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Claim Editing Policies

Claim Editing Policies

If our claim processing system does not recognize information on a claim, the claim is manually reviewed. The claim is then reviewed for medical eligibility based on our medical policy guidelines.
Our claim policy department will review all required medical documentation from you and determine if further review from the Medical Advisor's Office is necessary.

 Significant Claim Edits  

A significant claim edit is an edit that Horizon Blue Cross Blue Shield of New Jersey reasonably believes, will cause the denial or reduction in payment for a particular CPT® Code or HCPCS Level II Code more than two-hundred and fifty (250) times per year on the initial review of submitted claims. For a list of Horizon BCBSNJ's Significant Claim Edits, click  here.

Subsequent or Similar Services performed on the same day

If a physician, hospital, or vendor submits a claim with services following a primary service and these subsequent services are billed for the same date of service as the primary service, then the actual claim is reviewed to verify the billing, and the subsequent service lines are adjudicated at percentages of the primary service line.


Commercially Available Claim Editing Systems

Horizon Blue Cross Blue Shield of New Jersey uses the following commercially available claim editing systems:

Claim Editing SystemsCustomized
McKesson ClaimsXten® 5.02/CCI 20.2
YES
McKesson ClaimCheck® release 8.5 and Knowledge Base version 45
NO
TriZetto® ClaimFacts® version 6.71
NO
TriZetto® QNXT version 3.2SP15CP006
NO
Bloodhound Technologies (for AtlantiCare claims only)
NO

PROFESSIONAL RULES

The ClaimsXten® Knowledge Packs effective on December 17, 2010 are:

  1. ClaimsXten Core Knowledge Pack
    1. Invalid Age for Procedure Code Edits
    2. Invalid Gender for Procedure Code Edits
    3. Modifier to Procedure Code Validation Edits
    4. Invalid Procedure Code Edits
  2. Code Auditing Knowledge Pack:
    1. Assistant Surgeon Eligible Policy
    2. Frequency Validation/Alternate Code Edits
    3. McKesson Multiple Code Rebundling Edits
    4. CMS Correct Coding Initiative (CCI) Edits
    5. Global Surgery Period Edits (Pre/Post Op, Same Day Visit
    6. Multiple Units/Frequency Validation Edits
    7. McKesson Unbundling Edits
  3. Core Auditing Add-on Knowledge Pack:
    1. Add-on Procedure Code without Base Code edit
    2. Missing Professional Component Modifier-26 edit
  4. ClaimsXten Custom Rules
    1. Multiple Site Specific Modifiers
    2. Quantity Date Span.
  5. Other ClaimsXten Logic
    1. Multiple Surgery Procedures
    2. Multiple Radiology Procedures

The ClaimsXten® Knowledge Pack updates effective August 8, 2011 are :

  1. Code Auditing Premium
    1. ASA Anesthesia Not Eligible
    2. ASA Anesthesia Multiple Crosswalk
    3. ASA Anesthesia Standard Crosswalk

The ClaimsXten® Knowledge Pack updates effective Sept 5, 2011 are :

  1. Core Auditing Add-on Knowledge Pack:
    1. Global and Technical/Professional Component Billing Edits
    2. Bilateral Rule

The ClaimsXten® Knowledge Pack updates effective November 18, 2011 are:

  1. Core Auditing Add-on Knowledge Pack:
    1. Incomplete Diagnosis
    2. Invalid Diagnosis

The ClaimsXten® Knowledge Pack updates effective December 19, 2011:

  1. Core Auditing Add-on Knowledge Pack:
    1. Base Code Quantity

The ClaimsXten® Knowledge Pack updates effective April 16, 2012:

  1. Core Auditing Add-on Knowledge Pack:
    1. Lab Panel

The ClaimsXten® Core Knowledge Pack updates effective September 09, 2012:

  1. Deleted Code
  2. Female Specific Diagnosis
  3. Male Specific Diagnosis

The ClaimsXten® Core Knowledge Pack updates effective October 29, 2012:

  1. Supplies Same Day Surgery Inclusive
  2. Outpatient Consultations
  3. Inpatient Consultations
  4. Obstetrics Package Rule
  5. CMS Always Bundled Procedures (see the section Accessing the list of CMS Always Bundled Procedures below)

The ClaimsXten® Knowledge Pack updates effective April 15, 2013:

  1. Code Auditing Premium:
    1. New Patient Code for an Established Patient
  2. Waste and Abuse:
    1. CPAP BIPAP Supply Frequency
    2. Diabetic Supply Frequency

The ClaimsXten® Knowledge Pack updates effective April 20, 2014:

  1. Code Auditing Premium:
    1. Global Component

OUTPATIENT FACILITY RULES

The ClaimsXten® Knowledge Pack updates effective December 19, 2011 are:

  1. ClaimsXten Core Knowledge Pack :
    1. Age (Facility)
    2. Gender (Facility)
    3. Incomplete Diagnosis
    4. Diagnosis Invalid
    5. Procedure Invalid
    6. Procedure Modifier Validation
    7. Outpatient Code Editor (OCE edits)*

Only a subset of OCE edits will apply to participating facilities.

The ClaimsXten® Knowledge Pack updates effective April 16, 2012:

  1. ClaimsXten Core Knowledge Pack :
    1. Lab Panel

The ClaimsXten® Core Knowledge Pack updates effective September 09, 2012:

  1. Deleted Code
  2. Female Specific Diagnosis
  3. Male Specific Diagnosis

The ClaimsXten® Core Knowledge Pack updates effective October 29, 2012:

  1. Horizon Medical Policy Rule

The ClaimsXten® Core Knowledge Pack updates effective April 20, 2014:

  1. Global Component

The ClaimsXten® Knowledge Pack updates effective November 30, 2014:

  1. Facility MUE (Medically Unlikely Edits)
  2. McKesson's Outpatient Unbundled Pairs - applies to non-participating facilities only

Accessing the list of CMS Always Bundled Procedures

You may view a list that identifies CMS Always Bundled Procedures on the CMS website. Please follow the steps listed below to access this information.

  1. Visit www.cms.gov and click Medicare.
  2. Click Physician Fee Schedule under the Medicare Fee-for-Service Payment heading.
  3. Click PFS Relative Value Files from the options within the left navigation menu.
  4. Select the appropriate year and release.

  5. Please note: CMS will display multiple records for a given year based on the number of releases. Horizon BCBSNJ updates our files on a quarterly basis.
  6. Open the ZIP file within the Downloads section.
  7. Within the ZIP file folder, open the desired PPR RVU file (.xlsx, .csv or .txt extension).
  8. Locate the code in question and review the value within the Status Code column.

  9. A value of "B" in the Status Code column indicates a code that is always bundled.

    Helpful hint: To make it easier to view all CMS "B" codes, re-sort this file by the Status Code column.

Echocardiogram Procedures Billed With an E&M Service

Beginning on December 15, 2010, to prevent duplicate or erroneous billing issues, Horizon BCBSNJ updated our claims auditing software to apply incidental service coding logic to echocardiogram services when these services were billed with an inpatient Evaluation & Management (E&M) service on the same date of service for the same patient.

Since that time, we considered echocardiogram/inpatient E&M service code pair combinations for separate reimbursement if modifier 25 was appended to the E&M service code or if modifier 59 was appended to the echocardiogram code.

Effective October 1, 2012, Horizon BCBSNJ will no longer consider echocardiogram/inpatient E&M service code combinations appended with modifiers 25 or 59 for separate reimbursement.

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