Billing Guide

This guide is intended to offer hospitals, physicians and health care professionals the information required for Horizon NJ Health to accurately and efficiently process claims prepared by or for hospitals, physicians and health care professionals for medical services provided to members of our health plan.

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Horizon NJ Health - Billing Guide

This guide is intended to offer hospitals, physicians and
health care professionals the information required for
Horizon NJ Health to accurately and efficiently process
claims prepared by or for hospitals, physicians and health
care professionals for medical services provided to
members of our health plan. This section contains notes
of interest highlighting billing information relevant to
the topic detailed above them. The notes may be titled
as follows:

IMPORTANT ? Reminds the reader of claim submission
problems that can be avoided. These errors can result
in rejection, inaccurate claim payments or denials,
usually because required information is missing, invalid,
incomplete or inconsistent with standard billing practices.
Note: Reviews an associated piece of information, which
clarifies or explains specific details about the service, but
may not directly impact reimbursement. For example,
place of service is required to determine eligibility for
payment, but does not necessarily affect payment amount.

In the event of additional questions about Horizon NJ Health
programs or policies, please review the entire Manual or
contact the Provider Services at 1-800-682-9091.

In order to comply with contractual obligations, regulatory
requirements or state and federal law, Horizon NJ Health
reserves the right, at any time, to modify or update
information contained in this document. Notification will
be posted at least 30 days prior to the effective date
unless the effective date of a law or regulation does not
permit this time frame. Hospitals, physicians and health
care professionals may access the For Providers section of
the Horizon NJ Health website at horizonNJhealth.com
to check for updates on billing requirements and other
policies and procedures relevant to reimbursements
for services.

IMPORTANT ? Horizon NJ Health, its subcontracted
vendors or the State of New Jersey are responsible for
payment for all services included in the member?s benefit
package. Services not included in the benefit package
are reimbursable by the member only if the hospital,
physician or health care professional notifies the member
in writing and in advance of providing the service(s) of this
obligation. Members should not be billed for any service
covered under their benefit package. Should Horizon NJ
Health require a copayment for any service or population
group, an itemization of these items will be included in
the benefit listing and will be available on the website.
The practice of balance billing Medicaid/NJFC and DSNP
beneficiaries, whether eligible for FFS benefits or enrolled
in managed care, is prohibited under both federal and
State law. These prohibitions apply to both Medicaid/
NJFC-only beneficiaries, as well as those eligible for
Medicare coverage or other insurance. A provider enrolled
in the Medicaid/NJFC FFS program or in managed care is
required to accept as payment in full the reimbursement
rate established by the FFS program or managed care plan.

All costs related to the delivery of health care benefits to a
Medicaid/NJFC eligible beneficiary, other than authorized
cost sharing, are the responsibility of the FFS program,
the managed care plan, Medicare (if applicable) and/or
a third-party payer (if applicable). If a provider receives
a Medicaid/NJFC FFS or managed care payment, the
provider shall accept this payment as payment in full and
shall not bill the beneficiary or anyone on the beneficiary?s
behalf for any additional charges.

9.1 Requirements for Filing Claims

9.1.1 General Requirements
Horizon NJ Health will pay claims based only on eligible
charges. Unless the provider contract states otherwise,
claims will be paid on the lesser of billed charges or
the contracted rate (Horizon NJ Health fee schedule).
Horizon NJ Health is a Medicaid managed care plan
that is under contract with the New Jersey Department
of Human Services. Horizon NJ Health will pay claims
based only on eligible charges. Claims submitted by
nonparticipating Horizon NJ Health providers will be paid
on the lesser of billed charges or the Horizon NJ Health
nonparticipating provider fee schedule. Consistent with
CFR 42 Part ? 447.45: the following definition shall apply
to clean claims as used within the Horizon NJ Health
Billing Guide:

?Clean claim means one that can be processed without
obtaining additional information from the provider of the
service or from a third party. It does not include a claim
from a provider who is under investigation for fraud or
abuse or a claim under review for medical necessity.?



Horizon NJ Health - Billing Guide

Under the New Jersey Health Claims Authorization,
Processing and Payment Act, claims must also meet the
following criteria:

(a) the health care provider is eligible at the date
of service

(b) the person who received the health care service
was covered on the date of service

(c) the claim is for a service or supply covered under
the health benefits plan

(d) the claim is submitted with all the information
requested by the payor on the claim form or in other
instructions that were distributed in advance to the
health care provider or covered person in accordance
with the provisions of section 4 of P.L.2005, c.352
(C.17B:30-51)

(e) the payor has no reason to believe that the claim has
been submitted fraudulently

Other requirements, including timeliness of claims
processing, shall mean:

Horizon NJ Health must receive all claims within 180
calendar days from the initial date when services were
rendered. If claims are not received within 180 calendar
days from the initial date of service, claims will be denied
for untimely filing. Horizon NJ Health shall pay all clean
claims from hospitals, physicians and other health care
professionals within 30 days of the date of receipt of EDI
claims and within 40 days for paper claims. MLTSS claims
will be paid within 15 days of the receipt of EDI claims and
within 30 days for paper claims.

The time limitation does not apply to claims from
providers under investigation for fraud or abuse. The
date of receipt is the date Horizon NJ Health receives the
claim, as indicated by its date stamp on the claim. The
date of payment is the date of the check or other form
of payment.

Practitioners and facilities may not use a PO Box as an
acceptable billing address. A physical street address must
be used. In addition, when submitting ZIP codes anywhere
on a claim, practitioners and facilities must use the full
nine-digit format. Horizon NJ Health is required to report
all claims to the State of New Jersey for services provided
to members through electronic media. Therefore,
all billing addresses, whether submitted on paper or
electronically, must contain a physical billing address. To
have payments sent to a different address or PO Box, the
pay-to provider name and address field on the 837-I and
837-P transaction must be used.

Simple claims inquiries may be directed to Provider
Services at 1-800-682-9091. For more complex problems
? such as inquiries on 10 or more claims, providers must
complete a spreadsheet with the following data elements:

? Member Name
? Member ID Number
? Claim Number
? Date of Service
? CPT Codes
? Specific nature of inquiry
? Total billed charges

Send these inquiries to:
Provider Correspondence
PO Box 24077
Newark, NJ 07101-0406

We can only accept inquiries for claims in dispute when all
of the above elements are included. Other inquiries will
be returned.

Taxonomy codes must be provided on all claims. IT IS VITAL
THAT THE PROPER TAXONOMY CODE BE INCLUDED
WHEN BILLING AS A PCP OR SPECIALIST. WITHOUT THIS
CODE CLAIMS PAYMENT WILL BE DENIED.

In the majority of instances, EDI submission is the
appropriate claims submission mechanism. In 2017,
Horizon NJ Health began to limit the acceptance of paper
claims. The only paper claims we do accept are red
and white paper claims. We will be providing additional
guidance on this transition. We strongly recommend that
providers send claims electronically.

Benefits to sending claims electronically include:
? Cleaner claim submission
? Confirmation of submitted claims within 24 hours
? Faster processing and payment
? Administrative efficiencies
? No postage or handling of paper claims

For more information on EDI, review Section 9.3
Procedures for Electronic Submission ? Electronic Data
Interchange.

9.1.2 National Practitioner Identifier (NPI)
Horizon NJ Health requires all practitioners use their NPI
numbers for all claim submissions. To ensure our systems
properly identify you as an individual, group or facility,
Horizon NJ Health requires you register the NPI with
your taxonomy and tax identification numbers. Another
requirement that will affect both timeliness and payment
is the use of name differential on your W-9. Horizon
NJ Health continues to accept the use of your provider
identification numbers (legacy ID). The continued use of
the legacy ID is recommended, as the claims processing
system uses this number for adjudication and payment
activities. Please make sure your name matches the name
used on your W-9. Below are some helpful hints, which

Horizon NJ Health Billing Guide, August 2017



Horizon NJ Health - Billing Guide

will facilitate accurate and consistent management
of your claims.

? Physicians, facilities, and health care professionals are
required to have an NPI. Please register for one if you
have not already secured your NPI.

? Groups are not technically required to have an NPI,
but are encouraged to have one as long as there is
a legal entity associated with the business name and
tax identification number. To register the group NPI
with Horizon NJ Health, we will need the W-9 for the
business and all associated individual NPIs paid to
that tax ID number.

? Facilities, including hospitals and groups chosen to
subpart their type 2 NPI, will need to choose a master
NPI if all of the registered numbers are under the
same tax identification number. Designating a master
NPI number will help Horizon NJ Health assign claims
to the right location for payment purposes. A valid
W-9 for the business and all associated individual
NPIs that are paid to that tax ID number should be
registered with Horizon NJ Health.

? Where an NPI number is shared among different
locations using the same tax ID number, the Horizon
NJ Health legacy ID is needed to distinguish where
the claim payment should be sent.

? Nonparticipating practitioners and facilities are
also required to adhere to the NPI requirements.
To facilitate payment for claims, Horizon NJ Health
encourages you to register your NPI with us in
the same manner described above. To complete
this task, please visit the ?For Providers? section
of horizonNJhealth.com and download our NPI
Collection Form. Once completed, fax your forms
and CMS documentation to Horizon NJ Health at
1-609-583-3004.

9.1.3 Procedures for Claim Submission
Horizon NJ Health is required by state and federal
regulations to capture and report specific data regarding
services rendered to its members. All services rendered,
including capitated encounters and fee-for-service claims,
must be submitted on the CMS 1500 (HCFA1500) version
02/12 or UB-04 claims form, or via electronic submission
in a HIPAA ? compliant 837 or NCPDP format. Horizon
NJ Health does not accept handwritten or stamped
claims. These claims forms and electronic submissions
must be consistent with the instructions provided by CMS
requirements, as stated in the Claims Manual, which can
be accessed at cms.gov/Manuals/IOM/list.asp.

The hospital, physician and health care professional, to
appropriately account for services rendered and to ensure
timely processing of claims, must adhere to all billing
requirements.

When data elements are missing, incomplete, invalid or
coded incorrectly, Horizon NJ Health cannot process
the claims.

? Claims for billable services provided to Horizon NJ
Health members must be submitted by the hospital,
physician or health care professional that performed
the services.

? Professional services are not reimbursable to a hospital
unless the hospital is specifically contracted for
professional services. Horizon NJ Health policy is to
reimburse these services only when billed on a CMS
1500.

? Claims filed with Horizon NJ Health are subject to the
following procedures:
? Verification that all required fields are completed on

the claim
? Verification that all diagnosis codes, modifiers and

procedure codes are valid for the date of service
? When appropriate, verification of the referral for

specialist or non-primary care physician claims
(excluding ?self-referral? types of care)

? Verification of member?s eligibility for services under
Horizon NJ Health during the time period in which
services were provided

? Verification that the services were provided by a
participating or nonparticipating hospital, physician
or health care professional that has received
authorization to provide services to the eligible
member

? Verification that the hospital, physician or health care
professional has been given approval for services
that require prior authorization by Horizon NJ Health



Horizon NJ Health - Billing Guide

? Horizon NJ Health is the ?payor of last resort? on
all claims submitted for members of its health plan.
Hospitals, physicians and health care professionals
must verify whether the member has Medicare
coverage or any other third party resources and, if
so, provide documentation that the claim was first
processed by this other insurer as appropriate.

IMPORTANT ? Rejected claims are defined as claims
with invalid or missing data elements, such as the tax ID
number, that are returned to the submitter or EDI source
without registration in the claim processing system. Since
rejected claims are not registered in the claim processing
system, the hospital, physician or health care professional
must re-submit clean claims within 365 calendar days
from the date of service. This guideline applies to claims
submitted on paper or electronically. Rejected claims are
different than denied claims, which are registered in the
claim processing system, but do not meet requirements
for payment under Horizon NJ Health guidelines.

Horizon NJ Health encourages all hospitals, physicians,
and health care professionals to submit claims
electronically. We utilize the TriZetto Provider Solutions
(TTPS) Direct Data Entry (DDE) SimpleClaim system.
All providers that previously used Emdeon to directly
enter their Horizon NJ Health claims must switch to DDE
SimpleClaim.

For more information on registering, please go to
https://trizettoprovidersolutions.wufoo.com/forms/
horizon-nj-health-providers/. If you have any further
questions about registering with TTPS for DDE claim
submission, please call TriZetto at 1-800-556-2231 or
email ttpsupport@trizetto.com.

While Horizon NJ Health strongly encourages submitting
claims via EDI, if a paper claim is necessary, please submit
red and white paper claims only for all medical services to
Horizon NJ Health at the following address:

Horizon NJ Health
Claims Processing Department
PO Box 24078
Newark, NJ 07101-0406

Note: Out-of-state, non-Horizon NJ Health providers
should send claims to their local Blue Cross Blue Shield
Plan.

IMPORTANT ? Requests for reimbursement for retail
pharmacy and all outpatient drugs for persons designated
as aged, blind or disabled should be submitted directly to
the State of New Jersey.

IMPORTANT ? Requests for reimbursement for
mental health services for all enrollees, except the
developmentally disabled or MLTSS members, should be
submitted directly to the State of New Jersey.

Note: Be sure to include the member?s Medicaid ID
number on all claims submitted to the State of New Jersey.

Note: Horizon NJ Health subcontracts with Davis Vision
to provide and/or coordinate vision services for eligible
members. All services, except ophthalmologic procedures,
are coordinated and paid by Davis Vision. Please call
1-877-226-3729 for information about submitting
invoices.

Note: Horizon NJ Health subcontracts with Scion
Dental to provide and/or coordinate dental services for
eligible members. Please call the Provider Call Center
at 1-855-878-5368 for routine provider questions
related to eligibility, claims, authorizations, credentialing,
contracting, adding/changing provider data/locations,
and fee schedules.

Note: Horizon NJ Health subcontracts with Laboratory
Corporation of America, Inc. (LabCorp) for most routine
and specialized laboratory services. Generally,
Horizon NJ Health is responsible for payment of claims
for PAT/STAT laboratory service provided in hospitals
and ambulatory surgical centers. Horizon NJ Health will
also provide reimbursements for claims for laboratory
services included on LabCorp?s excluded test listing. An
authorization is required for any test included on this
listing; please submit claims to Horizon NJ Health as
specified above. Unless otherwise specified within
specific contractual arrangements, laboratory services
should be referred to LabCorp.



Horizon NJ Health - Billing Guide

9.1.4 Claim Filing Deadlines
Horizon NJ Health must receive all claims within 180
calendar days from the initial date when services were
rendered. If claims are not received within 180 calendar
days from the initial date of service, claims will be denied
for untimely filing. COB claims must be submitted within
60 days from the date of the primary insurer?s EOB.

? Horizon NJ Health?s Appeals department utilizes
specific criteria when reviewing valid proof of
timely filing.

? Member?s name
? Horizon NJ Health or Medicaid ID number
? Billed amount
? Date of service
? Billed/mailed date
? Address where the claim form was sent

(Horizon NJ Health or insurance code)
? For EDI submissions, a 999 report indicating

submission to the correct insurance code is required
for consideration of timely submission.

For claims selected electronically:
? Submit an electronic data interchange (EDI)

acceptance report. This must show that
Horizon NJ Health or one of its affiliates received,
accepted and/or acknowledged the claim submission.

Note: A submission report alone is not considered
proof of timely filing for electronic claims. It must be
accompanied by an acceptance report.

? The acceptance report must:
1. Include the actual wording that indicates the

claim was either ?accepted,? ?received? and/or
?acknowledged.?
(Abbreviations of those words are also acceptable.)

2. Show the claim was accepted, received, and/or
acknowledged within the timely filing period.

For paper claims:
1. The submission date must be within the

timely filing period.
2. Certified mail receipts as valid proof of timely filing.
3. Only red and white paper claims can be processed.

Other valid proof of timely filing documentation
Valid when incorrect insurance information was provided
by the patient at the time the service was rendered:

? A denial/rejection letter from another insurance carrier
? Another insurance carrier?s explanation of benefits
? Letter from another insurance carrier or employer

group indicating coverage termination prior to the
date of service of the claim

? Letter from another insurance carrier or employer
group indicating no coverage for the patient on the
date of service of the claim

All of the above must include documentation that the
claim is for the correct patient and the correct date
of service. The date on the other carrier?s payment
correspondence starts the timely filing period for
submission to Horizon NJ Health. In order to be
considered timely, the claim must be received by
Horizon NJ Health within 60 days from the date on the
other carrier?s correspondence. Not including all of the
information requested will result in a rejected inquiry or a
delay in response. If the claim is received after the timely
filing period, it will not meet timely filing criteria.
REFER TO SECTION 10 ? Section 10.0 Complaint
and Appeals Process for complete instructions of the
submission time frames and procedures for administrative
or medical appeals.

9.1.5. Filing Corrected Claims
For paper claims:
CMS-1500 should be submitted with the appropriate
resubmission code (value of 7) in Box 22 of the paper
claim with the original claim number of the corrected
claim and a copy of the original Explanation of Payment
(EOP). With the original claim number for which the
corrected claim is being submitted. Horizon NJ Health will
reject any claims that are not submitted on red and white
forms or that have any handwriting on them.

For UB-04 claims:
UB-04 claims should be submitted with the appropriate
resubmission code in the third digit of the bill type (for
corrected claim this will be 7), the original claim number in
Box 64 of the paper claim and a copy of the original EOP.

Send red and white paper corrected claims to:

Horizon NJ Health
Claims Processing Department
PO Box 24078
Newark, NJ 07101-0406



Horizon NJ Health - Billing Guide

Correcting electronic HCFA 1500 claims:
EDI 837P data should be sent in the 2300 Loop, segment
CLM05 (with value of 7) along with an addition loop in
the 2300 loop, segment REF*F8* with the original claim
number for which the corrected claim is being submitted.

Correcting electronic UB-04 claims:
EDI 837I data should be sent in the 2300 Loop, segment
CLM05 (with value of 7) along with an addition loop in
the 2300 loop, segment REF *F8* with the original claim
number for which the corrected claim is being submitted.

Both paper and electronic claims must be submitted
within 365 calendar days from the initial date of service.

9.2 Claim Forms (Paper)
Horizon NJ Health requires that all hospitals, physicians
and health care professionals use the standard CMS 1500
(HCFA 1500) or UB-04 claim forms to report services,
which are reimbursable or capitated. The CMS 1500
(HCFA 1500) claim form must be completed for all
professional medical services. The UB-04 claim form must
be completed for all facility claims. When services are
rendered by MLTSS providers, facilities should file a
UB-04 form, and nonfacilities should use the CMS 1500.
Horizon NJ Health does not accept handwritten or
black and white claims.

9.2.1 CMS 1500 (HCFA 1500) Claim Form
(Paper Submission)
The CMS 1500 (HCFA 1500) claim form must be used to
bill all professional services to Horizon NJ Health. Horizon
NJ Health only accepts form version 02/12. The National
Uniform Claim Committee (NUCC) created the CMS 1500
form (version 02/12) to accommodate coding changes for
ICD-10. There are two significant changes on the revised
CMS 1500, the claim form used to submit paper claims
to Medicare and the required claim form to submit paper
claims to Horizon NJ Health.

The CMS 1500 Form (version 02/12) gives physicians the
ability to

? Identify whether they are using ICD-9-CM or
ICD-10-CM codes.

? Include up to 12 codes in the diagnosis field (the
limit on the 08/05 version is four codes in the
diagnosis field).

? Include information that will improve the accuracy of
the data reported, such as being able to identify the
role of the provider and specific dates of illness.

? Align paper copy claim submissions with the ASC X12
Health Care Claim: Professional (837P) transaction.

CMS has advised providers to use the following process to
assure clean claims submission. All information must be:

? Aligned within the data fields.
? On an original red ink on white paper claim 02/12

version form.
? Typed. Do not print, handwrite or stamp any

extraneous data on the form.
? In black ink.
? In large, dark font, such as PICA or ARIAL 10-, 11- or

12-point type.
? In capital letters.

More information about Administrative Simplification
and Compliance Act (ASCA) exceptions can be found in
Chapter 24 of the ?Medicare Claims Processing Manual,?
which is available on the CMS website at
cms.gov/Regulations-and-Guidance/Guidance/
Manuals/Downloads/ clm104c24.pdf.

Required Fields for CMS 1500 (HCFA 1500)
Claim Form
This section will provide the list of required fields for
Horizon NJ Health; however, you must refer to the most
current CMS coding instructions for a complete list of
codes and requirements.

Horizon NJ Health Billing Guide, August 2017



Horizon NJ Health - Billing Guide

Place of Service Codes
Code Description

11 Office
12 Home
19 Off Campus - Outpatient Hospital
20 Urgent Care Facility
21 Inpatient Hospital
22 Outpatient Hospital
23 Emergency Room ? Hospital
24 Ambulatory Surgical Center
25 Birthing Center
26 Military Treatment Facility
31 Skilled Nursing Facility
32 Nursing Facility
33 Custodial Care Facility
34 Hospice
41 Ambulance ? Land
42 Ambulance ? Air or Water
50 Federally Qualified Health Center
51 Inpatient Psychiatric Facility
52 Psychiatric Residential Treatment Center
53 Community Mental Health Center
54 Intermediate Care Facility/Mentally Retarded
55 Residential Substance Abuse Treatment Center
56 Psychiatric Residential Treatment Center
60 Mass Immunization Center
61 Comprehensive Inpatient Rehabilitation Facility
62 Comprehensive Outpatient Rehabilitation Facility
65 End-Stage Renal Disease Treatment Facility
71 State or Local Public Health Clinic
72 Rural Health Clinic
81 Independent Laboratory
99 Other Unlisted Facility

Type of Service Codes
Code Description

1 Medical Services
2 Surgery
3 Consultations
4 Radiology (total component)
5 Laboratory (total component)
6 Radiation Therapy (total component)
7 Anesthesia
8 Assistant Surgery
9 Other (e.g., prosthetic eyewear, contacts, ambulance)
D DME
F ASC

Required and Conditional Field Indicator
IMPORTANT ? An authorization number and/or referral
number must be included in box #23 on a CMS 1500
(HCFA 1500) claim form or box #63 on a UB-04 form. The
required fields that must be completed for the standard
CMS 1500 (HCFA 1500) or UB-04 claim forms are in the
respective claim form areas. If the field is required without
exception, an ?R? (required) is noted in the ?Required or
Conditional? box. If completing the field is dependent
upon certain circumstances, the requirement is listed
as ?C? (conditional) and the relevant conditions are
explained in the ?Instructions and Comments? box.

9.2.2 The UB-04 (CMS 1450) Claim Form
(Paper)

The UB-04 (CMS 1450) claim form must be used to bill
all facility services to Horizon NJ Health. This section will
provide the list of required fields for Horizon NJ Health.
However, you must refer to the most current CMS coding
instructions for a complete list of codes and requirements.

Type of Bill Codes
Code Description

111 Hospital/Inpatient (Part A)/Admit through Discharge

Code Description
112 Hospital/Inpatient (Part A)/Interim ? First Claim
113 Hospital/Inpatient (Part A)/Interim ? Continuing

Claims
114 Hospital/Inpatient (Part A)/Interim ? Last Claim
115 Hospital/Inpatient (Part A)/Late Charge Only
117 Hospital/Inpatient (Part A)/Replacement of

Prior Claim
121 Hospital/Hospital Based or Inpatient(Part B)/Admit

Through Discharge
131 Hospital/Outpatient/Admit Through Discharge
211 Skilled Nursing/Inpatient (Part A)/Admit Through

Discharge
212 Skilled Nursing/Inpatient (Part A)/Interim ?

First Claim
213 Skilled Nursing/Inpatient (Part A)/Interim ?

Continuing Claims
214 Skilled Nursing/Inpatient (Part A)/Interim ?

