On January 1, 2017, Horizon NJ Health will be implementing a series of updates to our claim editing rules and processes using McKesson’s ClaimsXten, a clinically-based claims editing solution. This will help ensure that claims for members enrolled in Horizon NJ Health and Horizon NJ TotalCare (HMO SNP) plans are processed according to standard Centers for Medicare & Medicaid Services (CMS) medical necessity guidelines.
This includes claim editing rules that enable us to process claims in accordance with nationally recognized coding and code editing changes, as well as rules that reflect McKesson’s ongoing review of current claim processing/claim editing practices as well as our own administrative, reimbursement and/or medical policies.
We will soon give you more details about how these claim editing rules and processes will change, and what the impact of these changes will be. If you have questions, please call the Physician and Health Care Hotline at