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Reimbursement

Claims Submission Process

Electronic filing:

Horizon BCBSNJ strongly encourages the electronic submission of your claims and other supported HIPAA transactions. This time-saving feature decreases your paperwork and reduces payment errors, ensuring quick payment for you. The suite of electronically acceptable claims includes primary claims, secondary claims and adjustments. click HERE to learn more about how to submit a claim electronically.

Paper filing:

Although we recommend electronic filing, you may occasionally need to submit your payment requests on paper. To help expedite the process, we've implemented new technology that electronically scans, sorts and stores your paper claims. This reduces manual keying errors and improves the response time on your paper claims.

Please follow these guidelines when completing and submitting paper claims:

Claims Submissions - Professional

In order to help speed up your claim adjudication process, please be sure to submit the claim on the required CMS (formerly known as HCFA) 1500 format with current, compliant codes.

Some recent examples of noncompliant claim submissions include:

Invalid or Incomplete Diagnosis Codes

Effective October 1, 2003, CMS requires that an ICD-9 diagnosis code be submitted with the 4th or 5th digit when applicable, in order for the codes to be considered complete. Please be sure to review your ICD-9 manual for the most current codes.

Invalid Procedure Codes.

We use the most recent CPT-4 and HCPCS manuals to validate procedure codes. Please be sure to review your manuals for the most current codes.

Please note: Always fill out CMS 1500 forms completely and accurately, and disregard any group specific claim forms a patient may present. Pay close attention to required fields since that will help minimize processing delays. Claims are the most vital link between your office and Horizon BCBSNJ. Please submit them in a timely manner.

Helpful Hints are provided below for your reference. For best results, please use a redlined form instead of a black and white copy and use-typewritten data instead of handwriting. Click HERE for mailing addresses.

Mental Health Care and Substance Abuse Care Claims

When providing mental health and substance abuse care, please check the patient's ID card for information on the mental health and substance abuse care administrator. Most of our members have these services administered by Magellan Behavioral Health. Unless otherwise noted on the ID card, click HERE for the correct address to submit claims for these services.

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Claims Submissions - Institutional

The UB92 form must be used if you submit paper institutional claims. The UPIN number should always be present within the appropriate UB92 Box 51A, B and C.

Invalid or Incomplete Diagnosis codes

CMS requires that an ICD-9 diagnosis code be submitted with the 4th or 5th digit when applicable, in order for the codes to be considered complete. Please be sure to review the most recent ICD-9 manual for current codes.

CMS accepts only ICD-9 codes for Inpatient claims and HCPCS/CPT-4 codes for Outpatient claims in Boxes 80 and 81 on the UB92 1450 form.

Submit only valid CPT-4, HCPCS, Procedure and Value codes.

We use the most recent HINT/HIPAA guidelines. Please be sure to review your manuals for the most current codes Ensure you are using the appropriate codes for the date when services are rendered.

Invalid Admission Hour, Type, Source and Discharge Hour.

All inpatient claims require a valid admission hour, type, source and discharge hour.

Incomplete patient and insured's information.

Patient and Insured's name must be present on the UB92 with the appropriate patient relationship code.

Incomplete secondary claim processing information.

Please include the appropriate Payer information on all secondary claim submissions.

Missing or invalid dates.

  • Include valid dates when reporting the following codes:
    • Principal Procedure Code
    • Occurrence Code
    • Occurrence Span Code
    • Other Procedure Code

All institutional claims for Horizon BCBSNJ members should be mailed to:

Horizon BCBSNJ
PO Box 25
Newark, NJ 07101-0025

(FEP) Plan: Plan ID numbers begin with a single "R."
Horizon BCBSNJ
PO Box 656
Newark, NJ 07101-0656

BlueCard:
Horizon BCBSNJ
BlueCard Claims
PO Box 1301
Neptune, NJ 07754-1301

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HELPFUL HINTS

  • Always use accurate five-digit CPT-4 codes or HCPC codes.
  • Claims must include the entire ID number. Always use the prefixes or suffixes that surround the ID number. The only exceptions are the FEP products. Disregard any characters after the eighth numeric character following the R prefix.
  • Ask for the patient's ID card at each visit in order to have the most current enrollment information available. Always photocopy both sides of the ID card for your files.
  • 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.
  • Use the subscriber's and/or patient's full name. Avoid nicknames or initials.
  • Completing the date of birth for the patient is important.
  • Clearly itemize your charges and date(s) of service.
  • For date fields, please include month, day and year. We have found that some claims contain only the month and day, which delays processing.
  • Please do not circle or highlight information, as it may cover data and cause it to become illegible.
  • When the patient's primary insurance is Medicare, claims are sent to Horizon BCBSNJ from Xact or Empire Medicare Services only after the Medicare Payment Floor (14 days) has been reached regardless of when you receive a remittance advice from Medicare Xact or Medicare Empire Services. If you do not receive a provider summary from us or Xact or Empire Medicare Services did not pay your claim, submit the claim along with a copy of the Medicare Provider Summary to us.
  • If the patient has any other insurance, record it on the claim form. If another carrier is primary and we receive incomplete information, it will delay payment to you.
  • Please remember to include the total charge amount line for all claims.
  • For Inpatient claims please remember to include the covered days, coinsurance days, and lifetime reserve days when applicable.
  • For UB92 and UB04 claims, admission hour cannot be blank if admission date is populated.
  • For CMS 1500 (HCFA), state postal code must be provided if box 10B is marked "Yes" for Auto Accident.
  • For CMS 1500 (HCFA), hospitalization dates must be provided for inpatient claims in box 18.
  • For CMS 1500 (HCFA), a modifier of NU (New) or RR (Rental) is required for HCPC codes in the range of E0100-E9999 and K0000-K0599.
  • For specific claim edits, click HERE.