Last Claim
321 Home Health/Hospital Based or Inpatient (Part B)/

Admit Through Discharge
331 Home Health/Hospital Based or Inpatient (Part B)/

Admit Through Discharge



Horizon NJ Health - Billing Guide

711 Clinic/Rural Health Clinic (RHC)/Admit Through
Discharge

721 Clinic/Independent Renal Dialysis Facility/Admit
through Discharge

731 Clinic/FQHC/Admit Through Discharge
831 Special Facility or Hospital ASC/ASC for

Outpatients/Admit Through Discharge

Type of Admission Codes
Code Description

1 Emergency
2 Urgent
3 Elective

Patient Status Codes
Code Description

01 Discharged to Home or Self Care (routine discharge)
02 Discharged/Transferred to Another Short-Term

General Hospital
03 Discharged/Transferred to SNF
04 Discharged/Transferred to ICF
05 Discharged/Transferred to Another Type of Institution

(including distinct parts) or Referred for Outpatient
Services to Another Institution

06 Discharged/Transferred to Home Under Care of
Organized Home Health Service Organization
07 Left Against Medical Advice
08 Discharged/Transferred to Home Under Care of an

IV Drug Therapy Provider
09 Admitted as an Inpatient to this Hospital
20 Expired (or did not recover ? Christian Science

Patient)
30 Still Patient or Expected to Return for Outpatient

Services
40 Expired at Home (hospice claims only)
41 Expired in a Medical Facility, such as Hospital, SNF,

ICF or Freestanding Hospice (hospice claims only)
42 Expired ? Place Unknown (hospice claims only)
50 Hospice ? Home
51 Hospice ? Medical Facility

Commonly Used Revenue Codes
Code Description

100 ? 129 Room and Board Charges
130 ? 249 Semi-private; Private; Ward, Nursery,

Subacute, ICU, CCU
250 ? 259 Pharmacy
260 ? 269 IV Therapy
270 ? 279 Medical/Surgical Supplies & Devices
280 ? 289 Oncology
290 ? 299 Durable Medical Equipment (DME)
300 ? 319 Laboratory/Laboratory Pathological
320 ? 339 Radiology Diagnostic/Therapeutic
340 ? 349 Nuclear Medicine
350 ? 359 CT Scan
360 ? 369 Operating Room Services
370 ? 379 Anesthesia
410 ? 449 Therapy Services
450 ? 459 Emergency Codes
540 ? 548 Ambulance Services
720 ? 729 Labor and Delivery
730 ? 750 Outpatient Surgery
800 ? 880 Radiology
900 ? 919 Psychiatric/Psychological
920 ? 999 Nuclear Medicine

Required and Conditional Field Indicator
Required (R) fields must be completed on all claims.
Conditional (C) fields must be completed if the
information applies to the services rendered to Horizon
NJ Health members.

IMPORTANT ? Referrals are valid for up to 180 days.
The referral number on the claim does not generate a
payment. The actual referral must be submitted with each
claim to avoid claim processing delays or denials.

9.2.3 Taxonomy Codes
Taxonomy codes are administrative codes set for
identifying the provider type and area of specialization for
health care providers. Each taxonomy code is a unique
ten-character alphanumeric code that enables providers
to identify their specialty at the claim level.

Taxonomy codes are assigned at both the individual
provider and organizational provider level. Taxonomy
codes have three distinct levels: Level I is Provider
Type, Level II is Classification, and Level III is the
Area of Specialization. Examples and discussion of
taxonomy codes can be found at https://www.cms.
gov/medicare/providerenrollment-and certification/
medicareprovidersupenroll/taxonomy.html.



Horizon NJ Health - Billing Guide

For paper UB04 institutional claims, the taxonomy code
should be placed in box 81 and should be submitted with
the ?B3? qualifier. For CMS-1500 professional claims, the
taxonomy code should be identified with the qualifier
?ZZ? in the shaded portion of box 24i. The taxonomy
code should be placed in the shaded portion of box 24j
for the rendering level and in box 33b preceded with
the ?ZZ? qualifier for the billing level. Claims that do not
contain these codes cannot be processed.

CMS 1500 (08-05) Professional Claim Form
(for enumerated providers)

Billing Provider NPI Field 33a
Billing Provider TIN Field 25
Referring Provider NPI Field 17b
Rendering Provider NPI Field 24j
Service Facility Location NPI Field 32a

IMPORTANT ? Make sure that your claim software
supports the revised 1500 claim form (08-05). Reference
the 1500 Reference Instruction Manual at Nucc.org for
specific details on completing this form.

UB-04 Paper Institutional Claim Form
(for enumerated providers)

Billing Provider NPI Locator 56
Billing Provider TIN Locator 05
Billing Provider Taxonomy Code Locator 81
Attending Provider NPI Locator 76
Operating Provider NPI Locator 77
Other Provider NPI Locator 78-79

9.3 Procedures for Electronic Submission ?
Electronic Data Interchange

IMPORTANT ? Effective January 1, 2017, registered
providers must include their taxonomy code, tax
identification number, and NPI on all claims. Atypical
providers, as defined by CMS, must submit their
taxonomy code and their tax identification number.
IMPORTANT ? All claims submitted electronically must
be in a HIPAA compliant 837 or NCPDP format. Electronic
data interchange (EDI) allows faster, more efficient and
cost-effective claim submission for hospitals, physicians
and health care professionals. EDI, performed in
accordance with nationally recognized standards,
supports the industry?s efforts to reduce overhead
administrative costs.

The benefits of billing electronically include:
? Reduction of overhead and administrative costs.

EDI eliminates the need for paper claim submission.
It has also been proven to reduce claim rework
(adjustments).

? Receipt of reports as proof of claim receipt. This
makes it easier to track the status of claims.

? Faster transaction time for claims submitted
electronically. An EDI claim averages about 24 to 48
hours from the time it is sent to the time it is received.
This enables providers to easily track their claims.

? Validation of data elements on the claim. By the
time a claim is successfully received electronically,
information needed for processing is present. This
reduces the chance of data entry errors that occur
when completing paper claim forms.

? Quicker claim completion. Claims that do not need
additional investigation are generally processed
quicker. Reports have shown that a large percentage
of EDI claims are processed within 10 to 15 days of
their receipt.

IMPORTANT ? Referrals are valid for up to 180 days
and up to 6 visits. The referral number on the claim
does not generate a payment. The actual referral must
be submitted with each claim to avoid claim processing
delays or denials.

Note: Hospitals, physicians and health care professionals
submitting claims electronically should make sure the
referral number is present on the claim.

Note: EDI Technical Support Team is available during
regular business hours, 8 a.m. through 5 p.m., Monday
through Friday. It can be reached at 1-800-556-2231.

9.3.1 Hardware/Software Requirements
There are many different products that can be used to
bill electronically. Hospitals, physicians and health care
professionals should send EDI claims to TriZetto TTPS
whether through direct submission or through another
clearinghouse/vendor using payor number 22326. Only
TriZetto TTPS can submit claims electronically to Horizon
NJ Health.

Contracting with TriZetto and Other Electronic
Vendors
If you are a hospital, physician or health care professional
interested in submitting claims electronically to Horizon
NJ Health but do not have TriZetto EDI services, contact
TriZetto at 1-800-556-2231. You may also choose to
contract with another EDI clearinghouse or vendor who
already has access to TriZetto EDI services.



Horizon NJ Health - Billing Guide

Contacting the EDI Technical Support Group
Hospitals, physicians and health care professionals
interested in sending claims to Horizon NJ Health
electronically may contact the EDI Technical Support
Group for information and assistance.

Once Horizon NJ Health is notified of the intent to submit
claims through EDI, the organization?s contact will receive
a complete list of ID numbers for Horizon NJ Health
hospitals, physicians and health care professionals, the
electronic payor number, TriZetto-specific edits, and any
other information needed to initiate electronic billing with
Horizon NJ Health.

Note: Physicians can contact the EDI Technical Support
Group to obtain names of other EDI clearinghouses
and vendors.

Transmission Requirements
Once the material is received, proceed as follows:

? Read over the materials carefully
? Transmission can begin upon receipt of ID numbers

for Horizon NJ Health individual hospitals, physicians
and health care professionals

Contact the EDI Technical Support Group to answer
any questions you may have. If you wish to receive
confirmation to begin electronic submission, the EDI
Technical Support Group will contact you via fax, mail or
email on the effective day for EDI claim submission.

No approval is necessary. Contact your system vendor
and/or TriZetto to inform them that you are now
going to submit production claims electronically to
Horizon NJ Health. You will be asked for the electronic
payor address and the TriZetto-specific edits included in
your Horizon NJ Health documentation.

Note: Contact EDI Technical Support at 1-800-556-2231
to notify them of your intention to begin EDI
transmissions.

9.3.2 Specific Data Record Requirements
EDI claims should be submitted according to HIPAA
standards. These standards can be found in the
Implementation Guides written by the Designated
Standard Maintenance Organizations (DSMOs)
responsible for each transaction. Additional information
can be obtained through the Center for Medicare and
Medicaid Services website at cms.hhs.gov.

9.3.3 Electronic Claim Flow Description
In order to send claims electronically to Horizon NJ
Health, all EDI claims must first be forwarded to TriZetto
using payor number 22326. This can be completed
via a direct submission or through another EDI
clearinghouse or vendor. Once TriZetto receives the
transmitted claims, they are validated against TriZetto?s
proprietary specifications and Horizon NJ Health-specific
requirements. Claims not meeting the requirements are
immediately rejected and sent back to the sender via a
TriZetto error report. The name of this report can vary,
based on the physician?s contract with their intermediate
EDI vendor or TriZetto. Claims are then passed to
Horizon NJ Health, and TriZetto returns a conditional
acceptance report to the sender immediately.

Claims forwarded to Horizon NJ Health by TriZetto
are immediately validated against physician and
member eligibility records. Claims that do not meet
this requirement are rejected and sent back to TriZetto,
which also forwards this rejection to its trading partner ?
the intermediate EDI vendor or directly to the hospital,
physician or health care professional. Claims passing
eligibility requirements are then passed to the claim
processing queues. Claims are not considered received
under timely filing guidelines if rejected for missing or
invalid provider or member data.

Hospitals, physicians and health care professionals
are responsible for verification of EDI claims receipts.
Acknowledgements for accepted or rejected claims
received from TriZetto or other contracted vendors
must be reviewed and validated against transmittal
records daily.

Note: For a detailed list of TriZetto data requirements,
contact EDI Technical Support at 1-800-556-2231.

9.3.4 Invalid Electronic Claim Record
Rejections/Denials

All claim records sent to Horizon NJ Health must first pass
TriZetto?s proprietary edits and Horizon NJ Health-specific
edits prior to acceptance. Claim records that do not pass
these edits are invalid and will be rejected without being
recognized as received at Horizon NJ Health. In these
cases, the claim must be corrected and resubmitted within
the required filing deadline of 365 calendar days from
the date of service. It is important that you review the
rejection notices (the functional acknowledgements to
each transaction set and the unprocessed claim report)
received from TriZetto or your vendor in order to identify
and resubmit these claims accurately.



Horizon NJ Health - Billing Guide

Common Rejections

? Missing or invalid member ID
? Claims with missing or invalid batch level records
? Claim records with missing or invalid required fields
? Claim records with invalid (unlisted, discontinued, etc.)

codes (CPT-4, HCPCS, ICD-10, etc.)
? Claims without or that have invalid hospital, physician

or health care professional National Provider Identifier
(NPI) numbers whenever applicable. Per federal
requirements, atypical providers are excluded

? No physical billing address on file
? No taxonomy code

Note: Hospital, physician or health care professional
identification number validation is not performed at the
clearinghouse. Claims will be rejected if the hospital,
physician or healthcare professional number fields are empty.

9.3.5 Submitting Corrected Claims with EDI
Providers using electronic data interchange (EDI) can
submit corrected claims electronically rather than via
paper to Horizon NJ Health.

Note: A corrected claim is defined as a resubmission
of a claim with a specific change that you have made,
such as changes to CPT codes, diagnosis codes or billed
amounts. It is not a request to review the processing of a
claim. The electronic corrected claim submission capability
allows for faster processing, increased claims accuracy
and a streamlined submission process. For your EDI
clearinghouse or vendor to start using this new feature
they need to:

? Use ?6? for adjustment of prior claims ?7? for
replacement of a prior claim or ?8? for a voided claim
utilizing bill type in loop 2300, CLM05-03 (837P).

? Include the original claim number in segment
REF01=F8 and REF02=the original claim number; no
dashes or spaces.

? Include the Horizon NJ Health claim number in order
to submit your claim with the 6, 7 or 8.

? Bill all services, not just the services that need
corrections.

? Do use this indicator for claims that were previously
processed (approved or denied).

? Do not use this indicator for claims that contained
errors and were not processed (such as claims that
did not appear on a remittance advice; i.e., rejected
up front).

? Do not submit corrected claims electronically and via
paper at the same time.

? Please note that either a written or stamped note
stating that any claim is a corrected claim will result in
that claim being returned for correction.

9.3.6 Electronic Billing Inquiries
Please direct inquiries as follows:

Action
? If you would like to be authorized to transmit

electronic claims
? If you have specific EDI technical questions
? If you have general EDI questions or questions on

where to enter required data

Contact
? TriZetto Technical Support at 1-800-556-2231

Action
? If you have questions about your claims transmissions

or status reports
? Contact your System Vendor or call TriZetto at
1-800-556-2231

Action
? If you have questions about your claim status (receipt

or completion dates)
? If you have questions about claims that are reported

on the Remittance Advice
? If you need to know a provider ID number

Contact
? NaviNet.net. If the required information is not found,

call Provider Services at 1-800-682-9091.

Action
? If you would like to update provider, payee, UPIN,

tax ID number, physical billing address or payment
address information

? For questions about changing or verifying provider
information

Contact
Email: providerfileops2@horizonblue.com
fax: 1-973-274-4126
Provider Services at 1-800-682- 9091



Horizon NJ Health - Billing Guide

9.4 Common Coding Requirements

9.4.1 Diagnosis Codes
All claims must include the proper ICD-10-CM
diagnostic code.

The Centers for Medicare and Medicaid Services (CMS)
provides specific guidelines to aid in standardizing U.S.
coding practices. The guidelines for outpatient facilities,
physician offices and ancillary care are summarized below:

? Identify each service, procedure or supply with an
ICD-10-CM code to describe the diagnosis, symptom,
complaint, condition or problem.

? Identify services or visits for circumstances other
than disease or injury, such as follow-up care after
chemotherapy, with V codes provided for this purpose.

? Code the primary diagnosis first, followed by the
secondary, tertiary and so on. Code any coexisting
conditions that affect the treatment of the patient.
Do not code a diagnosis that is no longer applicable.

? Code to the highest degree of specificity. Carry
the numerical code to the fourth or fifth digit when
available. Remember, there are only approximately
100 valid three-digit codes; all other ICD-10-CM codes
require additional digits.

? Code a chronic diagnosis, when it is applicable to the
patient?s treatment.

? When only ancillary services are provided, list the
appropriate V code first and the problem second.
For example, if a patient is receiving only ancillary
therapeutic services, such as physical therapy, use the
V code first, followed by the code for the condition.

? For surgical procedures, code the diagnosis applicable
to the procedure. If, after the procedure has been
done, the condition necessitating the surgery is more
specifically identified, or even determined to be
different than the preoperative diagnosis, code the
most specific diagnosis determined to be the reason
for the surgery.

Horizon NJ Health has adopted these diagnosis
guidelines for its health plan and recommends that
hospitals, physicians and health care professionals remain
informed about these requirements through updated
ICD-10-CM coding manuals. Both the State of New Jersey
and the HIPAA transaction code sets require the use of
a diagnosis code on all claims. To ensure that diagnosis
codes are accurate, use the appropriate codes from the
most recent ICD-10-CM coding manuals. Using deleted or
incorrect codes will result in inability to process your claim
or payment delays.

9.4.2 Procedure Codes
Common Procedure Terminology
CPT is a standardized system of five-digit codes and
descriptive terms used to report the medical services
and procedures performed by physicians or health care
professionals. It was developed and is updated and
published annually by the American Medical Association
(AMA). CPT codes communicate to physicians, health
care professionals, patients and payors the procedures
performed during a medical encounter. Accurate coding
is crucial for proper reimbursement from payors and
compliance with government regulations.

The AMA revises and publishes the CPT Book on an
annual basis. Appendix B of CPT always consists of
asummary of additions, deletions and revisions to the
current edition. Of these three types of changes, only
the descriptions of revised codes appear in Appendix B,
so you must refer to the manual itself to look at the
descriptors of the new codes.

All physicians and health care professionals must use
the appropriate procedure codes from the most recent
HCPCS and CPT coding manuals or quarterly updates.
Claim processing cannot be completed without accurate
procedure codes, which reflect the services provided
to enrollees.

9.4.3 Modifiers
Modifiers are used to report that the procedure has been
altered by a specific circumstance. Modifiers provide
valuable information about the actual services rendered,
reimbursement and payment data. Modifiers also provide
for coding consistency and editing for Level I (Common
Procedure Terminology Codes) and Level II (Healthcare
Common Procedure Coding System).

Sometimes, CPT codes require the addition of two-digit
modifiers. CPT modifiers allow you to show that a service
was altered in some way from the stated CPT Book
description. Because the use of modifiers is frequently
the only way to alter the meaning of a CPT code, it is very
important to know how to use modifiers correctly.



Horizon NJ Health - Billing Guide

Modifiers can indicate:
? A service or procedure has both a professional and a

technical component
? A service or procedure was performed by more than

one physician
? Only part of a service was performed
? An adjunctive service was performed
? A bilateral procedure was performed
? A service or procedure was provided more than once
? Unusual events occurred

Use the appropriate modifier from the most recent HCPCS
and CPT coding manuals. Using deleted or incorrect
codes and failing to use a modifier can result in denials,
incorrect payments or claim payment delays.

IMPORTANT ? Modifiers should not be used for multiple
evaluation and management events unless the activity
occurs at separate times on the same day. The Evaluation
and Management Services Guide from CMS will be used
by Horizon NJ Health to determine the appropriateness
of coding submitted by physicians and health care
professions, including the use of modifiers.
For more information on the Evaluation and Management
Services Guide please visit the Medicare Learning
Network (MLN) at cms.gov/MLNGenInfo.

Note: These modifiers are subject to change. Consult the
current CPT or HCPCS publications for the most up-to-
date modifier list.

9.4.4 Units
The number of units or times a particular service is
performed must be accurately indicated on all claims.
When spanning dates of services, the number of units
must match the count of the actual days within the
spanned dates. If services were performed intermittently
throughout the spanned dates of services, each date must
be listed separately on the bill or an itemized statement
must be submitted along with the claim.

When billing for loaded mileage, exact mileage must
be identified on the claim. When billing for observation,
units are equivalent to hours. All anesthesia providers are
required to indicate the true amount of minutes in the
days/units field of the claim form when billing for services.
IMPORTANT ? The number of units and the service dates
must be coordinated in order to obtain the most accurate
reimbursement for the services billed. Services performed
once (one date of service) must be indicated with a ?1? in
the unit?s field.

9.4.5 Other Coding
Use the appropriate coding as indicated in the official
guides for the CMS 1500 and UB-04 claim forms or
HIPAA-compliant electronic transaction sets when
completing additional fields such as bill type, place of
service and type of service. Incorrect coding can cause
under- or over-payments or claim payment delays.

9.4.6 Taxonomy Codes
Taxonomy codes on electronic claim submissions with the
ASC X12N 837P and 837I format are placed in segment
PRV03 and loop 2000A for the billing level and segment
PRV03 and loop 2420A for the rendering level.

9.4.7 Pharmacy (HCPC Codes)
When billing for all ?J? and ?Q? codes via revenue codes,
the appropriate National Drug Codes (NDC) number,
metric units, unit of measure, and revenue code must be
submitted as well. Failure to submit the NDC number,
metric units, unit of measure, and revenue code along
with the ?J? or ?Q? code will result in the claim being
rejected. This guideline applies to all claims.



Horizon NJ Health - Billing Guide

9.5 Common Causes of Claim Processing
Delays, Rejections or Denials

? Authorization or referral number invalid or missing
? Billed charges missing or incomplete
? Claim information does not match authorization
? Coordination of benefits (COB) information missing

or incomplete
? Diagnosis code missing 4th or 5th digit
? Diagnosis, procedure or modifier codes invalid

or missing
? DRG codes missing or invalid
? Early and Periodic Screening, Diagnostic

andTreatment (EPSDT) information missing
or incomplete

? Eligibility/enrollment is not valid on DOS
? Employer identification number (EIN) missing

or invalid
? Explanation of benefits (EOB) missing or incomplete
? Hospital, physician or health care professional

identification number missing or invalid
? Illegible claim information
? Incomplete forms
? Payor or other insurer information missing

or incomplete
? Place of service code missing or invalid
? Procedure/service code does not match authorization
? Physician name missing or invalid
? Revenue codes missing or invalid
? Spanning dates of service do not match the listed

days/units
? Signature missing
? Third-party liability (TPL) information missing

or incomplete
? Type of service code missing or invalid
? When billing urgent care center claims, Horizon NJ

Health reimburses facilities only and not the individual
providers. Urgent care centers are reimbursed at an
all-inclusive case rate.

9.5.1 Newborn Claim Information Missing
or Invalid

All newborns receive an individual member number. Please
check the Electronic Medicaid Eligibility Verification System
(EMEVS) for the Medicaid number and include it when the
claim is billed. Always include the first and last name of the
mother and baby on the claim. If the baby has not been
named, insert ?Girl? or ?Boy? in front of the mother?s last
name as the baby?s first name. Verify that the appropriate
last name is recorded for the mother and baby.

IMPORTANT ? The claim for baby must include the baby?s
date of birth.

IMPORTANT ? On claims for twins or other multiple
births, indicate the birth order in the patient name field,
e.g., Baby Girl Smith A, Baby Girl Smith B, etc.

9.5.2 Attachments Missing from
Original Claim

Hospitals, physicians and health care professionals are
required to submit an invoice for implantable and other
insurance EOBs if they are denied. If these items are not
submitted with the claim or are submitted separately
(EDI and paper), incorrect payment or denials may occur.

Adjustments to these payments or denials should be
submitted as corrected claims not as a resubmission of
the original claim. Please submit to the correspondence
address below:

Horizon NJ Health
Claims Processing Department
PO Box 24078
Newark, NJ 07101-0406

Signed consent forms for sterilization are required for
payment under federal requirements. (See Section 3.3
Family Planning.) These forms should be submitted to the
address below:

Horizon NJ Health
PO Box 24078
Newark, NJ 07101-0406

Signed receipt of information form, FD-189 must be
submitted during the request for prior authorization for
hysterectomies.

9.5.3 Claims and Clinical Editing
The Centers for Medicare and Medicaid Services (CMS)
and the American Medical Association (AMA) have
spearheaded a correct coding initiative that intends to
establish norms for coding medical services. Medicaid
programs are required to apply National Correct Coding
Institute (NCCI) edits to physician and outpatient hospital
claims. Services deemed to be a part of a more complex
service as defined by the NCCI will be re-bundled or
denied as established by current criteria set by CMS in
its claims processing manual. Horizon NJ Health also
uses the CMS Claims Processing Manual as a guide to
managing payments for services provided to its
members, including the medically unlikely edits (MUE)
subset and redundant edits. CMS publishes the
majority of existing MUEs on the CMS website at
cms.gov/nationalCorrectCodInitEd/.



Horizon NJ Health - Billing Guide

Horizon NJ Health continues to enhance its software
used to adjudicate medical, professional and hospital
outpatient claims. Horizon NJ Health uses McKesson
ClaimsXten software. This is a clinically-based editing
solution, that helps ensure that our code and claim editing
rules are accurate and consistent with standard business
practices and ensures that the claim editing system is
transparent to all participating providers, and that claim
payments are accurate and consistent with standard
business practices and medical policies. ClaimsXten edits
are applied to all claims submitted to Horizon NJ Health
by physicians, health care professionals and hospitals.

9.6 Coordination of Benefits
Any services provided to a Horizon NJ Health member
are reviewed against benefits provided for that same
individual under other insurance carriers with whom the
member has coverage. Horizon NJ Health, as a managed
care program for Medicaid and NJ FamilyCare members
in New Jersey, is the ?payor of last resort? on claims for
services provided to members also covered by Medicare,
employee health plans or other third-party medical
insurance. Payors, which are primary to Horizon NJ Health,
include (but are not limited to):

? Private health insurance, including assignable
indemnity contracts

? Health maintenance organizations (HMOs)
? Public health programs, such as Medicare
? Profit and nonprofit health plans
? Self-insured plans
? No-fault automobile medical insurance
? Liability insurance
? Workers? compensation
? Long-term care insurance
? Other liable third parties

In cases where another insurer, including Medicare fee
for service, is deemed responsible for payment,
Horizon NJ Health will pay the lesser of the patient
responsibility as indicated on the primary carrier?s
explanation of benefits or the difference between our
maximum allowable expense and the amount paid
by the primary insurer. Please note, the total amount
reimbursed by all parties will not exceed the lowest
contractually agreed upon amount and will not exceed
the normal Horizon NJ Health benefits, which would have
been payable had no other insurance existed. Hospitals,
physicians and health care professionals should not file a

claim with Horizon NJ Health until they receive the EOB
from the member?s other insurance carrier(s). Make sure
you follow that insurer?s administrative requirements,
standard claim submission policies and forms.

Upon receipt of payment, submit applicable claims
to Horizon NJ Health for payment of deductibles and
coinsurance amounts. Horizon NJ Health reimburses
after coordination of benefits and only up to the primary
contracted rate for the service. The claim, PCP referral and
primary insurer?s explanation of benefits (EOBs) must be
submitted within 60 days of the date of the other carrier?s
correspondence or within 365 days of the date of service,
whichever is later. When preparing the claim, include a
complete record of the original charges and primary (or
additional) payor?s payment as well as the amount due
from the secondary or subsequent payor.

