Section 5 - Billing Guide

Billing

This section is intended to offer MLTSS providers the information required for Horizon NJ Health to accurately and efficiently process claims prepared by or for them for 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 rejections, 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.

REFER TO – Directs the reader to another more complete source of explanation or additional resource information within the document.

In the event of additional questions about Horizon NJ Health programs or policies, please review the entire Manual or contact MLTSS Provider Services at 1-855-777-0123.

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. Notifications 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 timeframe. MLTSS providers may access the For Providers section of the Horizon NJ Health website 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 provider 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/NJ FamilyCare beneficiaries, whether eligible for FFS benefits or enrolled in managed care, is prohibited under federal and state law. These prohibitions apply to both Medicaid/NJ FamilyCare-only beneficiaries, fully integrated dual eligible special needs (FIDE-SNP) members, as well as those eligible for Medicare coverage or other insurance. A provider enrolled in the Medicaid/NJ FamilyCare 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/NJ FamilyCare 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/NJ FamilyCare 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.

Requirements for Filing Claims

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). 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.”

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

  1. the health care provider is eligible at the date of service
  2. the person who received the health care service was covered on the date of service
  3. the claim is for a service or supply covered under the health benefits plan
  4. 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)
  5. the payor has no reason to believe that the claim has been submitted fraudulently

Other requirements, such as timeliness of claims processing, include:

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.

For MLTSS services, Horizon NJ Health shall pay all clean claims from hospitals, physicians and other providers within 15 days of the date of receipt of EDI claims and within 30 days for paper claims.

The timeframe does not apply to claims from providers under investigation for fraud or abuse. Nor does it include any claims that have been rejected.

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.

To have payments sent to a different address, the pay-to provider name and address field on the 837-I and 837-P transaction must be used.

The 21st Century Cures Act requires the use of Electronic Visit Verification (EVV) for all Medicaid-funded, personal-care services. EVV is a web-based system that verifies when a provider documents the precise time a service visit begins and ends, and the location where the service is being provided. Learn more about EVV requirements.

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 red and white (no black and white or copied) CMS 1500 (HCFA 1500) 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 black and white (copies or faxed) or handwritten claims 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.

The provider, 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 provider that performed the services.
  • 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
    • 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 provider that has received authorization to provide services to the eligible member
    • Verification that the provider 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.
  • Providers 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 provider must submit a clean claim within 180 days of 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. Submit 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

Horizon NJ Health encourages all providers to submit claims via EDI. You can get more information or enroll by calling TriZetto Trading Partners Solutions (TTPS) at 1-800-556-2231, or you may email physiciansales@trizetto.com.

One other option is the use of TriZetto SimpleClaim, a dedicated direct-data entry (DDE) system through which you can submit claims electronically and monitor them through the reimbursement process. Register for TriZetto Provider Solutions here. For questions about registering with TTPS for DDE claim submission, please call TTPS at 1-800-556-2231. To submit paper claims (only red and white are accepted without handwriting or stamps), please send to Horizon NJ Health at the following address:

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

NOTE – Be sure to include the member's Medicaid ID number on all claims submitted to the State of New Jersey.

IMPORTANT – Claims inquiries may be submitted by telephone to: Provider Claim Services 1-855-777-0123

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 Explanation of benefits (EOB).

  • Horizon NJ Health's Appeals Department utilizes specific criteria when reviewing valid proof of timely filing. The information submitted should consist of a computer-generated ledger that cannot be altered and includes the following information:
    • 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
  • Horizon NJ Health's Appeals Department will also accept certified mail receipts as valid proof of timely filing

REFER TO – Section 6.0 Grievance and Appeals Process for complete instructions of the submission timeframes and procedures for administrative or medical appeals.

NOTE – If the provider's ledger uses internal insurance codes, he or she must submit a copy of the code descriptions.

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.

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

Claims with an EOB from primary insurers that fall beyond the timely filing requirements must be submitted within 60 days from the date of the primary insurer's EOB.

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 Explanation of benefits (EOB).

  • Horizon NJ Health's Appeals Department utilizes specific criteria when reviewing valid proof of timely filing. The information submitted should consist of a computer-generated ledger that cannot be altered and includes the following information:
      • 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
  • Horizon NJ Health's Appeals Department will also accept certified mail receipts as valid proof of timely filing

REFER TO – Section 6.0 Grievance and Appeals Process for complete instructions of the submission timeframes and procedures for administrative or medical appeals.

