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Frequently Asked Questions - Claim Editing Updates for Medicaid and DSNP Claims

In January 2017 Horizon NJ Health implemented a series of updates to our claim editing rules and processes to help ensure that claims for members enrolled in our Medicaid and Horizon NJ TotalCare (HMO SNP) plans are processed according to standard Centers for Medicare & Medicaid Services (CMS) medical necessity guidelines.

Q1. Can you please explain the Medicaid/DSNP claim editing rule changes?

A1. In January 2017, Horizon NJ Health implemented changes to the way we process claims for services provided to Horizon NJ Health Medicaid and Horizon NJ TotalCare (HMO SNP) members. The goal of these claim editing changes is to more closely align how we process Medicaid and DSNP claims with the nationally recognized coding and code editing guidelines established by CMS. We also want to ensure that we are following industry standards.

Q2. What is ClaimsXten? Why has it been implemented?

A2. ClaimsXten (CXT) is a claims editing software solution that extends claims payment capabilities beyond traditional code auditing and resolves limitations in claims processing systems. It is a flexible full-service solution that helps us manage the complexities of benefit plans, provider contracts, payment policies and issues of inconsistency across multiple claims processing systems. CXT fully replaced ClaimCheck effective January 1, 2017.

Q3. Will these Medicaid and DSNP-specific claim editing rule changes impact claims for all providers?

A3. Yes, the Medicaid and DSNP-specific claim editing rule changes to be implemented will impact claims for services provided by:

  • Physicians
  • Other health care professionals, hospitals and ancillary providers

Q4. Will the Medicaid and DSNP-specific claim editing rule changes impact the reimbursement rates providers receive for eligible services provided to Horizon NJ Health and Horizon NJ TotalCare (HMO SNP) members?

A4. The Medicaid and DSNP-specific claim editing rule changes to be implemented will have no impact on the reimbursement rates these providers receive for specific services, but may impact the way the claims are processed.

Q5. Will the edit changes require the provider to submit additional information?

A5. No. Providers will not need to submit additional information to Horizon NJ Health.

Q6. Will there be changes in how providers submit claims?

A6. No. Providers will not need to make any changes in how claims are coded and submitted.

Q7. What happens if a provider disagrees with the ClaimsXten results and wants to appeal?

A7. The process differs depending on which network the provider belongs to. For Medicaid, a provider needs to submit an appeal within 90 days of claim denial. These appeals can be sent to:

Horizon NJ Health Claim Appeals
PO Box 63000
Newark, NJ 07101-8064

They can also be faxed to 1-973-522-4678.

Note: Only non-participating DSNP providers can appeal a claim, using the following address:

Horizon NJ TotalCare (HMO SNP) Claim Appeals
PO Box 24079
Newark, NJ 07101-0406

As DSNP participating providers do not have appeal rights, disputes must be sent to the following address:
Horizon NJ TotalCare Misc Member/Provider Correspondence
PO Box 24081
Newark, NJ 07101-0406

Q8. How do I identify ClaimsXten denials?

A8. The new edit codes implemented in ClaimsXten are shown in the attachment. A full description of the codes can be found on horizonNJhealth.com/for-providers/educational-material-providers.

Q9. Is there an online reference that providers may reference for more detail?

A9. You can reference Clear Claim Connection from horizonNJhealth.com/for-providers/resources. From there, click Login to NaviNet and go to Clear Claim Connection.