Submit all pages of the primary (or additional) insurer?s
EOB to avoid delays in completing claims due to missing
information or coding and message descriptions. This
information ensures accurate coordination of benefits.
With the exception of Medicare, Horizon NJ Health?s
same notification policies that are routinely applied and
required must be followed for any claims to be considered
for payment. In the case of Medicare as the primary
insurer, practitioners and facilities are advised to follow
Horizon NJ Health?s procedures, as some services may
be exhausted or not covered by Medicare.

IMPORTANT ? All coordination of benefit (COB) claims
must be submitted with a copy of the EOB from the
primary insurer. If the primary insurance claim has been
paid, the COB claim can be submitted through EDI
transmission. If the primary insurance claim has been
denied, a paper copy of the primary explanation of
payment should be sent. Submit paper claims for all
medical services to Horizon NJ Health at the following
address:

Horizon NJ Health
Claims Processing Department
PO Box 24078
Newark, NJ 07101-0406

When seeking reimbursement from Horizon NJ Health
as secondary insurer where Medicare is an enrollee?s
primary source of insurance, you must use one of the
following processes. When you provide services to a
member who has other coverage, you must bill the
member?s primary insurer directly. Be sure to follow
that insurer?s claims submission policies. You must then
submit a claim and the primary insurer?s explanation of



Horizon NJ Health - Billing Guide

benefits (EOB) to Horizon NJ Health within 60 days of the
date of the EOB or within 180 days of the date of service,
whichever is later. Alternatively, secondary/coordination
of benefits (COB) claims may be submitted electronically,
utilizing the following COB loops:

Loop Description Reported Data

2320 Other Subscriber Information Name of Primary Insurance
2330A Other Subscriber Name Name of Subscriber*
2330B Other Payer Name Payment Date from Other Insurance
2340 Line Adjudication Information Other Insurance Payment
Note: Although a primary insurer may have unique coding
specific to their business, providers must bill with valid
ICD-10-CM, CPT-4 and HCPCS codes. Unique or invalid
codes specific to other insurers will cause claim processing
delays or denials.

IMPORTANT ? The hospital, physician or health care
professional may not submit billed charges to
Horizon NJ Health that are different than charges
submitted to other insurers for the same services. The
submitted bill must contain the exact billed amounts by
procedure line as is reflected on the primary or additional
insurer?s EOB.

IMPORTANT ? The primary or additional insurer?s EOB
must include member name, billed amounts, paid
amounts, adjustments, coinsurance amounts, deductibles,
copayments and all associated messages and notes.
Incomplete information may result in a claim processing
delay or denial.

9.6.1 Medicare
When both Medicare and Medicaid cover a member
and the service is a benefit of both programs, the claim
must first be filed with Medicare. Hospitals, physicians
and health care professionals should not file a claim with
Horizon NJ Health until they receive the Medicare EOB.
Upon receipt of payment, submit the claim along with a
copy of the Medicare EOB to Horizon NJ Health within
60 days of the date of the Medicare EOB or 180 days
from the date of service, whichever is later.

Medicare primary members have no prior authorization
requirements and are not required to be seen by a
participating Horizon NJ Health hospital, physician or
health care professional, unless Medicare does not cover
the service. When Horizon NJ Health, by default, becomes
the primary payor, the hospital, physician or health care
professional must comply with all coverage requirements
indicated by Horizon NJ Health to be considered for
payment. Horizon NJ Health advises that services to
members covered by Medicare and Medicaid be reported
despite the fact that authorization is not required. This will
avoid delays in claims payment for services that Horizon
NJ Health must cover.

Medicare-eligible services denied by Medicare due to
failure to comply with medical, administrative or filing
requirements will not be covered by Horizon NJ Health.

Note: When Medicare is primary?

? and the procedure is covered by Medicare, an
authorization or referral is not required by
Horizon NJ Health, even if one is normally required
by Horizon NJ Health. Reporting these services to
Horizon NJ Health is advised.

? and the procedure is not covered by Medicare, an
authorization or referral is required by Horizon NJ Health
if one is normally required by Horizon NJ Health.

IMPORTANT ? The hospital, physician or health care
professional may re-bill for services originally denied
by Medicare when Medicare overturns the denial. The
hospital, physician or health care professional must submit
the re-bill within 60 days of the date of Medicare?s EOB or
180 days from the date of service, whichever is later.



Horizon NJ Health - Billing Guide

9.6.2 Other Third-Party Medical Insurance
Members covered by a primary insurer including
Medicare should be instructed to notify Horizon NJ Health
of their primary coverage. Claims submitted to
Horizon NJ Health as the secondary or tertiary insurer
are subject to eligibility and benefit coverage. To receive
payment for a claim submitted to Horizon NJ Health as
the secondary or tertiary insurer, the hospital, physician
or health care professional must submit a copy of the
primary insurer?s EOB or denial letter along with the claim
to Horizon NJ Health.

NOTE ? Submit claims to Horizon NJ Health within 60
days of the date of the primary insurer?s remittance and/
or EOB or 180 days from the date of service, whichever
is later. Participating hospitals, physicians or health care
professionals may not bill Horizon NJ Health members
for deductibles and coinsurance or balances above our
allowable fees. Medicaid is the ?payor of last resort;?
therefore, the payments received from the primary
insurer and/or Horizon NJ Health must be considered
payment in full. Members are not to be billed for any
Horizon NJ Health covered service. If the service is not
covered by the other insurer or Horizon NJ Health, there
must be prior written agreement to bill the member for
these non-covered services.

REFER TO ? Section 10.0 Complaint and Appeals Process,
for complete instructions of the submission time frames
and procedures for administrative or medical appeals.

IMPORTANT ? If there is any possibility that the services
provided will not be covered by the primary insurer, the
hospitals, physicians or health care professionals should
obtain the appropriate referrals or prior authorizations
needed to obtain coverage under Horizon NJ Health.
Failure to do so may result in denial for payment.

IMPORTANT ? If you provide services to a member who
is ill or injured as the result of a third party action, you
must notify Horizon NJ Health of this information. In the
event that this information is determined after the claim
is submitted and/or resolved, you are still required to
inform Horizon NJ Health. This includes recording the
information about the injury or condition on the claim and
notifying Horizon NJ Health of any lawsuits or legal action
in relation to the injury or condition.

IMPORTANT ? When completing the CMS 1500 (HCFA
1500) claim form, be sure to complete #7 on the form.

Motor Vehicle Accidents
Motor vehicle accident-related claims should be
submitted to the primary carrier prior to being
submitted to Horizon NJ Health. If benefits exhaust or
are unavailable, the claim may be submitted to Horizon
NJ Health along with an explanation of benefits or a
denial letter in order to be considered for payment. In
all cases, Horizon NJ Health?s referral, prior authorization
and notification policies that are routinely applied and
required must be followed for any claims to be considered
for payment.

Upon receipt of a letter of exhaustion or denial letter
from the primary carrier, the hospital, physician or health
care professional will have 60 days from the date of the
letter to submit the claim or 180 days from the date of
service, whichever is later. Upon receipt of an EOB from
the primary carrier, Horizon NJ Health will pay the lesser
of the patient responsibility as indicated on the primary
carrier?s EOB or the difference between our maximum
allowable expense and the amount paid by the primary
insurer.

Please note, the total amount reimbursed by all parties
will not exceed the lowest contractually agreed upon
amount and normal Horizon NJ Health benefits, which
would have been payable had no other insurance existed.

In all cases, Horizon NJ Health?s referral, prior
authorization and notification policies that are routinely
applied and required must be followed for any claims to
be considered for payment.

IMPORTANT ? When preparing the claim, all information
relating to the accident must be included on the claim.
This includes diagnosis codes, accident indicators and
occurrence codes (UB-04 claim forms) where appropriate.
Additionally, if a primary insurer has made payment
for services, the insurer?s EOB must be included when
submitting the claim for payment.

Workers? Compensation
Workers? compensation covers any injury that is the
result of a work-related accident. If Horizon NJ Health
is aware of a workers? compensation carrier, Horizon NJ
Health will reject the hospital, physician or health care
professional?s claim and direct that the claim be submitted
first to the primary workers? compensation carrier. If
insurance coverage is not available at the time the claim
is submitted or the workers? compensation carrier ceases
to provide coverage, the claim will be considered for
payment.



Horizon NJ Health - Billing Guide

Upon receipt of a letter of exhaustion or denial letter from
the primary carrier, the hospital, physician or health care
professional will have 60 days from the date of the letter
to submit the claim.

9.6.3 Reimbursement
Medicare
If a member has Medicaid and Medicare coverage,
the hospital, physician or health care professional may
bill for charges Medicare applied to the deductible or
coinsurance, or both. Horizon NJ Health will pay the lesser
of the patient responsibility as indicated on the primary
carrier?s EOB or the difference between our maximum
allowable expense and the amount paid by the primary
insurer. Please note, the total amount reimbursed by
all parties will not exceed the lowest contractually
agreed upon amount and normal Horizon NJ Health
benefits, which would have been payable had no other
insurance existed.

Note: Horizon NJ Health considers the deductible,
coinsurance and copayments a component of the total
primary care capitation for primary care reimbursement for
services, which are capitated. If your primary care contact
is for fee-for-service reimbursement, please first bill the
primary carrier and then bill Horizon NJ Health with the
carrier(s) EOB.

IMPORTANT ? Bills submitted to the secondary insurer
must exactly match the services and amount billed to the
primary insurer. This information, along with the primary
insurer?s EOB, is necessary to complete an accurate COB.
Incomplete information could result in processing delays
or denials.

Other Third-Party Medical Insurance
Horizon NJ Health will pay the lesser of the patient
responsibility as indicated on the primary carrier?s
explanation of benefits or the difference between our
maximum allowable expense and the amount paid by the
primary insurer. Please note, the total amount reimbursed
by all parties will not exceed the lowest contractually
agreed upon amount and normal Horizon NJ Health
benefits, which would have been payable had no other
insurance existed.

Guidelines on Billing Mileage for
MemberTransportation Services
Horizon NJ Health members shall be transported to and
from medical appointments in a manner that results in the
accrual of the least number of miles. Mileage is measured
by odometer from the place of departure or the point at
which the member enters the vehicle to the destination or
point at which the member exits the vehicle. At no time
shall the transportation provider?s base location be used
when calculating mileage.

9.6.4 Services That Do Not Require a Primary
Insurer EOB

Services Not Covered by Traditional Medicare
? Hearing aids
? Diapers/Under-pads/Incontinence items
? EPSDT
? Personal care assistants (Medicare FFS only)
? Medical day care (Medicare FFS only)

Physician and health care professionals may bill
Horizon NJ Health for these services without submission
of a primary insurer?s EOB.
Note: If a service is covered by Medicare Advantage,
please supply the resulting EOB.

IMPORTANT ? If billing for room and board only at a
skilled nursing facility, reimbursement will be considered
without submission of Medicare EOB.

Other Third-Party Medical Insurance
An EOB or notice of refusal must be submitted with all
commercial and Medicare Advantage insurers? claims.
Claims with primary payment can be submitted via EDI.

9.6.5 Denials from Primary Insurers
If the primary insurer denies payment to the hospital,
physician or health care professional based on coverage
exclusion, non-coverage, benefit exhaustion or non-
compliance with administrative guidelines, the physician
must submit a copy of the EOB or notice of refusal. The
EOB or notice of refusal must include an explanation of
the reason for the denial. Services denied by the primary
insurer and billed to Horizon NJ Health without an
explanation of the denial from the primary insurer will be
denied payment.

Services denied by the primary insurer for non-compliance
with medical or administrative guidelines may be
submitted to the secondary with a copy of the EOB or
notice of refusal and a copy of the final appeal denial
letter or notice of refusal. Medical and/or administrative
denials will not be considered without receipt of the final
appeal denial letter.



Horizon NJ Health - Billing Guide

IMPORTANT ? Horizon NJ Health will document receipt
of notices that the member?s primary carrier does not
cover a service or that the service is exhausted. No
additional notices will be required until the anniversary
date of the member?s policy with that other insurer.
Annually, on or after the anniversary date, the hospital,
physician or health care professional must provide notice
again that the service is exhausted or not covered by the
primary carrier.

Note: The hospital, physician or health care professional
must file a claim with the primary insurer within the
appropriate timely filing deadlines and according to
appropriate filing requirements. Failure to submit medical
and administrative denial information from a primary
insurer could result in processing delays or denials.

IMPORTANT ? Upon receipt of a letter of exhaustion
or denial letter from the primary carrier, the hospital,
physician or health care professional will have 60 days
from the date of the letter to submit the claim.

9.7 Early and Periodic Screening, Diagnosis
and Treatment (EPSDT)

EPSDT claims are paid based on the periodicity schedule.
The biological component of immunizations is only paid
where the Vaccines for Children (VFC) program does
not offer the biological or the supply is not available.
Administration of VFC-sponsored immunizations is paid on
a per-visit basis; therefore, multiple shots given in a single
visit will result in a per-vaccine administration payment.
Physicians and health care professionals are encouraged
to use combination immunizations when available.

The following CPT codes and modifiers should be used
when conducting lead screening:

36405 59 Venipuncture for lead screening for children
under three years of age, scalp vein

36406 59 Venipuncture for lead screening for children
under three years of age, other vein

36410 59 Venipuncture for lead screening for children
three years of age or older

36415 59 Collection of venous blood by Venipuncture for
lead screening for children 3 years and older

36416 59 Collection of capillary blood specimen for lead
screening (finger, heel, and ear stick)

83655 52 Lead test (diagnosis code required)

Horizon NJ Health sends quarterly EPSDT underutilization
reports to physicians, identifying members whose EPSDT
services are overdue. Compliance with using the EP
modifier will increasethe accuracy of these reports.

9.8 Risk Assessment Program
Horizon NJ Health is required by the State of New Jersey
to report encounter data for all services rendered to
our members, including capitated and fee-for-service
activities. All physicians, hospitals and health care
professionals are required to submit timely, accurate and
complete encounter data. This is required even when the
member is covered by another insurer.

Health care resource consumption in chronic disease
can be very high. The State of New Jersey is using a
risk adjustment payment model in an attempt to fairly
distribute Medicaid funds in proportion to the severity of
illness. Horizon NJ Health is required to submit encounter
data to the State of New Jersey as an estimate of the
prevalence of disease in the population we serve.

It is paramount that accurate data be gathered on the
prevalence of illness of Horizon NJ Health members. This
leads to accurate, severity-adjusted payment from the
State to the health plan and, ultimately, the provider.

For example: Not only should members seek medical care
for acute conditions, they should also visit their provider
for chronic conditions, such as diabetes or hypertension.
Moreover, if a member visits for an acute issue and a
chronic issue is relevant or discussed, we ask that this is
documented in both the records and the encounter
claim form.

For further information, please call Horizon NJ Health?s
Risk Adjustment nurse at 1-800-682-9094, x89625.

All services must be submitted on the CMS 1500
(HCFA 1500) or the UB-04 claim form, or via electronic
submission in a HIPAA-compliant 837I, 837P or NCPDP
format. Horizon NJ Health is required to submit this data
in a HIPAA standard file format to the State. Any coded
field or data element contained in a HIPAA transaction
must adhere to the national set of codes, including
medical services and diagnosis. Due to the requirement
to submit all services to the State, all requirements for
EDI transactions are also applied to paper claims.

The State of New Jersey will reject encounter data if it
does not meet their processing criteria. In some instances,
Horizon NJ Health will be required to reverse payment
already made to the provider if the encounter does not
meet the State?s criteria. A complete list of all possible
encounter rejections can be obtained by going to njmmis.
com. Under the Information section, select Edit Codes,
then Encounter Edits. The following are some causes for
rejections:



Horizon NJ Health - Billing Guide

Facility Services
? NPI ? Any practitioner who is required to have an

NPI must report that number in the Billing Provider,
Rendering Provider, Attending Provider, Operating
Provider and Other Provider fields, if applicable.
The NPI is required by the State of New Jersey?s
Division of Medical Assistance and Health Services
for both electronic and paper claims submissions.
Horizon NJ Health and all practitioners of facilities
serving members are required to comply with this
requirement.

? Type of Bill ? The bill type must be consistent with
the type of service rendered with applicable revenue
codes and corresponding HCPCS. Common bill types
are listed in Section 9.2.2 of this manual.

? Statement Covers Period ? Any practitioner billing
for services must ensure that the dates of service are
within the time period indicated in the Statement
Covers Period stated on the claim. If a date of service
is outside the dates placed in the From/Through field,
the encounter will be rejected.

? Principle Procedure Date ? Any practitioner billing for
surgical services must ensure that the dates of service
are within the time period indicated in the Statement
Covers Period indicated on the claim. If the Principle
Procedure date or Other Procedure date field is
outside the dates reported in the Statement Covers
Period, the encounter will be rejected.

? Revenue Codes ? All revenue codes billed must be
valid for the type of claim being billed.

? Laboratory Services ? When billing revenue codes
300-319, the corresponding HCPCS or CPT codes
must be billed.

? Physician Administered Drug ? All services are
required to report units of measure for all drugs,
including their corresponding NDC code when
billingwith ?J? or ?Q? codes. The corresponding 11
digit NDC code must be reported along with the
correct unit of measure:

A. NDC units are based upon the numeric quantity
administered to the patient and the unit of measure.

UOM Description Guidelines

F2 International
unit

International units will mainly be
used when billing for Factor

VIII-Antihemophilic Factors

GR Gram Grams are usually used when
an ointment, cream, inhaler,
or bulk powder in a jar are
dispensed. This unit of measure
will primarily be used in the
retail pharmacy setting and not
for physician-administered drug
billing.

ML Milliliter If a drug is supplied in a vial in
liquid form, bill in millimeters.

UN Unit If a drug is supplied in a vial
in powder form, and must
be reconstituted before
administration, bill each vial
(unit/each) used.

NDC Units

Submit the decimal quantity administered and the units of
measurement on the claim. If reporting a partial unit, use a
decimal point.

? GR0.025
? ML2.5
? UN3.0

The quantity should be eight digits before the decimal
and three digits after the decimal. If entering a whole
number, do not use a decimal. Do not use commas.
Do not zero fill, leave remaining positions blank. The
following are some examples:

? 1234.56
? 2
? 12345678.123

Paper Claim Requirements

CMS 1500 form:

? Enter the NDC in the shaded area of the service lines
in Field 24

? The six service lines in section 24 have been
divided horizontally to accommodate submission
of supplemental information to support the billed
service. The top portion in each of the six service
lines is shaded and is the location for reporting
supplemental information.



Horizon NJ Health - Billing Guide

? Submit the NDC code in the red-shaded portion of
the detail line item starting in positions 01.

? The NDC is to be preceded with the qualifier N4 and
followed immediately by the 11 digit NDC code (e.g.
N412345678901).

UB-04 form:

? Field 42: Revenue code
? Field 43: NDC 11 digit number, Unit of Measurement

Qualifier and Unit Quantity
? Field 44: HCPCS code

For EDI claims

LOOP Segment Element
Name

Information

2410 LIN 02 Product or Service ID
Qualifier

If billing for a national drug
code (NDC), enter N4.

2410 LIN 03 If billing for drugs, include
the NDC.

LIN**N4*1234567890

2410 CTP 04 Quantity

If an NDC was submitted in
LIN03, include the quantity
for the NDC billed.

2410 CTP 05-1 Unit or Basis for
Measurement Code

If an NDC was submitted
in LIN03, include the unit
or basis for measurement
code for the NDC billed.

F2 - International unit

GR - Gram ML - Milliliter
UN - Unit

Sample - CTP****3*UN

2410 REF 01 VY: Link Sequence
Number, XZ : Prescription
Number

Link Sequence # (to
report components for
compound drug)

2410 REF 02 Link Sequence

Number or Prescription
Number

Sample -
REF01*VY*123456

Claims cannot be paid by Horizon NJ Health without this
information.

For additional information on the valid NDC codes, unit
and units of measure, please refer to the NJ Medicaid
website. https://www.njmmis.com/ndcLookup.aspx

Professional Services
? NPI ? Any practitioner who is required to have an

NPI must report that number in the Billing Provider,
Rendering Provider and Service Facility Location
if applicable. The NPI is required by the State of
New Jersey?s Division of Medical Assistance and
Health Services for both electronic and paper claims
submissions. Horizon NJ Health and all practitioners of
facilities serving members are required to comply with
this requirement. Providers are prohibited from billing
under the NPI number of a different provider.

? Transportation Services ? When billing for
transportation services, a valid origin and
destination modifier are required. Horizon NJ Health
members shall be transported to and from medical
appointments in a manner that results in the accrual
of the least number of miles. Mileage is measured
by odometer from the place of departure or the
point at which the member enters the vehicle to the
destination or point at which the member exits the
vehicle. At no time shall the transportation provider?s
base location be used when calculating mileage.
The CMS-1500 claim form should be completed
by choosing modifiers that appropriately support
the member?s place of departure and destination
locations.



Horizon NJ Health - Billing Guide

? Procedure Codes ? All codes are to be in HIPAA-
compliant format. The use of CPT Level III codes
(local codes) is no longer valid.

? Diagnosis Codes ? All diagnosis codes must be
reported and coded to the 7th digit, if available.

? Retroactive Terminations ? Horizon NJ Health
participates in the Medicaid and NJ FamilyCare
programs. Our members must maintain eligibility in
order to receive services. There may be times when
a member?s eligibility is retroactively terminated, as
determined by the Medicaid/NJ FamilyCare program.
This retroactivity will result in an encounter rejection.
Horizon NJ Health is required to reverse payment
already made to the physician, hospital and health
care professional.

? Medical Claims for Fluoride Varnish ? Providers
should use the following procedure and diagnosis
codes when submitting medical claims for fluoride
varnish applications:

? 99188-DA
? Z41.8 (ICD-10)

9.9 Remittance Advice Documentation

Overview of Payment Summary Page
Horizon NJ Health provides a comprehensive summary
of financial information and activity on the Remittance
Advice (RA).

The body of the RA contains claim detail and the Payment
Summary page indicates whether the physician/payee has
a positive (+) or negative (-) balance.

Many hospitals, physicians or health care professionals
have requested ongoing notification of overpayments and
negative payee balances in relation to claim adjudication
activities, capitation payments, or accounts payable
adjustments. The Payment Summary page displays this
information as ?rolling balances? of overpaid amounts
that are owed to Horizon NJ Health. The ?rolling balance?
is updated on each RA after current claim payments and
other adjustments have been applied.

If, after reviewing the RA, you have questions or want
to request a reconsideration, go to NaviNet.net. If your
concerns are still not resolved, contact Provider Services at
1-800-682-9091 for assistance.

These explanation codes represent the current set of
codes that are returned to the hospital, physician or
health care professional on the RA. Please review the
following list before calling the Physician & Health Care
Hotline for questions about RA codes. If an electronic RA
is requested, it will be submitted in the HIPAA-compliant
835 format. The explanation codes do not apply to an
electronic RA transaction.

McKesson RA Explanation Codes can be found at
horizonNJhealth.com/sites/default/files/ClaimsXTen_
Edit_Codes_and_Messages.pdf.

9.10 LabCorp Testing/Professional Relations
Representatives Billing

Some tests are not available via LabCorp and must be
completed at a hospital or clinical setting and billed
accordingly. Some of these tests cannot be performed
in hospitals and will require prior authorization. Please
contact LabCorp Customer Service for more information
on tests that are not available via LabCorp.

LabCorp Customer Service
1-800-631-5250

Information about testing not available through LabCorp
is also available at genetests.org.

9.11 Out-of-State Medicaid Claims for
Blue Cross and Blue Shield
Association Plans

State Medicaid agencies contract with Blue Cross and/
or Blue Shield Plans as Managed Care Organizations
(MCOs) to provide comprehensive Medicaid benefits
on a risk basis. Both federal and state regulations
guide these relationships, but the eligible population,
covered benefits and specific rules regarding each state?s
Medicaid program may differ from state to state. Many
state Medicaid programs require providers to enroll as
Medicaid providers with that state?s Medicaid agency
before payment can be issued. In other cases, a state
Medicaid program will accept a provider?s Medicaid
enrollment in the state where the provider practices.

Medicaid Reimbursement and Billing
Claims for all Horizon NJ Health Medicaid members
should be submitted to your local BCBS Plan. If you are
contracted with Horizon NJ Health, your Medicaid rates
will only apply for services provided to Horizon NJ Health
members. These rates do not apply to services provided
to out-of-state Medicaid members. When you provide
services to a Medicaid member from another state,
you must accept that state?s Medicaid allowance (less
any member responsibility such as copayments) as
payment in full. Please note that billing out-of-state
Medicaid members for any amounts in excess of the
Medicaid-allowed amount for Medicaid-covered
services is specifically prohibited by federal regulations
(42 CFR 447.15).