NOTE – If the provider's ledger uses internal insurance codes, he or she must submit a copy of the code descriptions.

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.

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

Claims with an EOB from primary insurers that fall beyond the timely filing requirements must be submitted within 60 days from the date of the primary insurer's EOB.

1500 (HCFA 1500) Claim Form

Field # Field Type Field Description Instructions Required
1 Member Info Insurance Program Identification Mark as Medicaid Yes
1a Member Info Insured Identification Number Horizon NJ Health member identification Yes
2 Member Info Patient's Name Enter the patient's name as follows: LAST NAME, FIRST NAME, MIDDLE INITIAL Yes
3 Member Info Patient's Date of Birth and Sex MM/DD/YY and M or F (Male or Female) Yes
4 Member Info Insured's Name Enter the member's name as it appears on the Horizon NJ Health Member ID card as follows: LAST NAME, FIRST NAME, MIDDLE INITIAL Yes
5 Member Info Patient's Address Enter the member's complete address Yes
6 Member Info Patient Relationship to Insured Mark as "Self" Yes
7 Member Info Insured's Address Enter the member's complete address including city and state. (Do not punctuate the address or phone number) Yes
11a Member Info Is there another Health Benefit Plan Y or N by check box. If yes, complete #9 a-d Yes

Fields 21 through 24g cover the types of services performed and the dates you performed them. Do not forget to add the information on authorizations if services require an authorization. Use the codes that are appropriate to your service type.

1500 (HCFA 1500) Claim Form

Field # Field Type Field Description Instructions Required
21 Procedure Info Diagnosis or nature of Illness or injury Use the Diagnosis Code (DX) from the Type of Service Table Yes
23 Procedure Info Prior Authorization Number Enter the authorization number if services require a authorization Yes
24a Procedure Info Dates of Service From date: MM/DD/YY. If the service was performed on one day there is no need to Yes
24b Procedure Info Place of Service Enter the HCFA standard place of service code from the Type of Service Table Yes
24d Procedure Info Procedures, services or supplies CPT/HCPCS Modifier Use the HCPC code and Modifier on the Type of Service Table Yes
24f Procedure Info Charges Enter charges Yes
24g Procedure Info Days or Units Enter quantity Yes

For all provider types:

Please complete fields 24 through 33 using the instructions in the chart. This section covers your provider information – account number, identification numbers and facility locations/service locations. Horizon NJ Health needs this information for reimbursement.

1500 (HCFA 1500) Claim Form

Field # Field Type Field Description Instructions Required
24i Provider Info ID Qualifier Enter the Provider Taxonomy qualifier ZZ and the corresponding 10-digit Provider taxonomy code in the shaded area Yes
24j Provider Info Rendering provider ID Enter NPI or provider ID number Yes
25 Provider Info Federal Tax Identification Number SSN/EIN The Provider's Federal Tax ID number Yes
26 Provider Info Patient's Account Number The Provider's billing account number Yes
27 Provider Info Accept Assignment? Always indicate yes Yes
28 Provider Info Total Charge The total charge of the service Yes
29 Provider Info Amount Paid REQUIRED, when another carrier is the primary payer. Enter the payment received from the primary payer prior to invoicing Horizon NJ Health. Medicaid programs are always the payers of last resort. Yes
30 Provider Info Balance Due REQUIRED, when #29 is completed Yes
31 Provider Info Signature of Physician or supplier and date Please sign and date the paper claim form. If billed electronically then “Signature on file” should be this field Yes
32 Provider Info Service Facility Location Enter the physical location. Yes
32a NPI National Provider Identification number or Horizon NJ Health provider ID Enter the Horizon NJ Health assigned provider identification number Yes
32b Provider Info Other ID Number Enter the Provider Taxonomy qualifier ZZ and the corresponding 10-digit Provider Taxonomy Code for the NPI number reported in. Do not enter a space, hyphen or other separator between the qualifier and the number. Yes
33 Provider Info Billing Provider Information and Phone # (include area code) Enter the complete name and address of the provider. Do not punctuate the address or phone number. Enter the Horizon NJ Health assigned physician/supplier identification number. Yes
33b Provider Info Other ID Number Enter the Provider Taxonomy qualifier ZZ and the corresponding 10-digit Provider Taxonomy Code for the NPI number reported in. Do not enter a space, hyphen or other separator between the qualifier and the number. Yes

Claim Forms (Paper)

CMS 1500 Claim Form (Paper) Instructions

The CMS 1500 (HCFA 1500) claim form must be used to bill all professional services to Horizon NJ Health.

