Pre-Payment Documentation Requests for Facility Claims

Effective Date:

June 15, 2022

Purpose:

The purpose of this Policy is to establish time requirements for Horizon NJ Health Network Hospitals to submit documents requested by Horizon NJ Health for claims reviews or audits, and provide that if the requested documents are not submitted timely, the associated claim will be denied for lack of supporting records.

Scope:

Products included:

  • NJ FamilyCare/Medicaid
  • Fully Integrated Dual Eligible Special Needs Program (FIDE-SNP)
  • Managed Long Term Services & Supports (MLTSS)

Policy:

Upon request from Horizon NJ Health or its designee, facilities are required to submit documentation (i.e. itemized bill and/or medical record) within 30 calendar days from the date of the request for claims identified for pre-payment review or audit.

Applicable types of claim reviews include, but are not limited to:

  • Validation of the correct diagnosis related group (DRG) assignment/payment (DRG validation audits);
  • Validation that items and services charged are properly documented in a) the medical record and/or b) in an itemized bill for hospital bill audits, and in either case are items that are eligible to be separately billed;
  • Verification that services charged do not conflict with eligible benefits for covered persons; and
  • Verification that services charged are reimbursed at the agreed percent of the charges.

Procedure:

Upon pre-payment process claim review or audit, if a medical record, itemized bill or sign off sheet (on an audit referral) or other supporting documentation is needed to complete that review or audit, Horizon NJ Health will submit a request to the facility indicating they have thirty (30) calendar days to provide the requested information.

In the event the requested records or itemized bills are not received by Horizon NJ Health within the thirty (30) calendar days of the request, the claim or claims involved shall be denied for failure to submit the requested documentation for the claim or claims identified for pre-payment review or audit. Any denial of claim payments will be performed in accordance with the applicable provisions of HCAPPA.

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.