Medicaid Billing Data Requirements
When billing for a Medicaid member, please remember
to check the Medicaid website of the state where the



Horizon NJ Health - Billing Guide

member resides for information on Medicaid billing
requirements. Providers should always include their
National Provider Identifier (NPI) on Medicaid claims,
unless the provider is considered atypical. Providers
should also bill using National Drug Codes (NDC) on
applicable claims. As a reminder, applicable Medicaid
claims submitted without these data elements will
be denied.

Provider Enrollment Requirements
As indicated above, some states require that out-of-state
providers enroll in their state?s Medicaid program in order
to be reimbursed. Some of these states may accept a
provider?s Medicaid enrollment in the state where they
practice to fulfill this requirement. If you are required to
enroll in another state?s Medicaid program, you should
receive notification upon submitting an eligibility or
benefit inquiry. You should enroll in that state?s Medicaid
program before submitting the claim. If you submit a
claim without enrolling, your Medicaid claims will be
denied and you will receive information from your local
BCBS plan regarding the Medicaid provider enrollment
requirements. You will be required to enroll before the
Medicaid claim can be processed and before you may
receive reimbursement.

Horizon NJ Health Billing Guide - August 2017


cover and back.pdf
Provider manual cover.pdf
Provider Manual Cover 2017_FINAL (NoCrops)
Provider_Manual_2017_FINAL (NoCrops)
Provider Manual Cover 2017_FINAL (NoCrops)

Provider manual cover.pdf
Provider Manual Cover 2017_FINAL (NoCrops)
Provider_Manual_2017_FINAL (NoCrops)
Provider Manual Cover 2017_FINAL (NoCrops)


cover and back.pdf
Provider manual cover.pdf
Provider Manual Cover 2017_FINAL (NoCrops)
Provider_Manual_2017_FINAL (NoCrops)
Provider Manual Cover 2017_FINAL (NoCrops)

Provider manual cover.pdf
Provider Manual Cover 2017_FINAL (NoCrops)
Provider_Manual_2017_FINAL (NoCrops)
Provider Manual Cover 2017_FINAL (NoCrops)






January 2019

This guide is intended to offer hospitals, physicians and
health care professionals the information required for
???????? ???i>???????>VV??>?i???>?`?ivwV?i????????Vi???
claims prepared by or for hospitals, physicians and health
care professionals for medical services provided to
members of our health plan. This section contains notes
of interest highlighting billing information relevant to
the topic detailed above them. The notes may be titled
as follows:

+/2146#06 ? Reminds the reader of claim submission
problems that can be avoided. These errors can result
in rejection, inaccurate claim payments or denials,
usually because required information is missing, invalid,
incomplete or inconsistent with standard billing practices.
Note: Reviews an associated piece of information, which
V?>??wi?????i???>??????iV?wV?`i?>????>L??????i??i???Vi]?L???
may not directly impact reimbursement. For example,
place of service is required to determine eligibility for
payment, but does not necessarily affect payment amount.

In the event of additional questions about Horizon NJ Health
programs or policies, please review the entire Manual or
contact the Provider Services at 1-800-682-9091.

In order to comply with contractual obligations, regulatory
requirements or state and federal law, Horizon NJ Health
reserves the right, at any time, to modify or update
??v???>?????V???>??i`?????????`?V??i???? ???wV>??????????
be posted at least 30 days prior to the effective date
unless the effective date of a law or regulation does not
permit this time frame. Hospitals, physicians and health
care professionals may access the For Providers section of
the Horizon NJ Health website at horizonNJhealth.com
to check for updates on billing requirements and other
policies and procedures relevant to reimbursements
for services.

+/2146#06 ? Horizon NJ Health, its subcontracted
vendors or the State of New Jersey are responsible for
?>??i???v???>????i???Vi????V??`i`??????i??i?Li????Li?iw??
?>V?>}i??-i???Vi????????V??`i`??????i?Li?iw???>V?>}i?
are reimbursable by the member only if the hospital,
?????V?>??????i>????V>?i????vi?????>??????wi????i??i?Li??
in writing and in advance of providing the service(s) of this
obligation. Members should not be billed for any service
V??i?i`???`i????i???Li?iw???>V?>}i??-????`????????? ??
Health require a copayment for any service or population
group, an itemization of these items will be included in the
Li?iw????????}?>?`??????Li?>?>??>L?i??????i??iL???i??/?i?
practice of balance billing Medicaid/NJFC and FIDE-SNP
Li?iwV?>??i?]???i??i??i??}?L?i?v?????-?Li?iw??????i?????i`?
in managed care, is prohibited under both federal and
State law. These prohibitions apply to both Medicaid/
??
??????Li?iwV?>??i?]?>???i???>??????i?i??}?L?i?v???
Medicare coverage or other insurance. A provider enrolled

in the Medicaid/NJFC FFS program or in managed care is
required to accept as payment in full the reimbursement
rate established by the FFS program or managed care plan.

????V??????i?>?i`??????i?`i???i????v??i>????V>?i?Li?iw??????>?
?i`?V>?`? ??
?i??}?L?i?Li?iwV?>??]????i????>??>???????i`?
cost sharing, are the responsibility of the FFS program,
the managed care plan, Medicare (if applicable) and/or
a third-party payer (if applicable). If a provider receives
a Medicaid/NJFC FFS or managed care payment, the
provider shall accept this payment as payment in full and
??>???????L??????i?Li?iwV?>??????>????i??????i?Li?iwV?>?????
behalf for any additional charges.

9.1 Requirements for Filing Claims

9.1.1 General Requirements
Horizon NJ Health is a Medicaid managed care plan that
is under contract with the New Jersey Department of
Human Services. Horizon NJ Health will pay claims based
only on eligible charges. Unless the provider contract
states otherwise, claims will be paid on the lesser of billed
charges or
the contracted rate (Horizon NJ Health fee schedule).
Claims submitted by nonparticipating Horizon NJ Health
providers will be paid on the lesser of billed charges
or the Horizon NJ Health nonparticipating provider fee
schedule. Consistent with CFR 42 Part ? 447.45: the
v???????}?`iw?????????>???>????????V?i>??V?>????>????i`?
within the Horizon NJ Health Billing Guide:

?Clean claim means one that can be processed without
obtaining additional information from the provider of the
service or from a third party. It does not include a claim
from a provider who is under investigation for fraud or
abuse or a claim under review for medical necessity.?

Under the New Jersey Health Claims Authorization,
Processing and Payment Act, claims must also meet the
following criteria:

(a) the health care provider is eligible at the date
of service

(b) the person who received the health care service
was covered on the date of service

(c) the claim is for a service or supply covered under
??i??i>????Li?iw?????>?

(d) the claim is submitted with all the information
requested by the payor on the claim form or in other
instructions that were distributed in advance to the
health care provider or covered person in accordance
with the provisions of section 4 of P.L.2005, c.352
(C.17B:30-51)

(e) the payor has no reason to believe that the claim has
been submitted fraudulently

Horizon NJ Health - Billing Guide



Other requirements, such as timeliness of claims
processing includes:

Horizon NJ Health must receive all claims within 180
calendar days from the initial date when services were
rendered. If claims are not received within 180 calendar
days from the initial date of service, claims will be denied
v????????i???w???}?????????? ???i>??????>????>??>???V?i>??
claims from hospitals, physicians and other health care
professionals within 30 days of the date of receipt of EDI
claims and within 40 days for paper claims. MLTSS claims
will be paid within 15 days of the receipt of EDI claims and
within 30 days for paper claims.

The time limitation does not apply to claims from
providers under investigation for fraud or abuse. The
date of receipt is the date Horizon NJ Health receives the
claim, as indicated by its date stamp on the claim. The
date of payment is the date of the check or other form
of payment.

Horizon NJ Health is required to report all claims to the
State of New Jersey for services provided to members
through electronic media. Practitioners and facilities may
not use a PO Box as an acceptable billing address. A
physical street address must be used. In addition, when
submitting ZIP codes anywhere on a claim, practitioners
and facilities must use the full nine-digit format. Therefore,
all billing addresses, whether submitted on paper or
electronically, must contain a physical billing address. To
have payments sent to a different address or PO Box, the
?>??????????`i???>?i?>?`?>``?i???wi?`??????i?n?????>?`?
837-P transaction must be used.

??????0CVKQPCN?2TCEVKVKQPGT?+FGPVK?GT?
02+?
Horizon NJ Health requires all practitioners use their NPI
numbers for all claim submissions. To ensure our systems
properly identify you as an individual, group or facility,
Horizon NJ Health requires you register the NPI with
??????>???????>?`??>???`i???wV>????????Li?????????i??
requirement that will affect both timeliness and payment
is the use of name differential on your W-9. Horizon
NJ Health continues to accept the use of your provider
?`i???wV>????????Li?????i}>V???????/?i?V??????i`???i??v?
the legacy ID is recommended, as the claims processing
system uses this number for adjudication and payment
activities. Please make sure your name matches the name
used on your W-9. Below are some helpful hints, which
will facilitate accurate and consistent management
of your claims.

? Physicians, facilities, and health care professionals are
required to have an NPI. Please register for one if you
have not already secured your NPI.

? Groups are not technically required to have an NPI,
but are encouraged to have one as long as there is
a legal entity associated with the business name and
?>???`i???wV>????????Li???/???i}???i????i?}????? *??
with Horizon NJ Health, we will need the W-9 for the
business and all associated individual NPIs paid to
that tax ID number.

? Facilities, including hospitals and groups chosen to
subpart their type 2 NPI, will need to choose a master
NPI if all of the registered numbers are under the
?>?i??>???`i???wV>????????Li????i??}?>???}?>??>??i??
NPI number will help Horizon NJ Health assign claims
to the right location for payment purposes. A valid
W-9 for the business and all associated individual
NPIs that are paid to that tax ID number should be
registered with Horizon NJ Health.

? Where an NPI number is shared among different
locations using the same tax ID number, the Horizon
NJ Health legacy ID is needed to distinguish where
the claim payment should be sent.

? Nonparticipating practitioners and facilities are
also required to adhere to the NPI requirements.
To facilitate payment for claims, Horizon NJ Health
encourages you to register your NPI with us in
the same manner described above. To complete
this task, please visit the ?For Providers? section
of horizonNJhealth.com and download our NPI
Collection Form. Once completed, fax your forms
and CMS documentation to Horizon NJ Health at
1-609-583-3004.

9.1.3 Procedures for Claim Submission
Horizon NJ Health is required by state and federal
?i}??>?????????V>????i?>?`??i???????iV?wV?`>?>??i}>?`??}?
services rendered to its members. All services rendered,
including capitated encounters and fee-for-service claims,
must be submitted on the CMS 1500 (HCFA1500) version
02/12 or UB-04 claims form, or via electronic submission
in a HIPAA ? compliant 837 or NCPDP format. Horizon
NJ Health does not accept handwritten or stamped
claims. These claims forms and electronic submissions
must be consistent with the instructions provided by CMS
requirements, as stated in the CMS Claims Manual, which
can be accessed at EOU?IQX?/CPWCNU?+1/?NKUV?CUR.

The hospital, physician and health care professional, to
appropriately account for services rendered and to ensure
timely processing of claims, must adhere to all billing
requirements.

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January 2019



When data elements are missing, incomplete, invalid or
coded incorrectly, Horizon NJ Health cannot process
the claims.

? Claims for billable services provided to Horizon NJ
Health members must be submitted by the hospital,
physician or health care professional that performed
the services.

? Professional services are not reimbursable to a hospital
???i?????i???????>???????iV?wV>????V????>V?i`?v???
professional services. Horizon NJ Health policy is to
reimburse these services only when billed on a CMS
1500.
U??
?>????w?i`?????????????? ???i>????>?i???L?iV???????i?

following procedures:
? q??6i??wV>???????>??>????i????i`?wi?`??>?i?V????i?i`????

the claim
? q??6i??wV>???????>??>???`?>}??????V?`i?]???`?wi???>?`?

procedure codes are valid for the date of service
? q??7?i??>???????>?i]??i??wV>??????v???i??ivi??>??v???

specialist or non-primary care physician claims
(excluding ?self-referral? types of care)

? q??6i??wV>??????v??i?Li????i??}?L??????v????i???Vi????`i??
Horizon NJ Health during the time period in which
services were provided

? q??6i??wV>???????>????i??i???Vi???i?i??????`i`?L??>?
participating or nonparticipating hospital, physician
or health care professional that has received
authorization to provide services to the eligible
member

? q??6i??wV>???????>????i???????>?]??????V?>??????i>????V>?i?
professional has been given approval for services
that require prior authorization by Horizon NJ Health

? Horizon NJ Health is the ?payor of last resort? on
all claims submitted for members of its health plan.
Hospitals, physicians and health care professionals
must verify whether the member has Medicare
coverage or any other third party resources and, if
??]??????`i?`?V??i??>???????>????i?V?>????>??w????
processed by this other insurer as appropriate.
+/2146#06?q?,i?iV?i`?V?>????>?i?`iw?i`?>??V?>????
with invalid or missing data elements, such as the tax ID
number, that are returned to the submitter or EDI source
without registration in the claim processing system.
Since rejected claims are not registered in the claim
processing system, the hospital, physician or health care
professional must re-submit clean claims within
180 calendar days from the date of service. This
guideline applies to claims submitted on paper or
electronically. Rejected claims are different than denied
claims, which are registered in the claim processing
system, but do not meet requirements for payment
under Horizon NJ Health guidelines.

Horizon NJ Health encourages all hospitals, physicians,
and health care professionals to submit claims
electronically. We utilize the TriZetto Provider Solutions
(TTPS) Direct Data Entry (DDE) SimpleClaim system.
All providers that previously used Emdeon to directly
enter their Horizon NJ Health claims must switch to DDE
SimpleClaim.

For more information on registering, please go to
JVVRU???VTK\GVVQRTQXKFGTUQNWVKQPU?YWHQQ?EQO?HQTOU?
JQTK\QP?PL?JGCNVJ?RTQXKFGTU. If you have any further
questions about registering with TTPS for DDE claim
submission, please call TriZetto at 1-800-556-2231 or
email VVRUUWRRQTV"EQIPK\CPV?EQO.

While Horizon NJ Health strongly encourages submitting
claims via EDI, if a paper claim is necessary, please submit
red and white paper claims only for all medical services to
Horizon NJ Health at the following address:

Horizon NJ Health
Claims Processing Department
21?$QZ??????
0GYCTM??0,???????????

Note: Out-of-state, non-Horizon NJ Health providers
should send claims to their local Blue Cross Blue Shield
Plan.

+/2146#06 ? Requests for reimbursement for retail
pharmacy and all outpatient drugs for persons designated
as aged, blind or disabled should be submitted directly to
the State of New Jersey.

+/2146#06 ? Requests for reimbursement for
mental health services for all enrollees, except the
developmentally disabled, FIDE-SNP or MLTSS members,
should be submitted directly to the State of New Jersey.

Note: Be sure to include the member?s Medicaid ID
number on all claims submitted to the State of New Jersey.

Note: Horizon NJ Health subcontracts with Davis Vision
to provide and/or coordinate vision services for eligible
members. All services, except ophthalmologic procedures,
are coordinated and paid by Davis Vision. Please call
1-877-226-3729 for information about submitting
invoices.

Note: Horizon NJ Health subcontracts with Scion Dental
to provide and/or coordinate dental services for eligible
members. Please call the Provider Call Center at
1-855-878-5368 for routine provider questions related
to eligibility, claims, authorizations, credentialing,
contracting, adding/changing provider data/locations,
and fee schedules.

Horizon NJ Health - Billing Guide

January 2019



Note: Horizon NJ Health subcontracts with Laboratory
Corporation of America, Inc. (LabCorp) for most routine
and specialized laboratory services. Generally,
Horizon NJ Health is responsible for payment of claims
for PAT/STAT laboratory service provided in hospitals
and ambulatory surgical centers. Horizon NJ Health will
also provide reimbursements for claims for laboratory
services included on LabCorp?s excluded test listing. An
authorization is required for any test included on this
listing; please submit claims to Horizon NJ Health as
??iV?wi`?>L??i??1??i??????i????i???iV?wi`????????
??iV?wV?V????>V??>??>??>?}i?i???]??>L??>??????i???Vi??
should be referred to LabCorp.

9.1.4 Claim Filing Deadlines
Horizon NJ Health must receive all claims within 180
calendar days from the initial date when services were
rendered. If claims are not received within 180 calendar
days from the initial date of service, claims will be denied
v????????i???w???}??
" ?V?>?????????Li???L????i`????????
60 days from the date of the primary insurer?s EOB.

? Horizon NJ Health?s Appeals Department utilizes
??iV?wV?V???i??>???i???i??i???}??>??`?????v??v?
???i???w???}?

? Member?s name
? Horizon NJ Health or Medicaid ID number
? Billed amount
? Date of service
? Billed/mailed date
? Address where the claim form was sent

(Horizon NJ Health or insurance code)
? For EDI submissions, a 999 report indicating

submission to the correct insurance code is required
for consideration of timely submission.

For claims selected electronically:
? Submit an electronic data interchange (EDI)

acceptance report. This must show that
???????? ???i>?????????i??v?????>vw??>?i???iVi??i`]?
accepted and/or acknowledged the claim submission.

Note: A submission report alone is not considered
????v??v????i???w???}?v???i?iV?????V?V?>?????????????Li?
accompanied by an acceptance report.

? The acceptance report must:
1. Include the actual wording that indicates the

claim was either ?accepted,? ?received? and/or
?acknowledged.?
(Abbreviations of those words are also acceptable.)

2. Show the claim was accepted, received, and/or
>V?????i`}i`??????????i????i???w???}??i???`?

For paper claims:
1. The submission date must be within the
????i???w???}??i???`?

???
i???wi`??>????iVi?????>???>??`?????v??v????i???w???}?
3. Only red and white paper claims can be processed.

"??i???>??`?????v??v????i???w???}?`?V??i??>????

Valid when incorrect insurance information was provided
by the patient at the time the service was rendered:

? A denial/rejection letter from another insurance carrier
U??????i???????>?Vi?V>???i????i???>?>??????v?Li?iw??
? Letter from another insurance carrier or employer

group indicating coverage termination prior to the
date of service of the claim

? Letter from another insurance carrier or employer
group indicating no coverage for the patient on the
date of service of the claim

All of the above must include documentation that the
claim is for the correct patient and the correct date
of service. The date on the other carrier?s payment
V???i????`i?Vi???>??????i????i???w???}??i???`?v???
submission to Horizon NJ Health. In order to be
considered timely, the claim must be received by
Horizon NJ Health within 60 days from the date on the
other carrier?s correspondence. Not including all of the
information requested will result in a rejected inquiry or a
delay in response. If the claim is received after the timely
w???}??i???`]??????????????ii?????i???w???}?V???i??>?

4'('4?61?5'%6+10????? Section 10.0 Complaint
and Appeals Process for complete instructions of the
submission time frames and procedures for administrative
or medical appeals.

9.1.5. Filing Corrected Claims

For paper claims:
CMS-1500 should be submitted with the appropriate
resubmission code (value of 7) in Box 22 of the paper
claim with the original claim number of the corrected
claim and a copy of the original Explanation of Payment
(EOP). With the original claim number for which the
corrected claim is being submitted. Horizon NJ Health will
reject any claims that are not submitted on red and white
forms or that have any handwriting on them.

????1 ??{?V?>???\

UB-04 claims should be submitted with the appropriate
resubmission code in the third digit of the bill type (for
corrected claim this will be 7), the original claim number in
Box 64 of the paper claim and a copy of the original EOP.

Horizon NJ Health - Billing Guide

January 2019



Send red and white paper corrected claims to:

Horizon NJ Health
Claims Processing Department
21?$QZ??????
0GYCTM??0,???????????


???iV???}?i?iV?????V??
????x???V?>???\

EDI 837P data should be sent in the 2300 Loop, segment
CLM05 (with value of 7) along with an addition loop in
the 2300 loop, segment REF*F8* with the original claim
number for which the corrected claim is being submitted.


???iV???}?i?iV?????V?1 ??{?V?>???\

EDI 837I data should be sent in the 2300 Loop, segment
CLM05 (with value of 7) along with an addition loop in
the 2300 loop, segment REF *F8* with the original claim
number for which the corrected claim is being submitted.

Both paper and electronic claims must be submitted
within 365 calendar days from the initial date of service.

9.2 Claim Forms (Paper)
Horizon NJ Health requires that all hospitals, physicians
and health care professionals use the standard CMS 1500
(HCFA 1500) or UB-04 claim forms to report services,
which are reimbursable or capitated. The CMS 1500
(HCFA 1500) claim form must be completed for all
professional medical services. The UB-04 claim form must
be completed for all facility claims. When services are
?i?`i?i`?L????/--??????`i??]?v>V?????i???????`?w?i?>?
UB-04 form, and nonfacilities should use the CMS 1500.
*QTK\QP?0,?*GCNVJ?FQGU?PQV?CEEGRV?JCPFYTKVVGP?QT?
DNCEM?CPF?YJKVG?ENCKOU.

9.2.1 CMS 1500 (HCFA 1500) Claim Form

(Paper Submission)
The CMS 1500 (HCFA 1500) Paper Submissions claim
form must be used to bill all professional services to
Horizon NJ Health. Horizon NJ Health only accepts form
version 02/12. The National Uniform Claim Committee
(NUCC) created the CMS 1500 form (version 02/12) to
accommodate coding changes for ICD-10. There are
??????}??wV>???V?>?}i???????i??i???i`?
?-??x??]???i?
claim form used to submit paper claims to Medicare and
the required claim form to submit paper claims to
Horizon NJ Health.

The CMS 1500 Form (version 02/12) gives physicians the
ability to

? Identify whether they are using ICD-9-CM or
ICD-10-CM codes.
U????V??`i??????????V?`i???????i?`?>}??????wi?`????i?

limit on the 08/05 version is four codes in the
`?>}??????wi?`??

? Include information that will improve the accuracy of
the data reported, such as being able to identify the
???i??v???i??????`i??>?`???iV?wV?`>?i???v?????i???

? Align paper copy claim submissions with the ASC X12
Health Care Claim: Professional (837P) transaction.

CMS has advised providers to use the following process to
assure clean claims submission. All information must be:

U????}?i`??????????i?`>?>?wi?`??
? On an original red ink on white paper claim 02/12

version form.
? Typed. Do not print, handwrite or stamp any

extraneous data on the form.
? In black ink.
? In large, dark font, such as PICA or ARIAL 10-, 11- or

12-point type.
? In capital letters.

???i???v???>?????>L?????`???????>???i?-?????wV>?????
and Compliance Act (ASCA) exceptions can be found in
Chapter 24 of the ?Medicare Claims Processing Manual,?
which is available on the CMS website at
cms.gov/Regulations-and-Guidance/Guidance/
/CPWCNU?&QYPNQCFU??ENO???E???RFH.

,i????i`???i?`??v???
?-??x?????
????x????
Claim Form
/?????iV???????????????`i???i???????v??i????i`?wi?`??v???
Horizon NJ Health; however, you must refer to the most
current CMS coding instructions for a complete list of
codes and requirements.

Horizon NJ Health - Billing Guide

January 2019



Place of Service Codes
Code Description
???"vwVi
12 Home
19 Off Campus - Outpatient Hospital
20 Urgent Care Facility
21 Inpatient Hospital
22 Outpatient Hospital
23 Emergency Room ? Hospital
24 Ambulatory Surgical Center
25 Birthing Center
26 Military Treatment Facility
31 Skilled Nursing Facility
32 Nursing Facility
33 Custodial Care Facility
34 Hospice
41 Ambulance ? Land
42 Ambulance ? Air or Water
x???i`i?>????+?>??wi`??i>????
i??i?
51 Inpatient Psychiatric Facility
52 Psychiatric Residential Treatment Center
53 Community Mental Health Center
54 Intermediate Care Facility/Mentally Retarded
55 Residential Substance Use Disorder Treatment Center
56 Psychiatric Residential Treatment Center
60 Mass Immunization Center
61 Comprehensive Inpatient Rehabilitation Facility
62 Comprehensive Outpatient Rehabilitation Facility
65 End-Stage Renal Disease Treatment Facility
71 State or Local Public Health Clinic
72 Rural Health Clinic
81 Independent Laboratory
99 Other Unlisted Facility

Type of Service Codes
Code Description

1 Medical Services
2 Surgery
3 Consultations
4 Radiology (total component)
5 Laboratory (total component)
6 Radiation Therapy (total component)
7 Anesthesia
8 Assistant Surgery
9 Other (e.g., prosthetic eyewear, contacts, ambulance)
D DME
F ASC

Required and Conditional Field Indicator
+/2146#06?? An authorization number and/or referral
number must be included in box #23 on a CMS 1500
(HCFA 1500) claim form or box #63 on a UB-04 form. The
?i????i`?wi?`????>???????Li?V????i?i`?v?????i???>?`>?`?
CMS 1500 (HCFA 1500) or UB-04 claim forms are in the
?i??iV???i?V?>???v????>?i>????v???i?wi?`?????i????i`?????????
exception, an ?R? (required) is noted in the ?Required or

??`?????>???L?????v?V????i???}???i?wi?`????`i?i?`i???
upon certain circumstances, the requirement is listed
as ?C? (conditional) and the relevant conditions are
explained in the ?Instructions and Comments? box.

