeals Unit
199 Pomeroy Avenue, 3rd Floor
Parsippany, NJ 07054

Any written submission made by a physician, hospital or other health care professional intended to be a Claim Appeal that is not submitted on the NJ State DOBI prescribed application form or does not conform to the previous requirements will not be considered a Claim Appeal and will be handled as a written claims related inquiry.   In such instances, you will be notified and receive a written response to your correspondence.

Third Party Representation of Participating Physicians and Health Care Professionals

Physicians, hospitals and other health care professionals may wish to use the services of a third party organization or service to file a Claim Appeal on their behalf.   If so, Horizon BCBSNJ has specific requirements that must be met to safeguard the patient health information entrusted to us by our members/covered persons. Please contact the Participating Provider Appeals Unit for more details on these requirements.

Horizon BCBSNJ's Decision on your Claim Appeal

All Claim Appeals will be reviewed by a Horizon BCBSNJ employee who is not responsible on a day-to-day basis for the payment of claims. The Claim Appeal Reviewer will communicate the results of the review, in writing, to the physician, hospital and other health care professional within 30 calendar days of the date of Horizon BCBSNJ's receipt of the Claim Appeal application form.

The written decision will include the following information:

  • The names, titles and qualifying credentials of the person participating in the internal review
  • A statement of the physician's, hospital's and other health care professional's basis for the Claim Appeal
  • The decision of the claim appeal reviewer along with a detailed explanation of the contractual and/or medical basis for the decision
  • A description of the evidence or documentation which supports the decision

If an unfavorable determination is made for the physician, hospital or other health care professional, an external review of the decision via the state's external arbitration process may be applicable.

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External Appeals Process
The New Jersey Department of Banking and Insurance (DOBI) awarded the independent arbitration organization contract to MAXIMUMS, Inc.
As of July 2007, parties with claims eligible for arbitration may complete an application and submit it, together with required review and arbitration fees, directly to MAXIMUS, Inc.
External appeals are not submitted through Horizon BCBSNJ.
Visit www.njpicpa.maximus.com for additional information and applications.
Physicians, hospitals and other health care professionals must initiate a request for an external appeal of their claim within 90 calendar days of their receipt of Horizon BCBSNJ's internal appeal decision.
However, to be eligible for this second level arbitration appeals process, disputes must be in the amount of $1,000 or more.  Physicians, hospitals and other health care professionals may aggregate claims (by carrier and covered person or by carrier and CPT code) to reach the $1,000 minimum.
The independent arbitration’s decision must be issued on or before 30 calendar days following receipt of the required documentation.
The decision of the independent arbitrator is binding.
If payment is to be made, it must be issued within 10 business days of the arbitrator’s decision.

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Love Billing Dispute Resolution Process

Introduction:

Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ) has instituted an external billing dispute resolution process which is available, as of November 21, 2008, to participating and non-participating physicians and physician groups in New Jersey. 

The Love Class Action Settlement (LCAS) Billing Dispute Resolution Process is intended to resolve billing disputes related to:

  • Application of Horizon BCBSNJ’s coding and payment rules and methodologies for fee-for-service claims.  For example, billing disputes involving bundling, downcoding, application of CPT® modifiers, reassignment of codes etc.; and
  • Application of appropriate payment when two or more CPT® codes are billed together and whether a payment enhancing modifier is appropriate.

The LCAS Billing Dispute Resolution Process is not available  for claims related billing disputes that involve the following:

a.     Claim Disputes for delivery of services to individuals covered under:

  • Horizon NJ Health (NJ Medicaid), Horizon Casualty Services (Workers Compensation), Some Medicare Claims, Federal Employee Program (FEP);  
  • Other Blue Cross and/or Blue Shield plans utilizing the services of participating providers through the BlueCard program.

b.     Claim Disputes related to:

  • Payment policies related to claims reimbursement percentile, reasonable and customary charges or fee schedules;
  • Claim disputes or decisions that are based on a Utilization Management determination, where the services in question are reviewed for medical necessity or whether the services are experimental or investigational in nature;
  • Dental Services.

c.     Claim Disputes that do not meet the following LCAS Billing Dispute Resolution Process eligibility criteria –

  • The physician or the physician group must have exhausted Horizon BCBSNJ’s internal billing appeal process[1];
  • The physician or the physician group must submit the external appeal directly to Horizon BCBSNJ’s contracted Billing Dispute Review Organization within 90 calendar days from the date of completion of the Horizon BCBSNJ’s internal billing appeal process;
  • The physician or the physician group has not utilized other binding or non-binding external appeal process instituted by the State or Federal Government such as NJ DOBI ‘HCAPPA’ PICPA process;
  • The claims being disputed must have a date of service on or after May 24, 2008;
  • The physician or the physician group must submit the requisite filing fee, based on the disputed amount, to the external Billing Dispute Review Organization;
  • The amount in dispute for a single claim for covered services, or multiple claims involving similar issues submitted within 12 months from the date of the first appeal, must be greater than $500.