How to Complete the CMS 1500 Form

For all provider types:

Complete fields 1 through 11d with the member's information. The basic member information – name, address, patient relationships and identification numbers – is required.

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

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

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)

1 Discharged to Home or Self Care (routine discharge)

2 Discharged/Transferred to Another Short-Term General Hospital

3 Discharged/Transferred to SNF

4 Discharged/Transferred to ICF

5 Discharged/Transferred to Another Type of Institution (including distinct parts) or Referred for Outpatient Services to Another Institution

6 Discharged/Transferred to Home Under Care of Organized Home Health Service Organization

7 Left Against Medical Advice

8 Discharged/Transferred to Home Under Care of an IV Drug Therapy Provider

9 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

Paper Claims Submissions

Horizon NJ Health requires that all providers use the standard CMS 1500 (HCFA 1500) or UB-04 claim forms to report services that are reimbursable or capitated. The CMS 1500 (HCFA 1500) claim form must be completed for all non-institutional professional services. The UB-04 claim form must be completed for all facility claims. For timely processing of claims, providers are encouraged to submit electronically. If permitted under your Agreement and until the provider has the ability to submit electronically, to assure clean claim submission, paper claims (UB-04 and CMS 1500, or their successors) must adhere to the following CMS-mandated elements and formatting guidelines:

  • Paper claims must only be submitted on original (red ink on white paper) claim forms.
  • Any missing, illegible, incomplete or invalid information in any field will cause the claim to be rejected or processed incorrectly.
  • Information must be aligned within the data fields and must be on an original red ink on white paper claim form.
  • The information should be typed. Do not print, handwrite, or stamp any extraneous data on the form.
  • The typed information must not contain broken characters, script or italics.
  • Stylized font, mini font and dot-matrix font are not acceptable.

Procedures for Electronic Submission – Electronic Data Interchange

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 providers. 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 more quickly. Reports have shown that a large percentage of EDI claims are processed within 10 to 15 days of their receipt.

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 or ttpssupport@cognizant.com. Learn more about registering with TriZetto. You may also choose to contract with another EDI clearinghouse or vendor who already has access to TriZetto EDI services.

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 materials are 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.

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 CMS' website.

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 his or her 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.

Invalid Electronic Claim Record

Rejections/Denials

All claim records sent to Horizon NJ Health must first pass Cognizant'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 180 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 Cognizant TPS or your vendor in order to identify and resubmit these claims accurately.

Common Rejections

  • 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 provider National Provider Identifier (NPI) numbers whenever applicable. Per federal requirements, atypical providers are excluded
  • Missing/invalid member ID
  • No physical billing address on file
  • Missing Taxonomy code
  • NDC code not being billed for J and Q codes with the correct NDC unit of measure and the NDC unit dispensed
  • The PPCN field must be populated with the original claim number when billing a corrected claim

NOTE – Provider identification number validation is not performed at TriZetto. TriZetto will reject claims for provider information only if the provider number fields are empty.

Submitting Corrected Claims with EDI

Providers using electronic data interchange (EDI) can submit “professional” corrected claims electronically rather than 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 “7” for replacement of a prior 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 or 7.
  • 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.

Common Coding Requirements

Diagnosis Codes

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

CMS provides specific guidelines to aid in standardizing U.S. coding practices. The guidelines 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.

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.

NOTE – Horizon NJ Health does not have the ability to return invalid diagnosis codes to submitters. Invalid diagnosis codes are returned to the providers with zeros (00000) and an explanation that the codes are not valid.

Procedure Codes

Common Procedure Terminology (CPT)

CPT is a standardized system of five-digit codes and descriptive terms used to report the services provided by providers. It was developed and is updated and published annually by the American Medical Association (AMA). CPT codes communicate to physicians, providers, 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 providers 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.