9.2.2 The UB-04 (CMS 1450) Claim Form
(Paper)

The UB-04 (CMS 1450) claim form must be used to bill
all facility services to Horizon NJ Health. This section will
?????`i???i???????v??i????i`?wi?`??v??????????? ???i>?????
However, you must refer to the most current CMS coding
instructions for a complete list of codes and requirements.

Type of Bill Codes
Code Description

111 Hospital/Inpatient (Part A)/Admit through Discharge

Code Description
112 Hospital/Inpatient (Part A)/Interim ? First Claim
113 Hospital/Inpatient (Part A)/Interim ? Continuing

Claims
114 Hospital/Inpatient (Part A)/Interim ? Last Claim
115 Hospital/Inpatient (Part A)/Late Charge Only
117 Hospital/Inpatient (Part A)/Replacement of

Prior Claim
121 Hospital/Hospital Based or Inpatient(Part B)/Admit

Through Discharge
131 Hospital/Outpatient/Admit Through Discharge
211 Skilled Nursing/Inpatient (Part A)/Admit Through

Discharge
212 Skilled Nursing/Inpatient (Part A)/Interim ?

First Claim
213 Skilled Nursing/Inpatient (Part A)/Interim ?

Continuing Claims
214 Skilled Nursing/Inpatient (Part A)/Interim ?

Last Claim
321 Home Health/Hospital Based or Inpatient

(Part B)/Admit Through Discharge
322 Hospice Interim ? First Claim
323 Hospice Interim -- Continuing Claim
324 Hospice Interim ? Final Claim
331 Home Health/Hospital Based or Inpatient

(Part B)/Admit Through Discharge

Horizon NJ Health - Billing Guide

January 2019



711 Clinic/Rural Health Clinic (RHC)/Admit Through
Discharge

721 Clinic/Independent Renal Dialysis Facility/Admit
through Discharge

731 Clinic/FQHC/Admit Through Discharge
831 Special Facility or Hospital ASC/ASC for

Outpatients/Admit Through Discharge

Type of Admission Codes
Code Description

1 Emergency
2 Urgent
3 Elective

Patient Status Codes
Code Description

01 Discharged to Home or Self Care (routine discharge)
02 Discharged/Transferred to Another Short-Term

General Hospital
03 Discharged/Transferred to SNF
04 Discharged/Transferred to ICF
05 Discharged/Transferred to Another Type of Institution

(including distinct parts) or Referred for Outpatient
Services to Another Institution

06 Discharged/Transferred to Home Under Care of
Organized Home Health Service Organization
07 Left Against Medical Advice
08 Discharged/Transferred to Home Under Care of an

IV Drug Therapy Provider
09 Admitted as an Inpatient to this Hospital
20 Expired (or did not recover ? Christian Science

Patient)
30 Still Patient or Expected to Return for Outpatient

Services
40 Expired at Home (hospice claims only)
41 Expired in a Medical Facility, such as Hospital, SNF,

ICF or Freestanding Hospice (hospice claims only)
42 Expired ? Place Unknown (hospice claims only)
50 Hospice ? Home
51 Hospice ? Medical Facility

Commonly Used Revenue Codes
Code Description

100 ? 129 Room and Board Charges
130 ? 249 Semi-private; Private; Ward, Nursery,

Subacute, ICU, CCU
250 ? 259 Pharmacy
260 ? 269 IV Therapy
270 ? 279 Medical/Surgical Supplies & Devices
280 ? 289 Oncology
290 ? 299 Durable Medical Equipment (DME)
300 ? 319 Laboratory/Laboratory Pathological
320 ? 339 Radiology Diagnostic/Therapeutic
340 ? 349 Nuclear Medicine
350 ? 359 CT Scan
360 ? 369 Operating Room Services
370 ? 379 Anesthesia
410 ? 449 Therapy Services
450 ? 459 Emergency Codes
540 ? 548 Ambulance Services
720 ? 729 Labor and Delivery
730 ? 750 Outpatient Surgery
800 ? 880 Radiology
900 ? 919 Psychiatric/Psychological
920 ? 999 Nuclear Medicine

Required and Conditional Field Indicator
,i????i`??,??wi?`???????Li?V????i?i`????>???V?>?????

??`?????>???
??wi?`???????Li?V????i?i`??v???i?
information applies to the services rendered to Horizon
NJ Health members.

+/2146#06?? Referrals are valid for up to 180 days.
The referral number on the claim does not generate a
payment. The actual referral must be submitted with each
claim to avoid claim processing delays or denials.

9.2.3 Taxonomy Codes
Taxonomy codes are administrative codes set for
identifying the provider type and area of specialization for
health care providers. Each taxonomy code is a unique
ten-character alphanumeric code that enables providers
to identify their specialty at the claim level.

Taxonomy codes are assigned at both the individual
provider and organizational provider level. Taxonomy
codes have three distinct levels: Level I is Provider
/??i]??i?i????????
?>???wV>????]?>?`??i?i???????????i?
Area of Specialization. Examples and discussion of
taxonomy codes can be found at JVVRU???YYY?EOU?
gov/medicare/providerenrollment-and certification/
medicareprovidersupenroll/taxonomy.html.

Horizon NJ Health - Billing Guide

January 2019



For paper UB04 institutional claims, the taxonomy code
should be placed in box 81 and should be submitted with
??i?? ?????>??wi???????
?-??x??????vi?????>??V?>???]???i?
?>???????V?`i??????`?Li??`i???wi`????????i???>??wi??
?ZZ? in the shaded portion of box 24i. The taxonomy
code should be placed in the shaded portion of box 24j
for the rendering level and in box 33b preceded with
??i??<<????>??wi??v?????i?L?????}??i?i???
?>??????>??`??????
contain these codes cannot be processed.


?-??x?????n??x??*??vi?????>??
?>????????
(for enumerated providers)

Billing Provider NPI Field 33a
Billing Provider TIN Field 25
Referring Provider NPI Field 17b
Rendering Provider NPI Field 24j
Service Facility Location NPI Field 32a
+/2146#06 ? Make sure that your claim software
supports the revised 1500 claim form (08-05). Reference
the 1500 Reference Instruction Manual at Nucc.org for
??iV?wV?`i?>???????V????i???}??????v????

1 ??{?*>?i?????????????>??
?>???????
(for enumerated providers)

Billing Provider NPI Locator 56
Billing Provider TIN Locator 05
Billing Provider Taxonomy Code Locator 81
Attending Provider NPI Locator 76
Operating Provider NPI Locator 77
Other Provider NPI Locator 78-79

9.3 Procedures for Electronic Submission ?
Electronic Data Interchange

+/2146#06 ? Effective January 1, 2017, registered
providers must include their taxonomy code, tax
?`i???wV>????????Li?]?>?`? *?????>???V?>??????????V>??
?????`i??]?>??`iw?i`?L??
?-]????????L??????i???
?>???????V?`i?>?`???i????>???`i???wV>????????Li??

+/2146#06 ? All claims submitted electronically must
be in a HIPAA compliant 837 or NCPDP format. Electronic
`>?>????i?V?>?}i??
????>??????v>??i?]????i?ivwV?i???>?`?
cost-effective claim submission for hospitals, physicians
and health care professionals. EDI, performed in
accordance with nationally recognized standards,
supports the industry?s efforts to reduce overhead
administrative costs.

/?i?Li?iw????v?L?????}?i?iV?????V>??????V??`i\

? Reduction of overhead and administrative costs.
EDI eliminates the need for paper claim submission.
It has also been proven to reduce claim rework
(adjustments).

? Receipt of reports as proof of claim receipt. This
makes it easier to track the status of claims.

? Faster transaction time for claims submitted
electronically. An EDI claim averages about 24 to 48
hours from the time it is sent to the time it is received.
This enables providers to easily track their claims.

? Validation of data elements on the claim. By the
time a claim is successfully received electronically,
information needed for processing is present. This
reduces the chance of data entry errors that occur
when completing paper claim forms.

? Quicker claim completion. Claims that do not need
additional investigation are generally processed
quicker. Reports have shown that a large percentage
of EDI claims are processed within 10 to 15 days of
their receipt.

+/2146#06 ? Referrals are valid for up to 180 days
and up to 6 visits. The referral number on the claim
does not generate a payment. The actual referral must
be submitted with each claim to avoid claim processing
delays or denials.

Note: Hospitals, physicians and health care professionals
submitting claims electronically should make sure the
referral number is present on the claim.

Note: EDI Technical Support Team is available during
regular business hours, 8 a.m. through 5 p.m., Monday
through Friday, and can be reached at 1-800-556-2231.

??????*CTFYCTG?5QHVYCTG?4GSWKTGOGPVU
There are many different products that can be used to
bill electronically. Hospitals, physicians and health care
professionals should send EDI claims to TriZetto TTPS
whether through direct submission or through another
clearinghouse/vendor using payor number 22326. Only
TriZetto TTPS can submit claims electronically to Horizon
NJ Health.

Contracting with TriZetto and Other Electronic
6i?`???

If you are a hospital, physician or health care professional
interested in submitting claims electronically to Horizon
NJ Health but do not have TriZetto EDI services, contact
TriZetto at 1-800-556-2231. You may also choose to
contract with another EDI clearinghouse or vendor who
already has access to TriZetto EDI services.

Horizon NJ Health - Billing Guide

January 2019



Contacting the EDI Technical Support Group
Hospitals, physicians and health care professionals
interested in sending claims to Horizon NJ Health
electronically may contact the EDI Technical Support
Group for information and assistance.

"?Vi????????? ???i>???????????wi`??v???i????i????????L????
claims through EDI, the organization?s contact will receive
a complete list of ID numbers for Horizon NJ Health
hospitals, physicians and health care professionals, the
i?iV?????V??>???????Li?]?/??<i??????iV?wV?i`???]?>?`?>???
other information needed to initiate electronic billing with
Horizon NJ Health.

Note: Physicians can contact the EDI Technical Support
Group to obtain names of other EDI clearinghouses
and vendors.

Transmission Requirements
Once the material is received, proceed as follows:

? Read over the materials carefully
? Transmission can begin upon receipt of ID numbers

for Horizon NJ Health individual hospitals, physicians
and health care professionals

Contact the EDI Technical Support Group to answer
any questions you may have. If you wish to receive
V??w??>????????Li}???i?iV?????V???L???????]???i?
???
Technical Support Group will contact you via fax, mail or
email on the effective day for EDI claim submission.

No approval is necessary. Contact your system vendor
and/or TriZetto to inform them that you are now
going to submit production claims electronically to
Horizon NJ Health. You will be asked for the electronic
?>????>``?i???>?`???i?/??<i??????iV?wV?i`??????V??`i`????
your Horizon NJ Health documentation.

Note: Contact EDI Technical Support at 1-800-556-2231
to notify them of your intention to begin EDI
transmissions.

??????5RGEK?E?&CVC?4GEQTF?4GSWKTGOGPVU
EDI claims should be submitted according to HIPAA
standards. These standards can be found in the
Implementation Guides written by the Designated
Standard Maintenance Organizations (DSMOs) responsible
for each transaction. Additional information can be found
at hipaa-dsmo.org.

??????'NGEVTQPKE?%NCKO?(NQY?&GUETKRVKQP
In order to send claims electronically to Horizon NJ
?i>???]?>???
???V?>?????????w????Li?v???>?`i`????/??<i????
using payor number 22326. This can be completed
via a direct submission or through another EDI
clearinghouse or vendor. Once TriZetto receives the
transmitted claims, they are validated against TriZetto?s
??????i?>?????iV?wV>??????>?`????????? ???i>??????iV?wV?
requirements. Claims not meeting the requirements are
immediately rejected and sent back to the sender via a
TriZetto error report. The name of this report can vary,
based on the physician?s contract with their intermediate
EDI vendor or TriZetto. Claims are then passed to
Horizon NJ Health, and TriZetto returns a conditional
acceptance report to the sender immediately.

Claims forwarded to Horizon NJ Health by TriZetto
are immediately validated against physician and
member eligibility records. Claims that do not meet
this requirement are rejected and sent back to TriZetto,
which also forwards this rejection to its trading partner ?
the intermediate EDI vendor or directly to the hospital,
physician or health care professional. Claims passing
eligibility requirements are then passed to the claim
processing queues. Claims are not considered received
??`i?????i???w???}?}??`i???i???v??i?iV?i`?v?????????}????
invalid provider or member data.

Hospitals, physicians and health care professionals
>?i??i??????L?i?v????i??wV>??????v?
???V?>?????iVi??????
Acknowledgements for accepted or rejected claims
received from TriZetto or other contracted vendors
must be reviewed and validated against transmittal
records daily.

Note: For a detailed list of TriZetto data requirements,
contact EDI Technical Support at 1-800-556-2231.

9.3.4 Invalid Electronic Claim Record
4GLGEVKQPU?&GPKCNU

????V?>????iV??`???i?????????????? ???i>?????????w?????>???
/??<i????????????i?>???i`????>?`????????? ???i>??????iV?wV?
edits prior to acceptance. Claim records that do not pass
these edits are invalid and will be rejected without being
recognized as received at Horizon NJ Health. In these
cases, the claim must be corrected and resubmitted within
??i??i????i`?w???}?`i>`???i??v??n??V>?i?`>??`>???v????
the date of service. It is important that you review the
rejection notices (the functional acknowledgements to
each transaction set and the unprocessed claim report)
received from TriZetto or your vendor in order to identify
and resubmit these claims accurately.

Horizon NJ Health - Billing Guide

January 2019



Common Rejections
? Missing or invalid member ID
? Claims with missing or invalid batch level records
U?
?>????iV??`?????????????}???????>??`??i????i`?wi?`?
? Claim records with invalid (unlisted, discontinued, etc.)

codes (CPT-4, HCPCS, ICD-10, etc.)
? Claims without or that have invalid hospital, physician
????i>????V>?i????vi?????>?? >????>??*????`i???`i???wi??
(NPI) numbers whenever applicable. Per federal
requirements, atypical providers are excluded
U? ???????V>??L?????}?>``?i??????w?i
? No taxonomy code

Note: Hospital, physician or health care professional
?`i???wV>????????Li???>??`>?????????????i?v???i`?>????i?
clearinghouse. Claims will be rejected if the hospital,
?????V?>??????i>???V>?i????vi?????>?????Li??wi?`??>?i?i?????

??????5WDOKVVKPI?%QTTGEVGF?%NCKOU?YKVJ?'&+
Providers using electronic data interchange (EDI) can
submit corrected claims electronically rather than via
paper to Horizon NJ Health.

Note:???V???iV?i`?V?>??????`iw?i`?>??>??i??L????????
?v?>?V?>????????>???iV?wV?V?>?}i???>???????>?i??>`i]?
such as changes to CPT codes, diagnosis codes or billed
amounts. It is not a request to review the processing of a
claim. The electronic corrected claim submission capability
allows for faster processing, increased claims accuracy
and a streamlined submission process. For your EDI
clearinghouse or vendor to start using this new feature
they need to:

? Use ?6? for adjustment of prior claims ?7? for
replacement of a prior claim or ?8? for a voided claim
utilizing bill type in loop 2300, CLM05-03 (837P).

? Include the original claim number in segment
REF01=F8 and REF02=the original claim number; no
dashes or spaces.

? Include the Horizon NJ Health claim number in order
to submit your claim with the 6, 7 or 8.

? Bill all services, not just the services that need
corrections.

? Do use this indicator for claims that were previously
processed (approved or denied).

? Do not use this indicator for claims that contained
errors and were not processed (such as claims that
did not appear on a remittance advice; i.e., rejected
up front).

? Do not submit corrected claims electronically and via
paper at the same time.

? Please note that either a written or stamped note
stating that any claim is a corrected claim will result in
that claim being returned for correction.

9.3.6 Electronic Billing Inquiries
Please direct inquiries as follows:

Action
? If you would like to be authorized to transmit

electronic claims
U??v??????>?i???iV?wV?
????iV???V>????i??????
? If you have general EDI questions or questions on

where to enter required data

Contact
? TriZetto Technical Support at 1-800-556-2231

Action
? If you have questions about your claims transmissions

or status reports
? Contact your System Vendor or call TriZetto at

1-800-556-2231

Action
? If you have questions about your claim status (receipt

or completion dates)
? If you have questions about claims that are reported

on the Remittance Advice
? If you need to know a provider ID number

Contact
? NaviNet.net. If the required information is not found,

call Provider Services at 1-800-682-9091.

Action
? If you would like to update provider, payee, UPIN,

tax ID number, physical billing address or payment
address information

? For questions about changing or verifying provider
information

Contact
'OCKN??RTQXKFGTHKNGQRU?"*QTK\QP$NWG?EQO
fax: 1-973-274-4126
Provider Services at 1-800-682- 9091

Horizon NJ Health - Billing Guide

January 2019



This guide is intended to offer hospitals, physicians and
health care professionals the information required for
???????? ???i>???????>VV??>?i???>?`?ivwV?i????????Vi???
claims prepared by or for hospitals, physicians and health
care professionals for medical services provided to
members of our health plan. This section contains notes
of interest highlighting billing information relevant to
the topic detailed above them. The notes may be titled
as follows:

+/2146#06 ? Reminds the reader of claim submission
problems that can be avoided. These errors can result
in rejection, inaccurate claim payments or denials,
usually because required information is missing, invalid,
incomplete or inconsistent with standard billing practices.
Note: Reviews an associated piece of information, which
V?>??wi?????i???>??????iV?wV?`i?>????>L??????i??i???Vi]?L???
may not directly impact reimbursement. For example,
place of service is required to determine eligibility for
payment, but does not necessarily affect payment amount.

In the event of additional questions about Horizon NJ Health
programs or policies, please review the entire Manual or
contact the Provider Services at 1-800-682-9091.

In order to comply with contractual obligations, regulatory
requirements or state and federal law, Horizon NJ Health
reserves the right, at any time, to modify or update
??v???>?????V???>??i`?????????`?V??i???? ???wV>??????????
be posted at least 30 days prior to the effective date
unless the effective date of a law or regulation does not
permit this time frame. Hospitals, physicians and health
care professionals may access the For Providers section of
the Horizon NJ Health website at horizonNJhealth.com
to check for updates on billing requirements and other
policies and procedures relevant to reimbursements
for services.

+/2146#06 ? Horizon NJ Health, its subcontracted
vendors or the State of New Jersey are responsible for
?>??i???v???>????i???Vi????V??`i`??????i??i?Li????Li?iw??
?>V?>}i??-i???Vi????????V??`i`??????i?Li?iw???>V?>}i?
are reimbursable by the member only if the hospital,
?????V?>??????i>????V>?i????vi?????>??????wi????i??i?Li??
in writing and in advance of providing the service(s) of this
obligation. Members should not be billed for any service
V??i?i`???`i????i???Li?iw???>V?>}i??-????`????????? ??
Health require a copayment for any service or population
group, an itemization of these items will be included in the
Li?iw????????}?>?`??????Li?>?>??>L?i??????i??iL???i??/?i?
practice of balance billing Medicaid/NJFC and FIDE-SNP
Li?iwV?>??i?]???i??i??i??}?L?i?v?????-?Li?iw??????i?????i`?
in managed care, is prohibited under both federal and
State law. These prohibitions apply to both Medicaid/
??
??????Li?iwV?>??i?]?>???i???>??????i?i??}?L?i?v???
Medicare coverage or other insurance. A provider enrolled

in the Medicaid/NJFC FFS program or in managed care is
required to accept as payment in full the reimbursement
rate established by the FFS program or managed care plan.

????V??????i?>?i`??????i?`i???i????v??i>????V>?i?Li?iw??????>?
?i`?V>?`? ??
?i??}?L?i?Li?iwV?>??]????i????>??>???????i`?
cost sharing, are the responsibility of the FFS program,
the managed care plan, Medicare (if applicable) and/or
a third-party payer (if applicable). If a provider receives
a Medicaid/NJFC FFS or managed care payment, the
provider shall accept this payment as payment in full and
??>???????L??????i?Li?iwV?>??????>????i??????i?Li?iwV?>?????
behalf for any additional charges.

9.1 Requirements for Filing Claims

9.1.1 General Requirements
Horizon NJ Health is a Medicaid managed care plan that
is under contract with the New Jersey Department of
Human Services. Horizon NJ Health will pay claims based
only on eligible charges. Unless the provider contract
states otherwise, claims will be paid on the lesser of billed
charges or
the contracted rate (Horizon NJ Health fee schedule).
Claims submitted by nonparticipating Horizon NJ Health
providers will be paid on the lesser of billed charges
or the Horizon NJ Health nonparticipating provider fee
schedule. Consistent with CFR 42 Part ? 447.45: the
v???????}?`iw?????????>???>????????V?i>??V?>????>????i`?
within the Horizon NJ Health Billing Guide:

?Clean claim means one that can be processed without
obtaining additional information from the provider of the
service or from a third party. It does not include a claim
from a provider who is under investigation for fraud or
abuse or a claim under review for medical necessity.?

Under the New Jersey Health Claims Authorization,
Processing and Payment Act, claims must also meet the
following criteria:

(a) the health care provider is eligible at the date
of service

(b) the person who received the health care service
was covered on the date of service

(c) the claim is for a service or supply covered under
??i??i>????Li?iw?????>?

(d) the claim is submitted with all the information
requested by the payor on the claim form or in other
instructions that were distributed in advance to the
health care provider or covered person in accordance
with the provisions of section 4 of P.L.2005, c.352
(C.17B:30-51)

(e) the payor has no reason to believe that the claim has
been submitted fraudulently

Horizon NJ Health - Billing Guide

January 2019



Other requirements, such as timeliness of claims
processing includes:

Horizon NJ Health must receive all claims within 180
calendar days from the initial date when services were
rendered. If claims are not received within 180 calendar
days from the initial date of service, claims will be denied
v????????i???w???}?????????? ???i>??????>????>??>???V?i>??
claims from hospitals, physicians and other health care
professionals within 30 days of the date of receipt of EDI
claims and within 40 days for paper claims. MLTSS claims
will be paid within 15 days of the receipt of EDI claims and
within 30 days for paper claims.

The time limitation does not apply to claims from
providers under investigation for fraud or abuse. The
date of receipt is the date Horizon NJ Health receives the
claim, as indicated by its date stamp on the claim. The
date of payment is the date of the check or other form
of payment.

Horizon NJ Health is required to report all claims to the
State of New Jersey for services provided to members
through electronic media. Practitioners and facilities may
not use a PO Box as an acceptable billing address. A
physical street address must be used. In addition, when
submitting ZIP codes anywhere on a claim, practitioners
and facilities must use the full nine-digit format. Therefore,
all billing addresses, whether submitted on paper or
electronically, must contain a physical billing address. To
have payments sent to a different address or PO Box, the
?>??????????`i???>?i?>?`?>``?i???wi?`??????i?n?????>?`?
837-P transaction must be used.

??????0CVKQPCN?2TCEVKVKQPGT?+FGPVK?GT?
02+?
Horizon NJ Health requires all practitioners use their NPI
numbers for all claim submissions. To ensure our systems
properly identify you as an individual, group or facility,
Horizon NJ Health requires you register the NPI with
??????>???????>?`??>???`i???wV>????????Li?????????i??
requirement that will affect both timeliness and payment
is the use of name differential on your W-9. Horizon
NJ Health continues to accept the use of your provider
?`i???wV>????????Li?????i}>V???????/?i?V??????i`???i??v?
the legacy ID is recommended, as the claims processing
system uses this number for adjudication and payment
activities. Please make sure your name matches the name
used on your W-9. Below are some helpful hints, which
will facilitate accurate and consistent management
of your claims.

? Physicians, facilities, and health care professionals are
required to have an NPI. Please register for one if you
have not already secured your NPI.

? Groups are not technically required to have an NPI,
but are encouraged to have one as long as there is
a legal entity associated with the business name and
?>???`i???wV>????????Li???/???i}???i????i?}????? *??
with Horizon NJ Health, we will need the W-9 for the
business and all associated individual NPIs paid to
that tax ID number.

? Facilities, including hospitals and groups chosen to
subpart their type 2 NPI, will need to choose a master
NPI if all of the registered numbers are under the
?>?i??>???`i???wV>????????Li????i??}?>???}?>??>??i??
NPI number will help Horizon NJ Health assign claims
to the right location for payment purposes. A valid
W-9 for the business and all associated individual
NPIs that are paid to that tax ID number should be
registered with Horizon NJ Health.