Note: A physician or physician group may submit  claim disputes to the Billing Dispute Review Organization with a disputed amount less than the required $500 if the physician or physician group notifies the Billing Dispute Review Organization of their intent to submit additional claim disputes involving similar disputes (i.e., claim disputes related to same CPT/HCPC code and, where applicable, same ICD-9 diagnosis codes) within one year from the date of the submission of the initial claim dispute(s).

In such instances, the Billing Dispute Review Organization will defer consideration of the original claim dispute(s) until such additional disputes are submitted. If the physician or the physician group fails to submitted additional claims to reach the $500 threshold, the Billing Dispute Review Organization will dismiss all related appeals with prejudice.

Billing Dispute Filing Process:

The physician or the physician group intending to submit claim disputes to the Billing Dispute Review Organization must submit the Billing Dispute Resolution Form; a copy of Horizon BCBSNJ internal appeal resolution final letter; the prescribed filing fee and additional support documents, if any. Please submit these materials by mail, fax or through the Billing Dispute Review Organization,   MES Solutions’, Secure Web Portal, as follows:

MES Solutions Attn: BDRP Dept.

100 Morse Street

Norwood, MA 02062

Fax #: 1-888-868-2087

  Click here to access the MES Solutions website for the Billing Dispute Resolution Form necessary to file a LCAS Billing Dispute Resolution Process appeal and additional instructions.

MES Solutions may request additional documentation from the appealing physician or physician group. Any such additional documentation must be submitted back to MES Solutions within 15 calendar days of the request.

Retained Claims –

A retained claim is a claim for payment where, as of November 21, 2008, (1) a claim has been filed with Horizon BCBSNJ, but not finally adjudicated by it; or (2) no claim has yet been filed with Horizon BCBSNJ, so long as the period for filing such a claim has not elapsed. A claim is considered finally adjudicated when Horizon BCBSNJ’s internal appeals process has been completed.

As a part of the Love Class Action Settlement Agreement, the physician or physician group may submit Retained Claims for dispute resolution to MES Solutions for claims with date(s) of service on or after May 24, 2008

Filing Fee Details –

To file a billing dispute appeal under the LCAS Billing Dispute Resolution Process, the physician or the physician group must submit the proper filing fee as described below:

  • If the disputed amount is less than or equal to $1000, the physician must submit a filing fee of $50 per appeal;
  • If the disputed amount is greater than $1000, the physician must submit a filing fee of $50 + 5% of the amount in dispute exceeding $1000 per appeal but in no event more than 50% of the cost of the review.

 

  [1] Horizon BCBSNJ internal billing appeal process is posted on the Provider Portal at  https://services5.horizon-bcbsnj.com/eprise/main/horizon/tsnj/tsweb/appeals.html#billingappeals.

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Member U/M or Medical Appeals Process

Please note: This process applies to Insured business only. Members of self-funded groups, to whom Horizon BCBSNJ supplies administrative services (ASO), use a different UM medical appeals process.

Medical Appeals

Members and physicians, hospitals and other health care professionals, on behalf of the member and with the member's written consent, or any other authorized representative generally have the right to pursue an appeal of any adverse utilization management decision made by Horizon BCBSNJ. An adverse utilization management decision is a decision to deny or limit an admission, service, procedure or extension of stay based on Horizon BCBSNJ's clinical and medical necessity criteria. Adverse utilization management decisions may usually be appealed up to three times. Some ASOs only allow two appeals.[1]

Any written notification of an adverse Utilization Management determination (denial) will include a brochure, which will contain the appropriate contact information to pursue an appeal.

First Level Appeals

You will be advised how to initiate a first level appeal at the time the adverse utilization management decision is made. First level appeals are reviewed by our medical administration. First level urgent and emergent appeals are reviewed within 24 hours. Non-emergent appeals are reviewed within five business days. If the denial is upheld, members and physicians, hospitals and other health care professionals, on behalf of the member and with the member's written consent, or any other authorized representative may submit a second appeal.

Second Level Appeals

If a second level appeal is received, it is submitted to the Appeals Committee, which is made up of Horizon BCBSNJ Medical Directors and staff, physicians from the community and consumer advocates. The member/covered person is given the option of attending the hearing in person, or via telephone conference. The Appeal Coordinator makes the appropriate arrangements[2]. Appeals that involve requests for urgent or emergent care may be expedited. Members/or covered persons, or physicians, hospitals and other health care professionals on behalf of and with the written consent of members/or covered persons, who participate in the hearing are notified of the Committee's decision verbally by telephone on the day of the hearing whenever possible. Written confirmation of the decision is sent to the member/covered person, and/or the physician or health care professional who pursued the appeal on their behalf, within five business days of the decision. Members/covered persons who choose not to appear are notified of the Committee's decision in writing within two business days of the decision. Second Level expedited Appeals are decided as soon as possible in accordance with the medical urgency of the case, but will not exceed 48 hours from our receipt of the first level appeal request whenever possible. Standard Second Level Medical Appeals involving requests for services, supplies or benefits which require our prior authorization or approval in advance in order to receive coverage under your plan are reviewed and decided within fifteen calendar days of our receipt. All other Second Level Medical Appeals are decided within 20 business days of our receipt.

