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 (HCFA 1500) or UB-04 claim form, or via electronic submission in a HIPAA compliant 837 or NCPDP format.
These claims forms and electronic submissions must be consistent with the instructions provided by the CMS requirements as stated in the Claims Manual which can be accessed at http://www.cms.hhs.gov/Manuals/IOM/ .
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 who 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.
– 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 non-participating hospital, physician or health care professional who 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.
– 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 non-participating hospital, physician or health care professional who 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 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 identification 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 corrected 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.
Since rejected claims are not registered in the claim processing system, the hospital, physician or health care professional must re-submit corrected 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.