? Where an NPI number is shared among different
locations using the same tax ID number, the Horizon
NJ Health legacy ID is needed to distinguish where
the claim payment should be sent.

? Nonparticipating practitioners and facilities are
also required to adhere to the NPI requirements.
To facilitate payment for claims, Horizon NJ Health
encourages you to register your NPI with us in
the same manner described above. To complete
this task, please visit the ?For Providers? section
of horizonNJhealth.com and download our NPI
Collection Form. Once completed, fax your forms
and CMS documentation to Horizon NJ Health at
1-609-583-3004.

9.1.3 Procedures for Claim Submission
Horizon NJ Health is required by state and federal
?i}??>?????????V>????i?>?`??i???????iV?wV?`>?>??i}>?`??}?
services rendered to its members. All services rendered,
including capitated encounters and fee-for-service claims,
must be submitted on the CMS 1500 (HCFA1500) version
02/12 or UB-04 claims form, or via electronic submission
in a HIPAA ? compliant 837 or NCPDP format. Horizon
NJ Health does not accept handwritten or stamped
claims. These claims forms and electronic submissions
must be consistent with the instructions provided by CMS
requirements, as stated in the CMS Claims Manual, which
can be accessed at EOU?IQX?/CPWCNU?+1/?NKUV?CUR.

The hospital, physician and health care professional, to
appropriately account for services rendered and to ensure
timely processing of claims, must adhere to all billing
requirements.

Horizon NJ Health - Billing Guide

January 2019



When data elements are missing, incomplete, invalid or
coded incorrectly, Horizon NJ Health cannot process
the claims.

? Claims for billable services provided to Horizon NJ
Health members must be submitted by the hospital,
physician or health care professional that performed
the services.

? Professional services are not reimbursable to a hospital
???i?????i???????>???????iV?wV>????V????>V?i`?v???
professional services. Horizon NJ Health policy is to
reimburse these services only when billed on a CMS
1500.
U??
?>????w?i`?????????????? ???i>????>?i???L?iV???????i?

following procedures:
? q??6i??wV>???????>??>????i????i`?wi?`??>?i?V????i?i`????

the claim
? q??6i??wV>???????>??>???`?>}??????V?`i?]???`?wi???>?`?

procedure codes are valid for the date of service
? q??7?i??>???????>?i]??i??wV>??????v???i??ivi??>??v???

specialist or non-primary care physician claims
(excluding ?self-referral? types of care)

? q??6i??wV>??????v??i?Li????i??}?L??????v????i???Vi????`i??
Horizon NJ Health during the time period in which
services were provided

? q??6i??wV>???????>????i??i???Vi???i?i??????`i`?L??>?
participating or nonparticipating hospital, physician
or health care professional that has received
authorization to provide services to the eligible
member

? q??6i??wV>???????>????i???????>?]??????V?>??????i>????V>?i?
professional has been given approval for services
that require prior authorization by Horizon NJ Health

? Horizon NJ Health is the ?payor of last resort? on
all claims submitted for members of its health plan.
Hospitals, physicians and health care professionals
must verify whether the member has Medicare
coverage or any other third party resources and, if
??]??????`i?`?V??i??>???????>????i?V?>????>??w????
processed by this other insurer as appropriate.
+/2146#06?q?,i?iV?i`?V?>????>?i?`iw?i`?>??V?>????
with invalid or missing data elements, such as the tax ID
number, that are returned to the submitter or EDI source
without registration in the claim processing system.
Since rejected claims are not registered in the claim
processing system, the hospital, physician or health care
professional must re-submit clean claims within
180 calendar days from the date of service. This
guideline applies to claims submitted on paper or
electronically. Rejected claims are different than denied
claims, which are registered in the claim processing
system, but do not meet requirements for payment
under Horizon NJ Health guidelines.

Horizon NJ Health encourages all hospitals, physicians,
and health care professionals to submit claims
electronically. We utilize the TriZetto Provider Solutions
(TTPS) Direct Data Entry (DDE) SimpleClaim system.
All providers that previously used Emdeon to directly
enter their Horizon NJ Health claims must switch to DDE
SimpleClaim.

For more information on registering, please go to
JVVRU???VTK\GVVQRTQXKFGTUQNWVKQPU?YWHQQ?EQO?HQTOU?
JQTK\QP?PL?JGCNVJ?RTQXKFGTU. If you have any further
questions about registering with TTPS for DDE claim
submission, please call TriZetto at 1-800-556-2231 or
email VVRUUWRRQTV"EQIPK\CPV?EQO.

While Horizon NJ Health strongly encourages submitting
claims via EDI, if a paper claim is necessary, please submit
red and white paper claims only for all medical services to
Horizon NJ Health at the following address:

Horizon NJ Health
Claims Processing Department
21?$QZ??????
0GYCTM??0,???????????

Note: Out-of-state, non-Horizon NJ Health providers
should send claims to their local Blue Cross Blue Shield
Plan.

+/2146#06 ? Requests for reimbursement for retail
pharmacy and all outpatient drugs for persons designated
as aged, blind or disabled should be submitted directly to
the State of New Jersey.

+/2146#06 ? Requests for reimbursement for
mental health services for all enrollees, except the
developmentally disabled, FIDE-SNP or MLTSS members,
should be submitted directly to the State of New Jersey.

Note: Be sure to include the member?s Medicaid ID
number on all claims submitted to the State of New Jersey.

Note: Horizon NJ Health subcontracts with Davis Vision
to provide and/or coordinate vision services for eligible
members. All services, except ophthalmologic procedures,
are coordinated and paid by Davis Vision. Please call
1-877-226-3729 for information about submitting
invoices.

Note: Horizon NJ Health subcontracts with Scion Dental
to provide and/or coordinate dental services for eligible
members. Please call the Provider Call Center at
1-855-878-5368 for routine provider questions related
to eligibility, claims, authorizations, credentialing,
contracting, adding/changing provider data/locations,
and fee schedules.

Horizon NJ Health - Billing Guide

January 2019



Note: Horizon NJ Health subcontracts with Laboratory
Corporation of America, Inc. (LabCorp) for most routine
and specialized laboratory services. Generally,
Horizon NJ Health is responsible for payment of claims
for PAT/STAT laboratory service provided in hospitals
and ambulatory surgical centers. Horizon NJ Health will
also provide reimbursements for claims for laboratory
services included on LabCorp?s excluded test listing. An
authorization is required for any test included on this
listing; please submit claims to Horizon NJ Health as
??iV?wi`?>L??i??1??i??????i????i???iV?wi`????????
??iV?wV?V????>V??>??>??>?}i?i???]??>L??>??????i???Vi??
should be referred to LabCorp.

9.1.4 Claim Filing Deadlines
Horizon NJ Health must receive all claims within 180
calendar days from the initial date when services were
rendered. If claims are not received within 180 calendar
days from the initial date of service, claims will be denied
v????????i???w???}??
" ?V?>?????????Li???L????i`????????
60 days from the date of the primary insurer?s EOB.

? Horizon NJ Health?s Appeals Department utilizes
??iV?wV?V???i??>???i???i??i???}??>??`?????v??v?
???i???w???}?

? Member?s name
? Horizon NJ Health or Medicaid ID number
? Billed amount
? Date of service
? Billed/mailed date
? Address where the claim form was sent

(Horizon NJ Health or insurance code)
? For EDI submissions, a 999 report indicating

submission to the correct insurance code is required
for consideration of timely submission.

For claims selected electronically:
? Submit an electronic data interchange (EDI)

acceptance report. This must show that
???????? ???i>?????????i??v?????>vw??>?i???iVi??i`]?
accepted and/or acknowledged the claim submission.

Note: A submission report alone is not considered
????v??v????i???w???}?v???i?iV?????V?V?>?????????????Li?
accompanied by an acceptance report.

? The acceptance report must:
1. Include the actual wording that indicates the

claim was either ?accepted,? ?received? and/or
?acknowledged.?
(Abbreviations of those words are also acceptable.)

2. Show the claim was accepted, received, and/or
>V?????i`}i`??????????i????i???w???}??i???`?

For paper claims:
1. The submission date must be within the
????i???w???}??i???`?

???
i???wi`??>????iVi?????>???>??`?????v??v????i???w???}?
3. Only red and white paper claims can be processed.

"??i???>??`?????v??v????i???w???}?`?V??i??>????

Valid when incorrect insurance information was provided
by the patient at the time the service was rendered:

? A denial/rejection letter from another insurance carrier
U??????i???????>?Vi?V>???i????i???>?>??????v?Li?iw??
? Letter from another insurance carrier or employer

group indicating coverage termination prior to the
date of service of the claim

? Letter from another insurance carrier or employer
group indicating no coverage for the patient on the
date of service of the claim

All of the above must include documentation that the
claim is for the correct patient and the correct date
of service. The date on the other carrier?s payment
V???i????`i?Vi???>??????i????i???w???}??i???`?v???
submission to Horizon NJ Health. In order to be
considered timely, the claim must be received by
Horizon NJ Health within 60 days from the date on the
other carrier?s correspondence. Not including all of the
information requested will result in a rejected inquiry or a
delay in response. If the claim is received after the timely
w???}??i???`]??????????????ii?????i???w???}?V???i??>?

4'('4?61?5'%6+10????? Section 10.0 Complaint
and Appeals Process for complete instructions of the
submission time frames and procedures for administrative
or medical appeals.

9.1.5. Filing Corrected Claims

For paper claims:
CMS-1500 should be submitted with the appropriate
resubmission code (value of 7) in Box 22 of the paper
claim with the original claim number of the corrected
claim and a copy of the original Explanation of Payment
(EOP). With the original claim number for which the
corrected claim is being submitted. Horizon NJ Health will
reject any claims that are not submitted on red and white
forms or that have any handwriting on them.

????1 ??{?V?>???\

UB-04 claims should be submitted with the appropriate
resubmission code in the third digit of the bill type (for
corrected claim this will be 7), the original claim number in
Box 64 of the paper claim and a copy of the original EOP.

Horizon NJ Health - Billing Guide

January 2019



Send red and white paper corrected claims to:

Horizon NJ Health
Claims Processing Department
21?$QZ??????
0GYCTM??0,???????????


???iV???}?i?iV?????V??
????x???V?>???\

EDI 837P data should be sent in the 2300 Loop, segment
CLM05 (with value of 7) along with an addition loop in
the 2300 loop, segment REF*F8* with the original claim
number for which the corrected claim is being submitted.


???iV???}?i?iV?????V?1 ??{?V?>???\

EDI 837I data should be sent in the 2300 Loop, segment
CLM05 (with value of 7) along with an addition loop in
the 2300 loop, segment REF *F8* with the original claim
number for which the corrected claim is being submitted.

Both paper and electronic claims must be submitted
within 365 calendar days from the initial date of service.

9.2 Claim Forms (Paper)
Horizon NJ Health requires that all hospitals, physicians
and health care professionals use the standard CMS 1500
(HCFA 1500) or UB-04 claim forms to report services,
which are reimbursable or capitated. The CMS 1500
(HCFA 1500) claim form must be completed for all
professional medical services. The UB-04 claim form must
be completed for all facility claims. When services are
?i?`i?i`?L????/--??????`i??]?v>V?????i???????`?w?i?>?
UB-04 form, and nonfacilities should use the CMS 1500.
*QTK\QP?0,?*GCNVJ?FQGU?PQV?CEEGRV?JCPFYTKVVGP?QT?
DNCEM?CPF?YJKVG?ENCKOU.

9.2.1 CMS 1500 (HCFA 1500) Claim Form

(Paper Submission)
The CMS 1500 (HCFA 1500) Paper Submissions claim
form must be used to bill all professional services to
Horizon NJ Health. Horizon NJ Health only accepts form
version 02/12. The National Uniform Claim Committee
(NUCC) created the CMS 1500 form (version 02/12) to
accommodate coding changes for ICD-10. There are
??????}??wV>???V?>?}i???????i??i???i`?
?-??x??]???i?
claim form used to submit paper claims to Medicare and
the required claim form to submit paper claims to
Horizon NJ Health.

The CMS 1500 Form (version 02/12) gives physicians the
ability to

? Identify whether they are using ICD-9-CM or
ICD-10-CM codes.
U????V??`i??????????V?`i???????i?`?>}??????wi?`????i?

limit on the 08/05 version is four codes in the
`?>}??????wi?`??

? Include information that will improve the accuracy of
the data reported, such as being able to identify the
???i??v???i??????`i??>?`???iV?wV?`>?i???v?????i???

? Align paper copy claim submissions with the ASC X12
Health Care Claim: Professional (837P) transaction.

CMS has advised providers to use the following process to
assure clean claims submission. All information must be:

U????}?i`??????????i?`>?>?wi?`??
? On an original red ink on white paper claim 02/12

version form.
? Typed. Do not print, handwrite or stamp any

extraneous data on the form.
? In black ink.
? In large, dark font, such as PICA or ARIAL 10-, 11- or

12-point type.
? In capital letters.

???i???v???>?????>L?????`???????>???i?-?????wV>?????
and Compliance Act (ASCA) exceptions can be found in
Chapter 24 of the ?Medicare Claims Processing Manual,?
which is available on the CMS website at
cms.gov/Regulations-and-Guidance/Guidance/
/CPWCNU?&QYPNQCFU??ENO???E???RFH.

,i????i`???i?`??v???
?-??x?????
????x????
Claim Form
/?????iV???????????????`i???i???????v??i????i`?wi?`??v???
Horizon NJ Health; however, you must refer to the most
current CMS coding instructions for a complete list of
codes and requirements.

Horizon NJ Health - Billing Guide

January 2019



Place of Service Codes
Code Description
???"vwVi
12 Home
19 Off Campus - Outpatient Hospital
20 Urgent Care Facility
21 Inpatient Hospital
22 Outpatient Hospital
23 Emergency Room ? Hospital
24 Ambulatory Surgical Center
25 Birthing Center
26 Military Treatment Facility
31 Skilled Nursing Facility
32 Nursing Facility
33 Custodial Care Facility
34 Hospice
41 Ambulance ? Land
42 Ambulance ? Air or Water
x???i`i?>????+?>??wi`??i>????
i??i?
51 Inpatient Psychiatric Facility
52 Psychiatric Residential Treatment Center
53 Community Mental Health Center
54 Intermediate Care Facility/Mentally Retarded
55 Residential Substance Use Disorder Treatment Center
56 Psychiatric Residential Treatment Center
60 Mass Immunization Center
61 Comprehensive Inpatient Rehabilitation Facility
62 Comprehensive Outpatient Rehabilitation Facility
65 End-Stage Renal Disease Treatment Facility
71 State or Local Public Health Clinic
72 Rural Health Clinic
81 Independent Laboratory
99 Other Unlisted Facility

Type of Service Codes
Code Description

1 Medical Services
2 Surgery
3 Consultations
4 Radiology (total component)
5 Laboratory (total component)
6 Radiation Therapy (total component)
7 Anesthesia
8 Assistant Surgery
9 Other (e.g., prosthetic eyewear, contacts, ambulance)
D DME
F ASC

Required and Conditional Field Indicator
+/2146#06?? An authorization number and/or referral
number must be included in box #23 on a CMS 1500
(HCFA 1500) claim form or box #63 on a UB-04 form. The
?i????i`?wi?`????>???????Li?V????i?i`?v?????i???>?`>?`?
CMS 1500 (HCFA 1500) or UB-04 claim forms are in the
?i??iV???i?V?>???v????>?i>????v???i?wi?`?????i????i`?????????
exception, an ?R? (required) is noted in the ?Required or

??`?????>???L?????v?V????i???}???i?wi?`????`i?i?`i???
upon certain circumstances, the requirement is listed
as ?C? (conditional) and the relevant conditions are
explained in the ?Instructions and Comments? box.

9.2.2 The UB-04 (CMS 1450) Claim Form
(Paper)

The UB-04 (CMS 1450) claim form must be used to bill
all facility services to Horizon NJ Health. This section will
?????`i???i???????v??i????i`?wi?`??v??????????? ???i>?????
However, you must refer to the most current CMS coding
instructions for a complete list of codes and requirements.

Type of Bill Codes
Code Description

111 Hospital/Inpatient (Part A)/Admit through Discharge

Code Description
112 Hospital/Inpatient (Part A)/Interim ? First Claim
113 Hospital/Inpatient (Part A)/Interim ? Continuing

Claims
114 Hospital/Inpatient (Part A)/Interim ? Last Claim
115 Hospital/Inpatient (Part A)/Late Charge Only
117 Hospital/Inpatient (Part A)/Replacement of

Prior Claim
121 Hospital/Hospital Based or Inpatient(Part B)/Admit

Through Discharge
131 Hospital/Outpatient/Admit Through Discharge
211 Skilled Nursing/Inpatient (Part A)/Admit Through

Discharge
212 Skilled Nursing/Inpatient (Part A)/Interim ?

First Claim
213 Skilled Nursing/Inpatient (Part A)/Interim ?

Continuing Claims
214 Skilled Nursing/Inpatient (Part A)/Interim ?

Last Claim
321 Home Health/Hospital Based or Inpatient

(Part B)/Admit Through Discharge
322 Hospice Interim ? First Claim
323 Hospice Interim -- Continuing Claim
324 Hospice Interim ? Final Claim
331 Home Health/Hospital Based or Inpatient

(Part B)/Admit Through Discharge

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711 Clinic/Rural Health Clinic (RHC)/Admit Through
Discharge

721 Clinic/Independent Renal Dialysis Facility/Admit
through Discharge

731 Clinic/FQHC/Admit Through Discharge
831 Special Facility or Hospital ASC/ASC for

Outpatients/Admit Through Discharge

Type of Admission Codes
Code Description

1 Emergency
2 Urgent
3 Elective

Patient Status Codes
Code Description

01 Discharged to Home or Self Care (routine discharge)
02 Discharged/Transferred to Another Short-Term

General Hospital
03 Discharged/Transferred to SNF
04 Discharged/Transferred to ICF
05 Discharged/Transferred to Another Type of Institution

(including distinct parts) or Referred for Outpatient
Services to Another Institution

06 Discharged/Transferred to Home Under Care of
Organized Home Health Service Organization
07 Left Against Medical Advice
08 Discharged/Transferred to Home Under Care of an

IV Drug Therapy Provider
09 Admitted as an Inpatient to this Hospital
20 Expired (or did not recover ? Christian Science

Patient)
30 Still Patient or Expected to Return for Outpatient

Services
40 Expired at Home (hospice claims only)
41 Expired in a Medical Facility, such as Hospital, SNF,

ICF or Freestanding Hospice (hospice claims only)
42 Expired ? Place Unknown (hospice claims only)
50 Hospice ? Home
51 Hospice ? Medical Facility

Commonly Used Revenue Codes
Code Description

100 ? 129 Room and Board Charges
130 ? 249 Semi-private; Private; Ward, Nursery,

Subacute, ICU, CCU
250 ? 259 Pharmacy
260 ? 269 IV Therapy
270 ? 279 Medical/Surgical Supplies & Devices
280 ? 289 Oncology
290 ? 299 Durable Medical Equipment (DME)
300 ? 319 Laboratory/Laboratory Pathological
320 ? 339 Radiology Diagnostic/Therapeutic
340 ? 349 Nuclear Medicine
350 ? 359 CT Scan
360 ? 369 Operating Room Services
370 ? 379 Anesthesia
410 ? 449 Therapy Services
450 ? 459 Emergency Codes
540 ? 548 Ambulance Services
720 ? 729 Labor and Delivery
730 ? 750 Outpatient Surgery
800 ? 880 Radiology
900 ? 919 Psychiatric/Psychological
920 ? 999 Nuclear Medicine

Required and Conditional Field Indicator
,i????i`??,??wi?`???????Li?V????i?i`????>???V?>?????

??`?????>???
??wi?`???????Li?V????i?i`??v???i?
information applies to the services rendered to Horizon
NJ Health members.

+/2146#06?? Referrals are valid for up to 180 days.
The referral number on the claim does not generate a
payment. The actual referral must be submitted with each
claim to avoid claim processing delays or denials.

9.2.3 Taxonomy Codes
Taxonomy codes are administrative codes set for
identifying the provider type and area of specialization for
health care providers. Each taxonomy code is a unique
ten-character alphanumeric code that enables providers
to identify their specialty at the claim level.

Taxonomy codes are assigned at both the individual
provider and organizational provider level. Taxonomy
codes have three distinct levels: Level I is Provider
/??i]??i?i????????
?>???wV>????]?>?`??i?i???????????i?
Area of Specialization. Examples and discussion of
taxonomy codes can be found at JVVRU???YYY?EOU?
gov/medicare/providerenrollment-and certification/
medicareprovidersupenroll/taxonomy.html.

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January 2019



For paper UB04 institutional claims, the taxonomy code
should be placed in box 81 and should be submitted with
??i?? ?????>??wi???????
?-??x??????vi?????>??V?>???]???i?
?>???????V?`i??????`?Li??`i???wi`????????i???>??wi??
?ZZ? in the shaded portion of box 24i. The taxonomy
code should be placed in the shaded portion of box 24j
for the rendering level and in box 33b preceded with
??i??<<????>??wi??v?????i?L?????}??i?i???
?>??????>??`??????
contain these codes cannot be processed.


?-??x?????n??x??*??vi?????>??
?>????????
(for enumerated providers)

Billing Provider NPI Field 33a
Billing Provider TIN Field 25
Referring Provider NPI Field 17b
Rendering Provider NPI Field 24j
Service Facility Location NPI Field 32a
+/2146#06 ? Make sure that your claim software
supports the revised 1500 claim form (08-05). Reference
the 1500 Reference Instruction Manual at Nucc.org for
??iV?wV?`i?>???????V????i???}??????v????

1 ??{?*>?i?????????????>??
?>???????
(for enumerated providers)

Billing Provider NPI Locator 56
Billing Provider TIN Locator 05
Billing Provider Taxonomy Code Locator 81
Attending Provider NPI Locator 76
Operating Provider NPI Locator 77
Other Provider NPI Locator 78-79

9.3 Procedures for Electronic Submission ?
Electronic Data Interchange

+/2146#06 ? Effective January 1, 2017, registered
providers must include their taxonomy code, tax
?`i???wV>????????Li?]?>?`? *?????>???V?>??????????V>??
?????`i??]?>??`iw?i`?L??
?-]????????L??????i???
?>???????V?`i?>?`???i????>???`i???wV>????????Li??

+/2146#06 ? All claims submitted electronically must
be in a HIPAA compliant 837 or NCPDP format. Electronic
`>?>????i?V?>?}i??
????>??????v>??i?]????i?ivwV?i???>?`?
cost-effective claim submission for hospitals, physicians
and health care professionals. EDI, performed in
accordance with nationally recognized standards,
supports the industry?s efforts to reduce overhead
administrative costs.

/?i?Li?iw????v?L?????}?i?iV?????V>??????V??`i\

? Reduction of overhead and administrative costs.
EDI eliminates the need for paper claim submission.
It has also been proven to reduce claim rework
(adjustments).

? Receipt of reports as proof of claim receipt. This
makes it easier to track the status of claims.

? Faster transaction time for claims submitted
electronically. An EDI claim averages about 24 to 48
hours from the time it is sent to the time it is received.
This enables providers to easily track their claims.

? Validation of data elements on the claim. By the
time a claim is successfully received electronically,
information needed for processing is present. This
reduces the chance of data entry errors that occur
when completing paper claim forms.

? Quicker claim completion. Claims that do not need
additional investigation are generally processed
quicker. Reports have shown that a large percentage
of EDI claims are processed within 10 to 15 days of
their receipt.

+/2146#06 ? Referrals are valid for up to 180 days
and up to 6 visits. The referral number on the claim
does not generate a payment. The actual referral must
be submitted with each claim to avoid claim processing
delays or denials.

Note: Hospitals, physicians and health care professionals
submitting claims electronically should make sure the
referral number is present on the claim.

Note: EDI Technical Support Team is available during
regular business hours, 8 a.m. through 5 p.m., Monday
through Friday, and can be reached at 1-800-556-2231.

??????*CTFYCTG?5QHVYCTG?4GSWKTGOGPVU
There are many different products that can be used to
bill electronically. Hospitals, physicians and health care
professionals should send EDI claims to TriZetto TTPS
whether through direct submission or through another
clearinghouse/vendor using payor number 22326. Only
TriZetto TTPS can submit claims electronically to Horizon
NJ Health.

Contracting with TriZetto and Other Electronic
6i?`???

If you are a hospital, physician or health care professional
interested in submitting claims electronically to Horizon
NJ Health but do not have TriZetto EDI services, contact
TriZetto at 1-800-556-2231. You may also choose to
contract with another EDI clearinghouse or vendor who
already has access to TriZetto EDI services.

Horizon NJ Health - Billing Guide

January 2019



Contacting the EDI Technical Support Group
Hospitals, physicians and health care professionals
interested in sending claims to Horizon NJ Health
electronically may contact the EDI Technical Support
Group for information and assistance.