Third Level Appeals

If the Appeals Committee upholds the second level appeal, the member or the member's physician or health care professional, acting on behalf of the member and with the member's written consent, or any other authorized representative, may request a third level appeal with the Independent Utilization Review Organization (IURO) assigned by the New Jersey Department of Banking and Insurance. The IURO will only consider appeals on denials based on medical necessity. Denials based on contract issues are not reviewed by the IURO. Instructions on how to file with the IURO are included with the denial letter from the second level appeal where applicable. Third level appeals must be filed within 60 days from the receipt of the notice of determination of the second level appeal. The IURO will review the appeal and respond to the member or physician or health care professional within 30 business days. Members of certain plans such as self-funded plans and some Medicare plans may not appeal to the IURO. The IURO decision is binding. Some employers may offer an additional level of appeal.



[1] Members/covered persons in some plans do not have the appeal rights described here. For example, Horizon Medicare Blue, Horizon Medicare Blue Plus and Horizon Medicare Value Plus members follow a different appeal policy, and member/covered persons of certain plans such as ASO accounts and self-funded accounts may not have the appeal rights described here.

[2] Second level appeals related to in-patient facility denials or level of care downgrades are reviewed by an Appeals Committee made up of Horizon Medical Directors and appeal staff nurses only. There is no right to appear in person offered for inpatient facility related appeals.

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Love Medical Necessity External Review Process

The Love Class Action Settlement (LCAS) External Medical Necessity Review Process is intended to resolve eligible Claim disputes or decisions that are based on a Utilization Management determination, where the services in question are reviewed for medical necessity or whether the services are experimental or investigational in nature.

The LCAS Medical Necessity Review Process is not available for claims related post-service medical necessity disputes that involve the following:

a.     Disputes for delivery of services to individuals covered under:

  • Horizon NJ Health (NJ Medicaid), Horizon Casualty Services (Workers Compensation), Some Medicare Claims, Federal Employee Program (FEP);  
  • Self-Insured plans where the plan has not elected to participate in the LCAS External Medical Necessity Review Process;
  • Other Blue Cross and/or Blue Shield plans utilizing the services of participating providers through the BlueCard program.

b.     Disputes related to:

  • Pre-Service, Concurrent, or Urgent and Emergent review; these appeals will be processed according to member appeals process;
  • Application of Horizon BCBSNJ’s coding and payment rules and methodologies for fee-for-service claims.  For example, billing disputes involving bundling, downcoding, application of CPT® modifiers, reassignment of codes etc.;
  • Dental Services.

c.     Disputes that do not meet the following LCAS Medical Necessity Appeal Process eligibility criteria –

  • The physician or the physician group must have exhausted Horizon BCBSNJ’s internal post-service Medical Necessity Appeal Process;
  • Member or the Physician has not submitted a pre-service medical necessity appeal pertaining to the same denied service;
  • Member has submitted a post-service medical necessity appeal pertaining to the same claim;
  • The physician or the physician group must submit the external appeal directly to Horizon BCBSNJ’s contracted Medical Necessity Review Organization within 60 calendar days from the date of completion of the Horizon BCBSNJ’s internal post-service medical necessity appeal process;
  • The physician or the physician group has not utilized other binding or non-binding external appeal process instituted by the State or Federal Government such as NJ DOBI ‘HCAPPA’ IHCAP process;
  • The claims being disputed must have a date of service on or after April 19, 2009;
  • The physician or the physician group must submit the requisite filing fee, based on the disputed amount, to the external Medical Necessity Review Organization;

 External Medical Necessity Appeal Filing Process:

The physician or the physician group intending to submit post-service medical necessity appeal to the Medical Necessity Review Organization must submit the External Medical Necessity Appeal Form; a copy of Horizon BCBSNJ internal appeal resolution final letter; the prescribed filing fee and additional support documents, if any.

Please submit these materials by mail, fax or through Secure Web Portal to:

Crossland Med.

Attn: MNRO

PO BOX 487

Syosset, NY 11791

Fax #: 1-800-356-0488

Click here  to access the Crossland’s Website for the External Medical Necessity Appeal Form necessary to file a LCAS Medical Necessity Review Process appeal and additional instructions.

Crossland Medical Review Services Inc. may request additional documentation from the appealing physician or physician group. Any such additional documentation must be submitted back to Crossland Medical Review Services Inc.  within 15 calendar days of the request.

Filing Fee Details –

To file a medical necessity appeal under the LCAS Medical Necessity Review Process, the physician or the physician group must submit the proper filing fee as described below:

  • If the disputed amount is less than or equal to $1000, the physician must submit a filing fee of $50 per appeal;
  • If the disputed amount is greater than $1000, the physician must submit a filing fee of $250.

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