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Claims Submissions - Horizon Healthcare Dental Services Electronic Submissions

We strongly encourage all dentists and dental professionals to submit their claims and pre-determinations to us electronically. Electronic claim submissions ensure accurate and timely processing. They also save your office staff hours of completing paper claims! Attachments and radiographs are not necessary when you submit your claims electronically, although we reserve the right to request them if necessary.

For more information on enrolling to submit your claims electronically, please contact Horizon Healthcare Dental Services' Professional Relations Department at 1-800-4DENTAL or e-mail us at <horizon_dental@HorizonBlue.com>.

For technical questions pertaining to submitting your claims electronically please contact the Horizon BCBSNJ EDI Services Help Desk toll-free at 1-888-EDI-9242.

Paper Claims Submissions

Always complete the claim forms completely and accurately. Pay close attention to required fields since that will help minimize processing delays. Claims are the most vital link between your office and Horizon Healthcare Dental Services. Please submit them in a timely manner. "Helpful Hints" are provided below for your reference.

We encourage the following for more efficient claims processing:

Complete

  • The newest ADA claim forms or Horizon Healthcare claim forms.
  • Using computer-generated or typed data.
  • All necessary fields of the claim form.

Verify

  • All data is within the designated field/box.
  • Subscriber's ID number is correct.
  • Procedure code is valid CDT-4 or CDT-5.

Avoid

  • Handwritten submissions.
  • Outdated claim forms.
  • Photocopies.

Helpful Hints

For fast, accurate processing of your claims, please follow the helpful hints below:

  • Claims must include the subscriber's 12-digit identification number. Three-digit alpha prefixes should be removed for dental claim submissions.
  • Ask for the patient's ID card at each visit in order to have the most current enrollment information available. Always photocopy both sides of the ID card for your files.
  • Use the subscriber's and/or patient's full name, avoiding nicknames or initials.
  • Provide the patient's date of birth.
  • Complete the group number field on the claim form when it appears on the ID card. Please note that claims may be processed without that information.
  • If the patient has any other insurance, record it on the claim form. If another carrier is primary and we receive incomplete information, it will delay payment to you.
  • Claims must include the dentist's information to ensure correct processing for payment. This includes name, Taxpayer Identification Number, address and zip code.
  • For date fields, please include month, day and year. We have found that some claims contain only the month and day, which delays processing.
  • Please do not circle or highlight information, as it may cover data and cause it to become illegible.
  • Always use accurate six-digit CDT-4 or CDT-5 procedure codes for each service performed.
  • Include tooth and/or surface for procedure codes that require that information.
  • Clearly itemize your charges and date(s) of service.

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Submitting claims with Modifier 25

In accordance with AMA guidelines, Modifier 25 is appended to an E&M service to identify a significant, separately identifiable evaluation and management service performed by the same physician on the same patient on the same day as a procedure or other service.

Effective November 1, 2006, for services performed by physicians on or after August 1, 2006, Horizon BCBSNJ will systemically recognize Modifier 25 when appropriately billed with an Evaluation and Management (E&M) Code.

All eligible claims billed with Modifier 25 for services performed on or after August 1, 2006 will be automatically reviewed for potential adjustment (unless already appealed and determined to be ineligible). Physicians do not need to submit appeals for such previously systemically declined claims with respect to Modifier 25.

Effective July 1, 2007, for services performed on or after June 1, 2007, Horizon BCBSNJ will systemically recognize Modifier 25 when appropriately billed with multiple E&M codes. This is for services performed on the same day, to the same member, by the same physician.

Claims billed with multiple E&M codes with Modifier 25 and previously systemically declined for services performed on or after June 1, 2007 will be automatically reviewed for potential adjustment for systemic payment. Claims that were previously appealed will not be reopened or reviewed for adjustment.

The systematic recognition of Modifier 25 with one and multiple E&M codes does not apply to physical therapy and chiropractic services. If you were not eligible for separate reimbursement of E&M codes in the past, this Modifier 25 initiative has no impact on you. Also, this change will not impact services included in capitation rates.

As always, claims are subject to all member and group benefit limitations, conditions and exclusions. For example, claims for observation and hydration submitted with either Modifier 25 or 59 continue to be ineligible for payment as separate services: only the hydration code is eligbile for payment

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