"?Vi????????? ???i>???????????wi`??v???i????i????????L????
claims through EDI, the organization?s contact will receive
a complete list of ID numbers for Horizon NJ Health
hospitals, physicians and health care professionals, the
i?iV?????V??>???????Li?]?/??<i??????iV?wV?i`???]?>?`?>???
other information needed to initiate electronic billing with
Horizon NJ Health.

Note: Physicians can contact the EDI Technical Support
Group to obtain names of other EDI clearinghouses
and vendors.

Transmission Requirements
Once the material is received, proceed as follows:

? Read over the materials carefully
? Transmission can begin upon receipt of ID numbers

for Horizon NJ Health individual hospitals, physicians
and health care professionals

Contact the EDI Technical Support Group to answer
any questions you may have. If you wish to receive
V??w??>????????Li}???i?iV?????V???L???????]???i?
???
Technical Support Group will contact you via fax, mail or
email on the effective day for EDI claim submission.

No approval is necessary. Contact your system vendor
and/or TriZetto to inform them that you are now
going to submit production claims electronically to
Horizon NJ Health. You will be asked for the electronic
?>????>``?i???>?`???i?/??<i??????iV?wV?i`??????V??`i`????
your Horizon NJ Health documentation.

Note: Contact EDI Technical Support at 1-800-556-2231
to notify them of your intention to begin EDI
transmissions.

??????5RGEK?E?&CVC?4GEQTF?4GSWKTGOGPVU
EDI claims should be submitted according to HIPAA
standards. These standards can be found in the
Implementation Guides written by the Designated
Standard Maintenance Organizations (DSMOs) responsible
for each transaction. Additional information can be found
at hipaa-dsmo.org.

??????'NGEVTQPKE?%NCKO?(NQY?&GUETKRVKQP
In order to send claims electronically to Horizon NJ
?i>???]?>???
???V?>?????????w????Li?v???>?`i`????/??<i????
using payor number 22326. This can be completed
via a direct submission or through another EDI
clearinghouse or vendor. Once TriZetto receives the
transmitted claims, they are validated against TriZetto?s
??????i?>?????iV?wV>??????>?`????????? ???i>??????iV?wV?
requirements. Claims not meeting the requirements are
immediately rejected and sent back to the sender via a
TriZetto error report. The name of this report can vary,
based on the physician?s contract with their intermediate
EDI vendor or TriZetto. Claims are then passed to
Horizon NJ Health, and TriZetto returns a conditional
acceptance report to the sender immediately.

Claims forwarded to Horizon NJ Health by TriZetto
are immediately validated against physician and
member eligibility records. Claims that do not meet
this requirement are rejected and sent back to TriZetto,
which also forwards this rejection to its trading partner ?
the intermediate EDI vendor or directly to the hospital,
physician or health care professional. Claims passing
eligibility requirements are then passed to the claim
processing queues. Claims are not considered received
??`i?????i???w???}?}??`i???i???v??i?iV?i`?v?????????}????
invalid provider or member data.

Hospitals, physicians and health care professionals
>?i??i??????L?i?v????i??wV>??????v?
???V?>?????iVi??????
Acknowledgements for accepted or rejected claims
received from TriZetto or other contracted vendors
must be reviewed and validated against transmittal
records daily.

Note: For a detailed list of TriZetto data requirements,
contact EDI Technical Support at 1-800-556-2231.

9.3.4 Invalid Electronic Claim Record
4GLGEVKQPU?&GPKCNU

????V?>????iV??`???i?????????????? ???i>?????????w?????>???
/??<i????????????i?>???i`????>?`????????? ???i>??????iV?wV?
edits prior to acceptance. Claim records that do not pass
these edits are invalid and will be rejected without being
recognized as received at Horizon NJ Health. In these
cases, the claim must be corrected and resubmitted within
??i??i????i`?w???}?`i>`???i??v??n??V>?i?`>??`>???v????
the date of service. It is important that you review the
rejection notices (the functional acknowledgements to
each transaction set and the unprocessed claim report)
received from TriZetto or your vendor in order to identify
and resubmit these claims accurately.

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January 2019



Common Rejections
? Missing or invalid member ID
? Claims with missing or invalid batch level records
U?
?>????iV??`?????????????}???????>??`??i????i`?wi?`?
? Claim records with invalid (unlisted, discontinued, etc.)

codes (CPT-4, HCPCS, ICD-10, etc.)
? Claims without or that have invalid hospital, physician
????i>????V>?i????vi?????>?? >????>??*????`i???`i???wi??
(NPI) numbers whenever applicable. Per federal
requirements, atypical providers are excluded
U? ???????V>??L?????}?>``?i??????w?i
? No taxonomy code

Note: Hospital, physician or health care professional
?`i???wV>????????Li???>??`>?????????????i?v???i`?>????i?
clearinghouse. Claims will be rejected if the hospital,
?????V?>??????i>???V>?i????vi?????>?????Li??wi?`??>?i?i?????

??????5WDOKVVKPI?%QTTGEVGF?%NCKOU?YKVJ?'&+
Providers using electronic data interchange (EDI) can
submit corrected claims electronically rather than via
paper to Horizon NJ Health.

Note:???V???iV?i`?V?>??????`iw?i`?>??>??i??L????????
?v?>?V?>????????>???iV?wV?V?>?}i???>???????>?i??>`i]?
such as changes to CPT codes, diagnosis codes or billed
amounts. It is not a request to review the processing of a
claim. The electronic corrected claim submission capability
allows for faster processing, increased claims accuracy
and a streamlined submission process. For your EDI
clearinghouse or vendor to start using this new feature
they need to:

? Use ?6? for adjustment of prior claims ?7? for
replacement of a prior claim or ?8? for a voided claim
utilizing bill type in loop 2300, CLM05-03 (837P).

? Include the original claim number in segment
REF01=F8 and REF02=the original claim number; no
dashes or spaces.

? Include the Horizon NJ Health claim number in order
to submit your claim with the 6, 7 or 8.

? Bill all services, not just the services that need
corrections.

? Do use this indicator for claims that were previously
processed (approved or denied).

? Do not use this indicator for claims that contained
errors and were not processed (such as claims that
did not appear on a remittance advice; i.e., rejected
up front).

? Do not submit corrected claims electronically and via
paper at the same time.

? Please note that either a written or stamped note
stating that any claim is a corrected claim will result in
that claim being returned for correction.

9.3.6 Electronic Billing Inquiries
Please direct inquiries as follows:

Action
? If you would like to be authorized to transmit

electronic claims
U??v??????>?i???iV?wV?
????iV???V>????i??????
? If you have general EDI questions or questions on

where to enter required data

Contact
? TriZetto Technical Support at 1-800-556-2231

Action
? If you have questions about your claims transmissions

or status reports
? Contact your System Vendor or call TriZetto at

1-800-556-2231

Action
? If you have questions about your claim status (receipt

or completion dates)
? If you have questions about claims that are reported

on the Remittance Advice
? If you need to know a provider ID number

Contact
? NaviNet.net. If the required information is not found,

call Provider Services at 1-800-682-9091.

Action
? If you would like to update provider, payee, UPIN,

tax ID number, physical billing address or payment
address information

? For questions about changing or verifying provider
information

Contact
'OCKN??RTQXKFGTHKNGQRU?"*QTK\QP$NWG?EQO
fax: 1-973-274-4126
Provider Services at 1-800-682- 9091

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January 2019



9.4 Common Coding Requirements

9.4.1 Diagnosis Codes
All claims must include the proper ICD-10-CM
diagnostic code.

The Centers for Medicare and Medicaid Services (CMS)
?????`i????iV?wV?}??`i???i?????>?`??????>?`>?`????}?1?-??
coding practices. The guidelines for outpatient facilities,
?????V?>???vwVi??>?`?>?V???>???V>?i?>?i?????>???i`?Li???\

? Identify each service, procedure or supply with an
ICD-10-CM code to describe the diagnosis, symptom,
complaint, condition or problem.

? Identify services or visits for circumstances other
than disease or injury, such as follow-up care after
chemotherapy, with V codes provided for this purpose.
U??
?`i???i?????>???`?>}??????w???]?v?????i`?L????i?

secondary, tertiary and so on. Code any coexisting
conditions that affect the treatment of the patient.
Do not code a diagnosis that is no longer applicable.
U??
?`i??????i???}?i???`i}?ii??v???iV?wV?????
>????
??i????i??V>??V?`i??????i?v?????????wv???`?}?????i??
available. Remember, there are only approximately
100 valid three-digit codes; all other ICD-10-CM codes
require additional digits.

? Code a chronic diagnosis, when it is applicable to the
patient?s treatment.

? When only ancillary services are provided, list the
>???????>?i?6?V?`i?w????>?`???i????L?i???iV??`??
For example, if a patient is receiving only ancillary
therapeutic services, such as physical therapy, use the
6?V?`i?w???]?v?????i`?L????i?V?`i?v?????i?V??`??????

? For surgical procedures, code the diagnosis applicable
to the procedure. If, after the procedure has been
done, the condition necessitating the surgery is more
??iV?wV>?????`i???wi`]????i?i??`i?i????i`????Li?
different than the preoperative diagnosis, code the
???????iV?wV?`?>}??????`i?i????i`????Li???i??i>????
for the surgery.

Horizon NJ Health has adopted these diagnosis
guidelines for its health plan and recommends that
hospitals, physicians and health care professionals remain
informed about these requirements through updated
ICD-10-CM coding manuals. Both the State of New Jersey
and the HIPAA transaction code sets require the use of
a diagnosis code on all claims. To ensure that diagnosis
codes are accurate, use the appropriate codes from the
most recent ICD-10-CM coding manuals. Using deleted or
incorrect codes will result in inability to process your claim
or payment delays.

9.4.2 Procedure Codes

Common Procedure Terminology

*/????>???>?`>?`??i`?????i???v?w?i?`?}???V?`i??>?`?
descriptive terms used to report the medical services
and procedures performed by physicians or health care
professionals. It was developed and is updated and
published annually by the American Medical Association
(AMA). CPT codes communicate to physicians, health
care professionals, patients and payors the procedures
performed during a medical encounter. Accurate coding
is crucial for proper reimbursement from payors and
compliance with government regulations.

The AMA revises and publishes the CPT Book on an
annual basis. Appendix B of CPT always consists of a
summary of additions, deletions and revisions to the
current edition. Of these three types of changes, only
the descriptions of revised codes appear in Appendix B,
so you must refer to the manual itself to look at the
descriptors of the new codes.

All physicians and health care professionals must use
the appropriate procedure codes from the most recent
HCPCS and CPT coding manuals or quarterly updates.
Claim processing cannot be completed without accurate
???Vi`??i?V?`i?]????V???iyiV????i??i???Vi???????`i`?
to enrollees.

??????/QFK?GTU
??`?wi???>?i???i`?????i???????>????i????Vi`??i??>??Lii??
>??i?i`?L??>???iV?wV?V??V????>?Vi????`?wi????????`i?
valuable information about the actual services rendered,
?i??L???i?i???>?`??>??i???`>?>????`?wi???>?????????`i?
for coding consistency and editing for Level I (Common
Procedure Terminology Codes) and Level II (Healthcare
Common Procedure Coding System).

Sometimes, CPT codes require the addition of two-digit
??`?wi????
*/???`?wi???>???????????????????>??>??i???Vi?
was altered in some way from the stated CPT Book
`i?V????????? iV>??i???i???i??v???`?wi??????v?i??i?????
the only way to alter the meaning of a CPT code, it is very
??????>????????????????????i???`?wi???V???iV????

Horizon NJ Health - Billing Guide

January 2019



??`?wi???V>????`?V>?i\

? A service or procedure has both a professional and a
technical component

? A service or procedure was performed by more than
one physician

? Only part of a service was performed
? An adjunctive service was performed
? A bilateral procedure was performed
? A service or procedure was provided more than once
? Unusual events occurred

1?i???i?>???????>?i???`?wi??v??????i???????iVi????
*
-?
and CPT coding manuals. Using deleted or incorrect
V?`i??>?`?v>????}??????i?>???`?wi??V>???i????????`i??>??]?
incorrect payments or claim payment delays.

+/2146#06?q???`?wi????????`?????Li???i`?v??????????i?
evaluation and management events unless the activity
occurs at separate times on the same day. The Evaluation
and Management Services Guide from CMS will be used
by Horizon NJ Health to determine the appropriateness
of coding submitted by physicians and health care
???vi??????]???V??`??}???i???i??v???`?wi???

For more information on the Evaluation and Management
Services Guide, please visit the Medicare Learning
Network (MLN) at cms.gov/MLNGenInfo.

Note:?/?i?i???`?wi???>?i???L?iV?????V?>?}i??
?????????i?
current CPT or HCPCS publications for the most up-to-
`>?i???`?wi???????

9.4.4 Units
The number of units or times a particular service is
performed must be accurately indicated on all claims.
When spanning dates of services, the number of units
must match the count of the actual days within the
spanned dates. If services were performed intermittently
throughout the spanned dates of services, each date must
be listed separately on the bill or an itemized statement
must be submitted along with the claim.

When billing for loaded mileage, exact mileage must
Li??`i???wi`??????i?V?>????7?i??L?????}?v????L?i??>????]?
units are equivalent to hours. All anesthesia providers are
required to indicate the true amount of minutes in the
`>?????????wi?`??v???i?V?>???v??????i??L?????}?v????i???Vi??

+/2146#06 ? The number of units and the service dates
must be coordinated in order to obtain the most accurate
reimbursement for the services billed. Services performed
once (one date of service) must be indicated with a ?1? in
??i????????wi?`?

??????1VJGT?%QFKPI
1?i???i?>???????>?i?V?`??}?>????`?V>?i`??????i??vwV?>??
guides for the CMS 1500 and UB-04 claim forms or
HIPAA-compliant electronic transaction sets when
V????i???}?>``?????>??wi?`????V??>??L???????i]???>Vi??v?
service and type of service. Incorrect coding can cause
under- or over-payments or claim payment delays.

9.4.6 Taxonomy Codes
Taxonomy codes on electronic claim submissions with the
ASC X12N 837P and 837I format are placed in segment
PRV03 and loop 2000A for the billing level and segment
PRV03 and loop 2420A for the rendering level.

9.4.7 Pharmacy (HCPC Codes)
When billing for all ?J? and ?Q? codes via revenue codes,
the appropriate National Drug Codes (NDC) number,
metric units, unit of measure, and revenue code must be
submitted as well. Failure to submit the NDC number,
metric units, unit of measure, and revenue code along
with the ?J? or ?Q? code will result in the claim being
rejected. This guideline applies to all claims.

9.4.8 Vaccine Administration Services
When billing for the administration of vaccines, only
one initial administration code can be reported per
day, regardless of vaccine administration method. For
example: CPT codes 90460 (18 years and younger), 90471
and 90473 are initial administration codes and cannot be
billed on the same date. When billing multiple vaccine
administration codes, please report as multiple units on
one line. For example, if you have 3 units of one vaccine
administration code, please bill the code on one line with
3 units.

9.5 Common Causes of Claim Processing
&GNC[U??4GLGEVKQPU?QT?&GPKCNU

? Authorization or referral number invalid or missing
? Billed charges missing or incomplete
? Claim information does not match authorization
U??
???`??>??????v?Li?iw????
" ????v???>???????????}?

or incomplete
? Diagnosis code missing 4th or 5th digit
U????>}?????]????Vi`??i??????`?wi??V?`i?????>??`?

or missing
? DRG codes missing or invalid
? Early and Periodic Screening, Diagnostic

andTreatment (EPSDT) information missing
or incomplete

Horizon NJ Health - Billing Guide

January 2019



? Eligibility/enrollment is not valid on DOS
U??
?????i???`i???wV>????????Li???
? ????????}?

or invalid
U?
???>?>??????v?Li?iw????
" ????????}??????V????i?i
? Hospital, physician or health care professional
?`i???wV>????????Li????????}???????>??`

? Illegible claim information
? Incomplete forms
? Payor or other insurer information missing

or incomplete
? Place of service code missing or invalid
? Procedure/service code does not match authorization
? Physician name missing or invalid
? Revenue codes missing or invalid
? Spanning dates of service do not match the listed

days/units
? Signature missing
? Third-party liability (TPL) information missing

or incomplete
? Type of service code missing or invalid
? When billing urgent care center claims, Horizon NJ

Health reimburses facilities only and not the individual
providers. Urgent care centers are reimbursed at an
all-inclusive case rate.

???????0GYDQTP?%NCKO?+PHQTOCVKQP?/KUUKPI?
or Invalid

All newborns receive an individual member number. Please
V?iV????i?
?iV?????V??i`?V>?`?
??}?L??????6i??wV>?????-???i??
(EMEVS) for the Medicaid number and include it when the
V?>??????L???i`?????>?????V??`i???i?w????>?`??>????>?i??v???i?
mother and baby on the claim. If the baby has not been
named, insert ?Girl? or ?Boy? in front of the mother?s last
?>?i?>????i?L>L????w?????>?i??6i??v????>????i?>???????>?i?
last name is recorded for the mother and baby.

+/2146#06 ? The claim for baby must include the baby?s
date of birth.

+/2146#06 ? On claims for twins or other multiple
L?????]???`?V>?i???i?L???????`i???????i??>??i????>?i?wi?`]?
e.g., Baby Girl Smith A, Baby Girl Smith B, etc.

9.5.2 Attachments Missing from
1TKIKPCN?%NCKO

Hospitals, physicians and health care professionals are
required to submit an invoice for implantable and other
insurance EOBs if they are denied. If these items are not
submitted with the claim or are submitted separately
(EDI and paper), incorrect payment or denials may occur.

Adjustments to these payments or denials should be
submitted as corrected claims not as a resubmission of
the original claim. Please submit to the correspondence
address below:

Horizon NJ Health
Claims Processing Department
21?$QZ??????
0GYCTM??0,???????????

Signed consent forms for sterilization are required for
payment under federal requirements. (See Section 3.3
Family Planning.) These forms should be submitted to the
address below:

Horizon NJ Health
21?$QZ??????
0GYCTM??0,???????????

Signed receipt of information form, FD-189 must be
submitted during the request for prior authorization for
hysterectomies.

9.5.3 Claims and Clinical Editing
The Centers for Medicare and Medicaid Services (CMS)
and the American Medical Association (AMA) have
spearheaded a correct coding initiative that intends to
establish norms for coding medical services. Medicaid
programs are required to apply National Correct Coding
Institute (NCCI) edits to physician and outpatient hospital
claims. Services deemed to be a part of a more complex
?i???Vi?>??`iw?i`?L????i?

???????Li??i?L??`?i`????
denied as established by current criteria set by CMS in
its claims processing manual. Horizon NJ Health also
uses the CMS Claims Processing Manual as a guide to
managing payments for services provided to its
members, including the medically unlikely edits (MUE)
subset and redundant edits. CMS publishes the
majority of existing MUEs on the CMS website at
cms.gov/nationalCorrectCodInitEd/.

Horizon NJ Health continues to enhance its software
used to adjudicate medical, professional and hospital
outpatient claims. Horizon NJ Health uses McKesson
ClaimsXten software. This is a clinically-based editing
solution, that helps ensure that our code and claim editing
rules are accurate and consistent with standard business
practices and ensures that the claim editing system is
transparent to all participating providers, and that claim
payments are accurate and consistent with standard
business practices and medical policies. ClaimsXten edits
are applied to all claims submitted to Horizon NJ Health
by physicians, health care professionals and hospitals.

Horizon NJ Health - Billing Guide

January 2019



Horizon NJ Health - Billing Guide

????%QQTFKPCVKQP?QH?$GPG?VU
Any services provided to a Horizon NJ Health member
>?i??i??i?i`?>}>?????Li?iw????????`i`?v?????>???>?i?
individual under other insurance carriers with whom the
member has coverage. Horizon NJ Health, as a managed
care program for Medicaid and NJ FamilyCare members
in New Jersey, is the ?payor of last resort? on claims for
services provided to members also covered by Medicare,
employee health plans or other third-party medical
insurance. Payors, which are primary to Horizon NJ Health,
include (but are not limited to):

? Private health insurance, including assignable
indemnity contracts

? Health maintenance organizations (HMOs)
? Public health programs, such as Medicare
U?*??w??>?`???????w???i>??????>??
? Self-insured plans
? No-fault automobile medical insurance
? Liability insurance
? Workers? compensation
? Long-term care insurance
? Other liable third parties

In cases where another insurer, including Medicare fee
for service, is deemed responsible for payment,
Horizon NJ Health will pay the lesser of the patient
responsibility as indicated on the primary carrier?s
i???>?>??????v?Li?iw????????i?`?vvi?i?Vi?Li??ii??????
maximum allowable expense and the amount paid
by the primary insurer. Please note, the total amount
reimbursed by all parties will not exceed the lowest
contractually agreed upon amount and will not exceed
??i?????>?????????? ???i>????Li?iw??]????V??????`??>?i?
been payable had no other insurance existed. Hospitals,
?????V?>???>?`??i>????V>?i????vi?????>????????`?????w?i?>?
claim with Horizon NJ Health until they receive the EOB
from the member?s other insurance carrier(s). Make sure
you follow that insurer?s administrative requirements,
standard claim submission policies and forms.

Upon receipt of payment, submit applicable claims
to Horizon NJ Health for payment of deductibles and
coinsurance amounts. Horizon NJ Health reimburses
>v?i??V???`??>??????v?Li?iw???>?`??????????????i?????>???
contracted rate for the service. The claim, PCP referral and
????>????????i????i???>?>??????v?Li?iw????
" ????????Li?
submitted within 60 days of the date of the other carrier?s
correspondence or 180 days from the date of service,
whichever is later. When preparing the claim, include a
complete record of the original charges and primary (or
additional) payor?s payment as well as the amount due

from the secondary or subsequent payor.

Submit all pages of the primary (or additional) insurer?s
EOB to avoid delays in completing claims due to missing
information or coding and message descriptions. This
??v???>?????i????i??>VV??>?i?V???`??>??????v?Li?iw????
With the exception of Medicare, Horizon NJ Health?s
?>?i?????wV>?????????V?i????>??>?i???????i???>????i`?>?`?
required must be followed for any claims to be considered
for payment. In the case of Medicare as the primary
insurer, practitioners and facilities are advised to follow
Horizon NJ Health?s procedures, as some services may
be exhausted or not covered by Medicare.

+/2146#06?q?????V???`??>??????v?Li?iw???
" ??V?>????
must be submitted with a copy of the EOB from the
primary insurer. If the primary insurance claim has been
paid, the COB claim can be submitted through EDI
transmission. If the primary insurance claim has been
denied, a paper copy of the primary explanation of
payment should be sent. Submit paper claims for all
medical services to Horizon NJ Health at the following
address:

Horizon NJ Health
Claims Processing Department
21?$QZ??????
0GYCTM??0,???????????

When seeking reimbursement from Horizon NJ Health
as secondary insurer where Medicare is an enrollee?s
primary source of insurance, you must use one of the
following processes. When you provide services to a
member who has other coverage, you must bill the
member?s primary insurer directly. Be sure to follow
that insurer?s claims submission policies. You must then
submit a claim and the primary insurer?s explanation of
benefits (EOB) to Horizon NJ Health within 60 days of the
date of the EOB or within 180 days of the date of service,
whichever is later. Alternatively, secondary/coordination
of benefits (COB) claims may be submitted electronically,
utilizing the following COB loops:

Loop Description Reported Data

2320 Other Subscriber Information Name of Primary Insurance
2330A Other Subscriber Name Name of Subscriber*
2330B Other Payer Name Payment Date from Other Insurance
2340 Line Adjudication Information Other Insurance Payment
Note: Although a primary insurer may have unique coding
??iV?wV??????i???L????i??]??????`i????????L??????????>??`?
ICD-10-CM, CPT-4 and HCPCS codes. Unique or invalid
V?`i????iV?wV???????i???????i????????V>??i?V?>??????Vi????}?
delays or denials.

January 2019



+/2146#06 ? The hospital, physician or health care
professional may not submit billed charges to
Horizon NJ Health that are different than charges
submitted to other insurers for the same services. The
submitted bill must contain the exact billed amounts by
???Vi`??i????i?>??????iyiV?i`??????i?????>??????>``?????>??
insurer?s EOB.

+/2146#06 ? The primary or additional insurer?s EOB
must include member name, billed amounts, paid
amounts, adjustments, coinsurance amounts, deductibles,
copayments and all associated messages and notes.
Incomplete information may result in a claim processing
delay or denial.

9.6.1 Medicare
When both Medicare and Medicaid cover a member
>?`???i??i???Vi????>?Li?iw???v?L???????}?>??]???i?V?>???
?????w????Li?w?i`???????i`?V>?i????????>??]??????V?>???
>?`??i>????V>?i????vi?????>????????`?????w?i?>?V?>????????
Horizon NJ Health until they receive the Medicare EOB.
Upon receipt of payment, submit the claim along with a
copy of the Medicare EOB to Horizon NJ Health within
60 days of the date of the Medicare EOB or 180 days
from the date of service, whichever is later.