IMPORTANT – Procedure coding must meet the current criteria set by the AMA for medical practice norms. Horizon NJ Health does not have the ability to return invalid procedure codes to submitters. Invalid procedure codes are returned to the providers with zeros (00000) and an explanation that the codes are not valid.

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 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.

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 – The correct modifier must be used when required by the current CPT or HCPCS publications. A valid modifier must be used to indicate the circumstance under which the service or item is being billed. Using appropriate modifiers provides valuable information when evaluating claims for payment. Missing or inaccurate modifiers, as well as missing required medical documentation, may result in inaccurate reimbursements or inaccurate denials for duplicate services.

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 providers, including the use of modifiers. For more information on the Evaluation and Management Services Guide please visit the Medicare Learning Network (MLN).

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

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.

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.

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.

Common Causes of Claim Processing Delays, Rejections or Denials

  • Authorization 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 and Treatment (EPSDT) information missing or incomplete
  • Eligibility/enrollment is not valid on DOS
  • Explanation of benefits (EOB) missing or incomplete
  • 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
  • Provider identification number missing or invalid
  • Revenue codes missing or invalid
  • Spanning dates of service do not match the listed days/units
  • Signature missing
  • Employer identification number (EIN) missing or invalid
  • Third party liability (TPL) information missing or incomplete
  • Type of service code missing or invalid

Attachments Missing From Original Claim

Providers are required to submit an invoice for implantable items, and other insurance EOBs, if the primary insurance denied the service. 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

Coordination of Benefits (COB)

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 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 will not exceed the normal Horizon NJ Health benefits, which would have been payable had no other insurance existed. Providers 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 and primary insurer's EOBs must be submitted within 60 days of the date of the EOB or within 180 days of the dates 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 COB claims must be submitted with a copy of the EOB from the primary insurer. Submit COB 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

NOTE – Although a primary insurer may have unique coding specific to its 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 provider 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.

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. Providers 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 provider, unless Medicare does not cover the service. When Horizon NJ Health, by default, becomes the primary payor, the hospital, physician or provider 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 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 is required by Horizon NJ Health if one is normally required by Horizon NJ Health.

IMPORTANT – The provider may re-bill for services originally denied by Medicare when Medicare overturns the denial. The provider must submit the re-bill within 60 days of the date of Medicare's EOB.

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 provider must submit a copy of the primary insurer's EOB or final 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 providers may not bill Horizon NJ Health members for deductibles and coinsurance or balances above its 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 6.0 Grievance and Appeals Process for complete instructions of the submission timeframes 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 providers should obtain the appropriate prior authorizations needed to obtain coverage under Horizon NJ Health. Failure to do so may result in denial of 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 item #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 EOB or a denial letter in order to be considered for payment.

In all cases, Horizon NJ Health's 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 provider will have 60 days from the date of the letter to submit the claim. 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 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 provider'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.

Upon receipt of a letter of exhaustion or denial letter from the primary carrier, the provider will have 60 days from the date of the letter to submit the claim.

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

Reimbursement

Medicare

If a member has Medicaid and Medicare coverage, the provider 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.

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 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.

Guidelines on Billing Mileage for Member Transportation Services

Horizon NJ Health members shall be transported to and from medical appointments in a manner resulting 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.

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 SNF, 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.

Denials from Primary Insurers

If the primary insurer denies payment to the provider 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 noncompliance 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.

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 provider must provide notice again that the service is exhausted or not covered by the primary carrier.

NOTE – The provider 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 provider will have 60 days from the date of the letter to submit the claim.

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 providers 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.

Providers may also register for Electronic Funds Transfer (EFT) to receive payments.Reviewinformation and instructions for enrolling in EFT. Note that if you register for EFT, you must also register for ERA or else you will not receive RAs.

If, after reviewing the RA, you have questions or want to request a reconsideration, contact MLTSS Provider Services at 1-855-777-0123 for assistance.

Cost Share/Patient Pay Liability (PPL)

Long-term care providers (i.e., Specialty Care Nursing Facilities, Nursing Facilities and Assisted Living Facilities) collect the Cost Share/PPL monthly from a Medicaid beneficiary and/or their designee to offset the cost of long-term care. Individuals living in the community will pay Cost Share/PPL directly to the State of New Jersey with the exception of Program for All-inclusive Care for the Elderly (PACE) participants. Refer to DMAHS for more information.