Reimbursement Policy:

Pre-Payment Coding Reviews Documentation Requests

Effective Date:

March 1, 2023

Purpose:

To provide pre-payment coding validation review requirements for professional and all outpatient facility claims.

Scope:

Products/Plans included:

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

Policy:

Horizon NJ Health or its designee may conduct a pre-payment coding validation review of services provided to our members. Horizon NJ Health or its designee may request medical records during the pre-payment coding validation review to help ensure accuracy in our processing of claims.

Providers are required to submit the requested medical records within 25 calendar days for the services identified for pre-payment review. In the event the requested records are not received by Horizon NJ Health or its designee within 25 days, the services shall be denied for failure to submit the requested medical records.

Types of claim reviews that may require documentation include, but are not limited to:

• National Correct Coding Initiative (NCCI) Modifiers
  Modifiers appended to Physician and Outpatient Hospital Medicare and Medicaid claims that bypass code pair edits designed to prevent payment for inappropriate coding combinations.

• Global Surgical Package Modifiers
  Modifiers appended to surgical procedure codes that bypass a specified post-surgical period during which certain services related to a surgical procedure, furnished by the physician who performed the surgery, are to be included in the payment of the surgical procedure code.

• Add-On Procedure Codes
  Procedure codes that are not eligible for reimbursement that are billed without the primary procedure.

• Cross Provider Duplicates
  Cross-Provider Duplicates occur when more than one provider has submitted a claim for the same service on the same day for the same patient.

• Unbundled Code Combination Modifiers
  Modifiers appended to procedure codes that bypass edits related to the appropriate billing of code combinations.

• Evaluation and Management Codes billed with Modifier 25
  Appending Modifier -25 to an Evaluation and Management procedure code bypasses claim edits that allow only one E&M code to be considered for reimbursement on a single day by the same practitioner or provider.

Procedure:

Horizon NJ Health or its designee will submit a written request for medical records (when applicable) indicating the provider has 25 days to submit the requested documentation.

Horizon NJ Health will deny the service(s) when the requested medical records are not received within 25 calendar days of the written request.

Horizon NJ Health will deny the service(s) when the medical records do not support the services billed.

Limitations and Exclusions:

Notwithstanding the foregoing, all payment determinations are subject to all other, applicable limitations, including but not limited to, the following:

• 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.

History:

6/30/2022: Policy Approved