Medicare primary members have no prior authorization
requirements and are not required to be seen by a
participating Horizon NJ Health hospital, physician or
health care professional, unless Medicare does not cover
the service. When Horizon NJ Health, by default, becomes
the primary payor, the hospital, physician or health care
professional must comply with all coverage requirements
indicated by Horizon NJ Health to be considered for
payment. Horizon NJ Health advises that services to
members covered by Medicare and Medicaid be reported
despite the fact that authorization is not required. This will
avoid delays in claims payment for services that Horizon
NJ Health must cover.

Medicare-eligible services denied by Medicare due to
v>????i????V????????????i`?V>?]?>`???????>???i????w???}?
requirements will not be covered by Horizon NJ Health.

Note: When Medicare is primary and the procedure?

? is covered by Medicare, an authorization or referral
is not required by Horizon NJ Health, even if one is
normally required by Horizon NJ Health. Reporting
these services to Horizon NJ Health is advised.

? is not covered by Medicare, an authorization or referral
is required by Horizon NJ Health if one is normally
required by Horizon NJ Health.

+/2146#06 ? The hospital, physician or health care
professional may re-bill for services originally denied
by Medicare when Medicare overturns the denial. The

hospital, physician or health care professional must submit
the re-bill within 60 days of the date of Medicare?s EOB or
180 days from the date of service, whichever is later.

??????1VJGT?6JKTF?2CTV[?/GFKECN?+PUWTCPEG
Members covered by a primary insurer including
Medicare should be instructed to notify Horizon NJ Health
of their primary coverage. Claims submitted to
Horizon NJ Health as the secondary or tertiary insurer
>?i???L?iV?????i??}?L??????>?`?Li?iw??V??i?>}i??/???iVi??i?
payment for a claim submitted to Horizon NJ Health as
the secondary or tertiary insurer, the hospital, physician
or health care professional must submit a copy of the
primary insurer?s EOB or denial letter along with the claim
to Horizon NJ Health.

016' ? Submit claims to Horizon NJ Health within 60
days of the date of the primary insurer?s remittance and/
or EOB or 180 days from the date of service, whichever
is later. Participating hospitals, physicians or health care
professionals may not bill Horizon NJ Health members
for deductibles and coinsurance or balances above our
allowable fees. Medicaid is the ?payor of last resort;?
therefore, the payments received from the primary
insurer and/or Horizon NJ Health must be considered
payment in full. Members are not to be billed for any
Horizon NJ Health covered service. If the service is not
covered by the other insurer or Horizon NJ Health, there
must be prior written agreement to bill the member for
these non-covered services.

4'('4?61 ? Section 10.0 Grievances and Appeals Process,
for complete instructions of the submission time frames and
procedures for administrative or medical appeals.

+/2146#06 ? If there is any possibility that the services
provided will not be covered by the primary insurer, the
hospitals, physicians or health care professionals should
obtain the appropriate referrals or prior authorizations
needed to obtain coverage under Horizon NJ Health.
Failure to do so may result in denial for payment.

+/2146#06 ? If you provide services to a member who
is ill or injured as the result of a third party action, you
must notify Horizon NJ Health of this information. In the
event that this information is determined after the claim
is submitted and/or resolved, you are still required to
inform Horizon NJ Health. This includes recording the
information about the injury or condition on the claim and
notifying Horizon NJ Health of any lawsuits or legal action
in relation to the injury or condition.

+/2146#06 ? When completing the CMS 1500 (HCFA
1500) claim form, be sure to complete #7 on the form.

January 2019

Horizon NJ Health - Billing Guide



??????6i??V?i??VV?`i???

Motor vehicle accident-related claims should be
submitted to the primary carrier prior to being
??L????i`???????????? ???i>??????v?Li?iw???i??>???????
are unavailable, the claim may be submitted to Horizon
???i>????>???}??????>??i???>?>??????v?Li?iw??????>?
denial letter in order to be considered for payment. In
all cases, Horizon NJ Health?s referral, prior authorization
>?`?????wV>?????????V?i????>??>?i???????i???>????i`?>?`?
required must be followed for any claims to be considered
for payment.

Upon receipt of a letter of exhaustion or denial letter
from the primary carrier, the hospital, physician or health
care professional will have 60 days from the date of the
letter to submit the claim or 180 days from the date of
service, whichever is later. Upon receipt of an EOB from
the primary carrier, Horizon NJ Health will pay the lesser
of the patient responsibility as indicated on the primary
carrier?s EOB or the difference between our maximum
allowable expense and the amount paid by the primary
insurer.

Please note, the total amount reimbursed by all parties
will not exceed the lowest contractually agreed upon
>??????>?`?????>?????????? ???i>????Li?iw??]????V??
would have been payable had no other insurance existed.

In all cases, Horizon NJ Health?s referral, prior
>???????>?????>?`?????wV>?????????V?i????>??>?i???????i???
applied and required must be followed for any claims to
be considered for payment.

+/2146#06 ? When preparing the claim, all information
relating to the accident must be included on the claim.
This includes diagnosis codes, accident indicators and
occurrence codes (UB-04 claim forms) where appropriate.
Additionally, if a primary insurer has made payment
for services, the insurer?s EOB must be included when
submitting the claim for payment.

Workers? Compensation
Workers? compensation covers any injury that is the
result of a work-related accident. If Horizon NJ Health
is aware of a workers? compensation carrier, Horizon NJ
Health will reject the hospital, physician or health care
professional?s claim and direct that the claim be submitted
w?????????i?????>???????i????V???i??>?????V>???i????v?
insurance coverage is not available at the time the claim
is submitted or the workers? compensation carrier ceases
to provide coverage, the claim will be considered for
payment.

Upon receipt of a letter of exhaustion or denial letter from
the primary carrier, the hospital, physician or health care
professional will have 60 days from the date of the letter
to submit the claim.

9.6.3 Reimbursement

Medicare
If a member has Medicaid and Medicare coverage,
the hospital, physician or health care professional may
bill for charges Medicare applied to the deductible or
coinsurance, or both. Horizon NJ Health will pay the lesser
of the patient responsibility as indicated on the primary
carrier?s EOB or the difference between our maximum
allowable expense and the amount paid by the primary
insurer. Please note, the total amount reimbursed by
all parties will not exceed the lowest contractually
agreed upon amount and normal Horizon NJ Health
Li?iw??]????V??????`??>?i?Lii???>?>L?i??>`???????i??
insurance existed.

Note: Horizon NJ Health considers the deductible,
coinsurance and copayments a component of the total
primary care capitation for primary care reimbursement for
services, which are capitated. If your primary care contact
???v???vii?v????i???Vi??i??L???i?i??]???i>?i?w????L??????i?
primary carrier and then bill Horizon NJ Health with the
carrier(s) EOB.

+/2146#06 ? Bills submitted to the secondary insurer
must exactly match the services and amount billed to the
primary insurer. This information, along with the primary
insurer?s EOB, is necessary to complete an accurate COB.
Incomplete information could result in processing delays
or denials.

Other Third-Party Medical Insurance
Horizon NJ Health will pay the lesser of the patient
responsibility as indicated on the primary carrier?s
i???>?>??????v?Li?iw????????i?`?vvi?i?Vi?Li??ii??????
maximum allowable expense and the amount paid by the
primary insurer. Please note, the total amount reimbursed
by all parties will not exceed the lowest contractually
agreed upon amount and normal Horizon NJ Health
Li?iw??]????V??????`??>?i?Lii???>?>L?i??>`???????i??
insurance existed.

Guidelines on Billing Mileage for
MemberTransportation Services
Horizon NJ Health members shall be transported to and
from medical appointments in a manner that results in the
accrual of the least number of miles. Mileage is measured
by odometer from the place of departure or the point at
which the member enters the vehicle to the destination or
point at which the member exits the vehicle. At no time
shall the transportation provider?s base location be used
when calculating mileage.

January 2019

Horizon NJ Health - Billing Guide



9.6.4 Services That Do Not Require a Primary
+PUWTGT?'1$

Services Not Covered by Traditional Medicare
? Hearing aids
? Diapers/Under-pads/Incontinence items
? EPSDT
? Personal care assistants (Medicare FFS only)
? Medical day care (Medicare FFS only)
? Private Duty Nursing

Physician and health care professionals may bill
Horizon NJ Health for these services without submission
of a primary insurer?s EOB.
Note: If a service is covered by Medicare Advantage,
please supply the resulting EOB.

+/2146#06 ? If billing for room and board only at a
skilled nursing facility, reimbursement will be considered
without submission of Medicare EOB.

Other Third-Party Medical Insurance
An EOB or notice of refusal must be submitted with all
commercial and Medicare Advantage insurers? claims.
Claims with primary payment can be submitted via EDI.

9.6.5 Denials from Primary Insurers
If the primary insurer denies payment to the hospital,
physician or health care professional based on coverage
i?V??????]?????V??i?>}i]?Li?iw??i??>??????????????
compliance with administrative guidelines, the physician
must submit a copy of the EOB or notice of refusal. The
EOB or notice of refusal must include an explanation of
the reason for the denial. Services denied by the primary
insurer and billed to Horizon NJ Health without an
explanation of the denial from the primary insurer will be
denied payment.

Services denied by the primary insurer for non-compliance
with medical or administrative guidelines may be
submitted to the secondary with a copy of the EOB or
????Vi??v??iv??>??>?`?>?V?????v???i?w?>??>??i>??`i??>??
letter or notice of refusal. Medical and/or administrative
`i??>????????????Li?V????`i?i`??????????iVi?????v???i?w?>??
appeal denial letter.

+/2146#06 ? Horizon NJ Health will document receipt
of notices that the member?s primary carrier does not
cover a service or that the service is exhausted. No
additional notices will be required until the anniversary
date of the member?s policy with that other insurer.
Annually, on or after the anniversary date, the hospital,
physician or health care professional must provide notice
again that the service is exhausted or not covered by the
primary carrier.

Note: The hospital, physician or health care professional
?????w?i?>?V?>??????????i?????>????????i???????????i?
>???????>?i????i???w???}?`i>`???i??>?`?>VV??`??}????
>???????>?i?w???}??i????i?i??????>????i??????L?????i`?V>??
and administrative denial information from a primary
insurer could result in processing delays or denials.

+/2146#06 ? Upon receipt of a letter of exhaustion
or denial letter from the primary carrier, the hospital,
physician or health care professional will have 60 days
from the date of the letter to submit the claim.

9.7 Early and Periodic Screening, Diagnosis
and Treatment (EPSDT)

EPSDT claims are paid based on the periodicity schedule.
The biological component of immunizations is only paid
where the Vaccines for Children (VFC) program does
not offer the biological or the supply is not available.
Administration of VFC-sponsored immunizations is paid on
a per-visit basis; therefore, multiple shots given in a single
visit will result in a per-vaccine administration payment.
Physicians and health care professionals are encouraged
to use combination immunizations when available.

/?i?v???????}?
*/?V?`i??>?`???`?wi????????`?Li???i`?
when conducting lead screening:

36405 59 Venipuncture for lead screening for children
under three years of age, scalp vein

36406 59 Venipuncture for lead screening for children
under three years of age, other vein

36410 59 Venipuncture for lead screening for children
three years of age or older

36415 59 Collection of venous blood by Venipuncture for
lead screening for children 3 years and older

36416 59 Collection of capillary blood specimen for lead
?V?ii???}??w?}i?]??ii?]?>?`?i>?????V??

83655 52 Lead test (diagnosis code required)

Horizon NJ Health sends quarterly EPSDT underutilization
reports to physicians, identifying members whose EPSDT
services are overdue. Compliance with using the EP
??`?wi?????????V?i>?i??i?>VV??>V???v???i?i??i??????

????4KUM?#UUGUUOGPV?2TQITCO
Horizon NJ Health is required by the State of New Jersey
to report encounter data for all services rendered to
our members, including capitated and fee-for-service
activities. All physicians, hospitals and health care
professionals are required to submit timely, accurate and
complete encounter data. This is required even when the
member is covered by another insurer.

Health care resource consumption in chronic disease
can be very high. The State of New Jersey is using a

January 2019

Horizon NJ Health - Billing Guide



risk adjustment payment model in an attempt to fairly
distribute Medicaid funds in proportion to the severity of
illness. Horizon NJ Health is required to submit encounter
data to the State of New Jersey as an estimate of the
prevalence of disease in the population we serve.

It is paramount that accurate data be gathered on the
prevalence of illness of Horizon NJ Health members. This
leads to accurate, severity-adjusted payment from the
State to the health plan and, ultimately, the provider.

For example: Not only should members seek medical care
for acute conditions, they should also visit their provider
for chronic conditions, such as diabetes or hypertension.
Moreover, if a member visits for an acute issue and a
chronic issue is relevant or discussed, we ask that this is
documented in both the records and the encounter
claim form.

For further information, please call Horizon NJ Health?s
Risk Adjustment nurse at 1-800-682-9094, x89625.

All services must be submitted on the CMS 1500
(HCFA 1500) or the UB-04 claim form, or via electronic
submission in a HIPAA-compliant 837I, 837P or NCPDP
format. Horizon NJ Health is required to submit this data
???>???*?????>?`>?`?w?i?v???>???????i?-?>?i??????V?`i`?
wi?`????`>?>?i?i?i???V???>??i`????>???*?????>??>V?????
must adhere to the national set of codes, including
medical services and diagnosis. Due to the requirement
to submit all services to the State, all requirements for
EDI transactions are also applied to paper claims.

The State of New Jersey will reject encounter data if it
does not meet their processing criteria. In some instances,
Horizon NJ Health will be required to reverse payment
already made to the provider if the encounter does not
meet the State?s criteria. A complete list of all possible
encounter rejections can be obtained by going to njmmis.
com. Under the Information section, select Edit Codes,
then Encounter Edits. The following are some causes for
rejections:

Facility Services
? NPI ? Any practitioner who is required to have an

NPI must report that number in the Billing Provider,
Rendering Provider, Attending Provider, Operating
*????`i??>?`?"??i??*????`i??wi?`?]??v?>????V>L?i??
The NPI is required by the State of New Jersey?s
Division of Medical Assistance and Health Services
for both electronic and paper claims submissions.
Horizon NJ Health and all practitioners of facilities
serving members are required to comply with this
requirement.

? Type of Bill ? The bill type must be consistent with
the type of service rendered with applicable revenue
codes and corresponding HCPCS. Common bill types
are listed in Section 9.2.2 of this manual.

? Statement Covers Period ? Any practitioner billing
for services must ensure that the dates of service are
within the time period indicated in the Statement
Covers Period stated on the claim. If a date of service
????????`i???i?`>?i????>Vi`??????i??????/????}??wi?`]?
the encounter will be rejected.

? Principle Procedure Date ? Any practitioner billing for
surgical services must ensure that the dates of service
are within the time period indicated in the Statement
Covers Period indicated on the claim. If the Principle
*??Vi`??i?`>?i????"??i??*??Vi`??i?`>?i?wi?`????
outside the dates reported in the Statement Covers
Period, the encounter will be rejected.

? Revenue Codes ? All revenue codes billed must be
valid for the type of claim being billed.

? Laboratory Services ? When billing revenue codes
300-319, the corresponding HCPCS or CPT codes
must be billed.

? Physician Administered Drug ? All services are
required to report units of measure for all drugs,
including their corresponding NDC code when
billingwith ?J? or ?Q? codes. The corresponding 11
digit NDC code must be reported along with the
correct unit of measure:

January 2019

Horizon NJ Health - Billing Guide



A. NDC units are based upon the numeric quantity
administered to the patient and the unit of measure.

UOM Description Guidelines

F2 International
unit

International units will mainly be
used when billing for Factor

VIII-Antihemophilic Factors

GR Gram Grams are usually used when
an ointment, cream, inhaler,
or bulk powder in a jar are
dispensed. This unit of measure
will primarily be used in the
retail pharmacy setting and not
for physician-administered drug
billing.

ML Milliliter If a drug is supplied in a vial in
liquid form, bill in millimeters.

UN Unit If a drug is supplied in a vial
in powder form, and must
be reconstituted before
administration, bill each vial
(unit/each) used.

NDC Units

Submit the decimal quantity administered and the units of
measurement on the claim. If reporting a partial unit, use a
decimal point.

? GR0.025
? ML2.5
? UN3.0

The quantity should be eight digits before the decimal
and three digits after the decimal. If entering a whole
number, do not use a decimal. Do not use commas.
????????i???w??]??i>?i??i?>????}???????????L?>????/?i?
following are some examples:

? 1234.56
? 2
? 12345678.123

Paper Claim Requirements

CMS 1500 form:

? Enter the NDC in the shaded area of the service lines
in Field 24

? The six service lines in section 24 have been
divided horizontally to accommodate submission
of supplemental information to support the billed
service. The top portion in each of the six service
lines is shaded and is the location for reporting
supplemental information.

? Submit the NDC code in the red-shaded portion of
the detail line item starting in positions 01.
U??/?i? ?
???????Li???iVi`i`????????i???>??wi?? {?>?`?

followed immediately by the 11 digit NDC code (e.g.
N412345678901).

UB-04 form:

? Field 42: Revenue code
? Field 43: NDC 11 digit number, Unit of Measurement
+?>??wi??>?`?1????+?>?????

? Field 44: HCPCS code
For EDI claims

LOOP Segment Element
Name

Information

2410 LIN 02 Product or Service ID
3WCNK?GT

If billing for a national drug
code (NDC), enter N4.

2410 LIN 03 If billing for drugs, include
the NDC.

LIN**N4*1234567890

2410 CTP 04 3WCPVKV[?

If an NDC was submitted in
LIN03, include the quantity
for the NDC billed.

2410 CTP 05-1 Unit or Basis for
Measurement Code

If an NDC was submitted
in LIN03, include the unit
or basis for measurement
code for the NDC billed.

F2 - International unit

GR - Gram ML - Milliliter
UN - Unit

Sample - CTP****3*UN

2410 REF 01 VY: Link Sequence
Number, XZ : Prescription
Number

Link Sequence # (to
report components for
compound drug)

2410 REF 02 Link Sequence

Number or Prescription
Number

Sample -
REF01*VY*123456

January 2019

Horizon NJ Health - Billing Guide



Claims cannot be paid by Horizon NJ Health without this
information.

For additional information on the valid NDC codes, unit
and units of measure, please refer to the NJ Medicaid
website. JVVRU???YYY?PLOOKU?EQO?PFE.QQMWR?CURZ

Professional Services
? NPI ? Any practitioner who is required to have an

NPI must report that number in the Billing Provider,
Rendering Provider and Service Facility Location
if applicable. The NPI is required by the State of
New Jersey?s Division of Medical Assistance and
Health Services for both electronic and paper claims
submissions. Horizon NJ Health and all practitioners of
facilities serving members are required to comply with
this requirement. Providers are prohibited from billing
under the NPI number of a different provider.

? Transportation Services ? When billing for
transportation services, a valid origin and
`i????>???????`?wi??>?i??i????i`?????????? ???i>????
members shall be transported to and from medical
appointments in a manner that results in the accrual
of the least number of miles. Mileage is measured
by odometer from the place of departure or the
point at which the member enters the vehicle to the
destination or point at which the member exits the
vehicle. At no time shall the transportation provider?s
base location be used when calculating mileage.
The CMS-1500 claim form should be completed
L??V??????}???`?wi?????>??>???????>?i???????????
the member?s place of departure and destination
locations.

? Procedure Codes ? All codes are to be in HIPAA-
compliant format. The use of CPT Level III codes
(local codes) is no longer valid.

? Diagnosis Codes ? All diagnosis codes must be
reported and coded to the 7th digit, if available.

? Retroactive Terminations ? Horizon NJ Health
participates in the Medicaid and NJ FamilyCare
programs. Our members must maintain eligibility in
order to receive services. There may be times when
a member?s eligibility is retroactively terminated, as
determined by the Medicaid/NJ FamilyCare program.
This retroactivity will result in an encounter rejection.
Horizon NJ Health is required to reverse payment
already made to the physician, hospital and health
care professional.

? Medical Claims for Fluoride Varnish ? Providers
should use the following procedure and diagnosis
V?`i????i????L??????}??i`?V>??V?>????v???y????`i?
varnish applications:

? 99188
? Z41.8 (ICD-10)

9.9 Remittance Advice Documentation

Overview of Payment Summary Page
Horizon NJ Health provides a comprehensive summary
?v?w?>?V?>????v???>?????>?`?>V????????????i?,i????>?Vi?
Advice (RA).

The body of the RA contains claim detail and the Payment
Summary page indicates whether the physician/payee has
a positive (+) or negative (-) balance.

Many hospitals, physicians or health care professionals
?>?i??i??i??i`???}???}?????wV>??????v???i??>??i????>?`?
negative payee balances in relation to claim adjudication
activities, capitation payments, or accounts payable
adjustments. The Payment Summary page displays this
information as ?rolling balances? of overpaid amounts
that are owed to Horizon NJ Health. The ?rolling balance?
is updated on each RA after current claim payments and
other adjustments have been applied.

If, after reviewing the RA, you have questions or want
to request a reconsideration, go to NaviNet.net. If your
concerns are still not resolved, contact Provider Services at
1-800-682-9091 for assistance.

These explanation codes represent the current set of
codes that are returned to the hospital, physician or
health care professional on the RA. Please review the
following list before calling the Physician & Health Care
Hotline for questions about RA codes. If an electronic RA
is requested, it will be submitted in the HIPAA-compliant
835 format. The explanation codes do not apply to an
electronic RA transaction.

9.10 LabCorp Testing/Professional Relations
Representatives Billing

Some tests are not available via LabCorp and must be
completed at a hospital or clinical setting and billed
accordingly. Some of these tests cannot be performed
in hospitals and will require prior authorization. Please
contact LabCorp Customer Service for more information
on tests that are not available via LabCorp.

LabCorp Customer Service
1-800-631-5250

Information about testing not available through LabCorp
is also available at genetests.org.

January 2019



Horizon NJ Health - Billing Guide

??????1WV?QH?5VCVG?/GFKECKF?%NCKOU?HQT?
Blue Cross and Blue Shield
Association Plans

State Medicaid agencies contract with Blue Cross and/
or Blue Shield Plans as Managed Care Organizations
??
"???????????`i?V????i?i????i??i`?V>?`?Li?iw???
on a risk basis. Both federal and state regulations
guide these relationships, but the eligible population,
V??i?i`?Li?iw???>?`???iV?wV????i???i}>?`??}?i>V????>?i???
Medicaid program may differ from state to state. Many
state Medicaid programs require providers to enroll as
Medicaid providers with that state?s Medicaid agency
before payment can be issued. In other cases, a state
Medicaid program will accept a provider?s Medicaid
enrollment in the state where the provider practices.

Medicaid Reimbursement and Billing
Claims for all Horizon NJ Health Medicaid members
should be submitted to your local BCBS Plan. If you are
contracted with Horizon NJ Health, your Medicaid rates
will only apply for services provided to Horizon NJ Health
members. These rates do not apply to services provided
to out-of-state Medicaid members. When you provide
services to a Medicaid member from another state,
you must accept that state?s Medicaid allowance (less
any member responsibility such as copayments) as
payment in full. Please note that billing out-of-state
Medicaid members for any amounts in excess of the
Medicaid-allowed amount for Medicaid-covered
?i???Vi???????iV?wV>?????????L??i`?L??vi`i?>???i}??>??????
(42 CFR 447.15).

Medicaid Billing Data Requirements
When billing for a Medicaid member, please remember
to check the Medicaid website of the state where the
member resides for information on Medicaid billing
requirements. Providers should always include their
>????>??*????`i???`i???wi??? *???????i`?V>?`?V?>???]?
unless the provider is considered atypical. Providers
should also bill using National Drug Codes (NDC) on
applicable claims. As a reminder, applicable Medicaid
claims submitted without these data elements will
be denied.

Provider Enrollment Requirements
As indicated above, some states require that out-of-state
providers enroll in their state?s Medicaid program in order
to be reimbursed. Some of these states may accept a
provider?s Medicaid enrollment in the state where they
??>V??Vi????v??w?????????i????i?i?????v?????>?i??i????i`????
enroll in another state?s Medicaid program, you should
?iVi??i?????wV>????????????L??????}?>??i??}?L?????????
Li?iw???????????9????????`?i???????????>????>?i????i`?V>?`?
program before submitting the claim. If you submit a
claim without enrolling, your Medicaid claims will be
denied and you will receive information from your local
BCBS plan regarding the Medicaid provider enrollment
requirements. You will be required to enroll before the
Medicaid claim can be processed and before you may
receive reimbursement.

January 2019