Claim Editing Policy

Effective Date: October 14, 2019

Purpose:
Provide general guidelines and information regarding claim edits and policies.

Scope:
Products included:

  • NJ FamilyCare/Medicaid Plan
  • Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP)

Claim Edits:

General Edit Purpose
Additional Service, Missing Primary Service The service reported was not reported in conjunction with a required primary service.
Age The service reported was inappropriate for the patient's age.
Assistant at Surgery Reduction Assistant at surgery is reimbursed for services in accordance with their degree of responsibility for the surgery.
Benefit The service either was not covered or exceeded the coverage limitations of the member's benefits.
Bundled Procedure When these services are covered, payment for these services are bundled into another service to which they are incident.
Co/Assistant Surgeon Not Allowed A co-surgeon and/or assistant surgeon are not eligible for the service submitted.
COB Service must be submitted to the member's primary coverage
COB Paid Primary coverage has paid the service in full.
Contracting Limitations The service was reduced or denied based on the terms of the physician's or health care professional's contract.
Diagnosis/CPT Matching The service was invalid for the diagnosis reported.
Diagnosis/Modifier Matching The modifier was invalid for the diagnosis reported.
Duplicate/Similar Service There was a duplicate or similar service that was previously reported for the patient for the same date of service.
Eligibility According to Horizon NJ Health’s records, the patient was not eligible for coverage on the date the service was performed.
Global Period Payments for services associated with a surgical procedure are included in a single payment for services that fall within the specified date range (a/k/a global surgical package).
Inappropriate Use of Modifier The service was missing the appropriate modifier or was reported with an incorrect modifier.
Incomplete/Incorrect Claim Data The information on the claim was incomplete or incorrect.
Invalid Code The service code reported was not valid.
Invalid Date Range Submitted on Claim The date range on the claim is inconsistent or invalid.
Medical Policy The reimbursement for the service was reduced or denied due to failure to meet Medical Policy guidelines.
Medicare/CMS Guidelines The service was not covered under Medicare/CMS guidelines.
Modifier/CPT Mismatch The modifier was invalid for the service reported.
Multiple Procedure When multiple procedures are performed on the same day, on the same patient, the subsequent procedure(s) are paid at a lesser amount than the primary procedure.
Multiple Surgery Reduction When multiple surgeries are performed on the same day, on the same patient the subsequent surgeries are paid at a lesser amount than the primary surgery.
Mutually Exclusive Combination of procedures that differ in technique or approach but lead to the same outcome, may be anatomically impossible or represent overlapping services, the lesser procedure is denied.
Other Coverage The patient was not insured by Horizon NJ Health
Place of Service The service reported was inappropriate for the place of service indicated on the claim.
Pre-Determination An approved Pre-Determination was required prior to performing this service.
Prior Authorization Required An approved Prior Authorization was required prior to performing this service.
Provider Adjustment An adjustment was made based on contracted rates.
Referral Required A referral from the patient's PCP was required prior to performing this service.
Service Unit Maximum The service exceeds the maximum number of units eligible for reimbursement.
Specialty Not Eligible The service reported was invalid for the health professional's specialty.
Timely Filing The service was submitted after the timely filing deadline.
Type of Service The service reported was inappropriate to the type of service indicated on the claim.
Un-Bundling When these services are covered, they should be reported as separate services.

 

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

  • Benefit Limitations
  • The terms of any applicable provider participation agreement;
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
  • Medical necessity; and
  • Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.