Manual for Medical Billing

9.0 BILLING GUIDE Introduction: Welcome to the Horizon NJ Health Claims Billing Guide. This guide is intended to offer hospitals, physicians and health care professionals the information required for Horizon NJ Health to accurately and efficiently process claims prepared by or for hospitals, physicians and health care professionals for medical services provided to members of our health plan. The information provided in this guide represents the claims billing policy as of December, 2006. About the Guide This guide 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 rejection, 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 this document. In the event of additional questions about Horizon NJ Health programs or policies, please review the entire Hospital, Physician and Health Care Professional Manual or contact the Physician & Health Care Hotline at 1-800-682-9091. Hospitals, Physicians and Health Care Professionals may access the Horizon NJ Health Physician & Health Care Center Web site to check member eligibility and claim status at www.horizonNJhealth.com. Hospitals, Physicians and Health Care Professionals may also check member eligibility by calling the Physician & Health Care Hotline at 1-800-682-9091. 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 time frame. Hospitals, Physicians and Health Care Professionals may access the Horizon NJ Health Physician & Health Care Center 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 hospital, physician or health care professional 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 co-pay for any service or population group, an itemization of these items will be included in the benefit listing and will be available on the Web site. Horizon NJ Health Physician and Health Care Professional Manual, December 2007 9-1 9.1 9.1.1 Requirements for Filing Claims General Requirements Consistent with CFR 42 Part § 447.45 - Timely claims payment: 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: the health care provider is eligible at the date of service; the person who received the health care service was covered on the date of service; the claim is for a service or supply covered under the health benefits plan; 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); and (e) the payor has no reason to believe that the claim has been submitted fraudulently. Other requirements, including timeliness of claims processing shall mean: 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 initial the date of service, claims will be denied for untimely filing. Horizon NJ Health shall pay all clean claims from hospitals, physicians and other health care professionals within 30 days of the date of receipt of EDI claims and within 40 days for paper claims. The time limitation does not apply to claims from providers under investigation for fraud or abuse. 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. (a) (b) (c) (d) 9.1.2 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 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. 9-2 Horizon NJ Health Physician and Health Care Professional Manual, December 2007 • 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. • 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. Submit claims for all medical services, except Family Planning, to Horizon NJ Health at the following address: Horizon NJ Health Claim Processing Department P.O. Box 7117 London, KY 40742 NOTE – Out of state, non-Horizon NJ Health providers should send claims to their local Blue Cross Blue Shield Plan. IMPORTANT – Requests for adjustments may be submitted by telephone to: Physician Claim Services 1-800-682-9091 Submit Family Planning claims to Horizon HMO at the following address: Horizon NJ Health P.O. Box 789 Newark, NJ 07101-0789 NOTE – Be sure to include the member’s Horizon NJ Health or Medicaid identification number on all Family Planning claims. IMPORTANT – Requests for adjustments for Family Planning Claims only may be submitted by telephone to: Horizon HMO Member Services 1-800-833-3344 Horizon NJ Health Physician and Health Care Professional Manual, December 2007 9-3 IMPORTANT – Requests for reimbursement for retail pharmacy and all outpatient drugs for persons designated as aged, blind or disabled should be submitted directly to the State of New Jersey. IMPORTANT – Requests for reimbursement for mental health services for all enrollees except the developmentally disabled should be submitted directly to the State of New Jersey. NOTE – Be sure to include the member’s Medicaid identification number on all claims submitted to the State of New Jersey. NOTE – Horizon NJ Health subcontracts with Davis Vision who provides and/or coordinates vision services for eligible members. All services, except ophthalmological procedures, are coordinated and paid by Davis Vision. Please call 877-226-3729 for information about submitting invoices. NOTE – Horizon NJ Health subcontracts with Laboratory Corporation of America, Inc. (LabCorp) for most routine and specialized laboratory services. Generally, Horizon NJ Health is responsible for payment of claims for PAT/STAT laboratory service provided in hospitals and ambulatory surgical centers. Horizon NJ Health will also provide reimbursements for claims for laboratory services included on LabCorp’s excluded test listing. An authorization is required for any test included on this listing; please submit claims to Horizon NJ Health as specified above. Unless otherwise specified within specific contractual arrangements, laboratory services should be referred to LabCorp. Horizon NJ Health encourages all hospitals, physicians and health care professionals to submit claims electronically. For those interested in electronic claim filing, call the EDI Technical Support Hotline at 1-877-234-4273 or send an e-mail to edi.hm@kmhp.com to obtain more information. Benefits to sending claims electronically include: • • • • • Cleaner claim submission Confirmation of submitted claims within 24 hours Faster processing and payment Administrative efficiencies No postage or handling of paper claims NOTE – EDI Technical Support Team is available during regular business hours 8:00 am through 5:00 pm, Monday through Friday. For more information on EDI, review Section 9.3, Procedures for Electronic SubmissionElectronic Data Interchange. 9.1.3 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. • 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 ID # or Medicaid Identification 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 997 report indicating submission to the correct Insurance Code is required for consideration of timely submission. 9-4 Horizon NJ Health Physician and Health Care Professional Manual, December 2007 REFER TO Section 10.0, Complaint and Appeals Process, for complete instructions of the submission timeframes and procedures for administrative or medical appeals. NOTE – If the physician/facility’s ledger uses internal insurance codes, they must submit a copy of the code descriptions. NOTE – Horizon NJ Health’s Appeals Area will also accept Certified Mail Receipts as valid proof of timely filing. NOTE – If a physician/facility receives a Claim Rejection Form from the Claims Department, a copy of the form will also serve as valid proof of timely filing. Corrected claims must be submitted within 365 calendar days from the initial date of service to the following address: Horizon NJ Health Claim Processing Department P.O. Box 7117 London, KY 40742 Exceptions Claims with an Explanation of Benefits (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. 9.2 Claim Forms (Paper) Horizon NJ Health requires that all hospitals, physicians and health care professionals use the standard CMS 1500 (HCFA 1500) or UB-04 claim forms to report services which are reimbursable or capitated. The required fields that must be completed for the standard CMS 1500 (HCFA 1500) or UB-04 claim forms are in the respective claim form areas. If the field is required without exception, an “R” (Required) is noted in the “Required or Conditional” box. If completing the field is dependent upon certain circumstances, the requirement is listed as “C” (Conditional) and the relevant conditions are explained in the “Instructions and Comments” box. The CMS 1500 (HCFA 1500) claim form must be completed for all professional medical services. The UB-04 claim form must be completed for all facility claims. 9.2.1 CMS 1500 (HCFA 1500) Claim Form (Paper Submissions) The CMS 1500 (HCFA 1500) claim form must be used to bill all professional 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. Selected Codes Place of Service Codes Code Description 11 12 21 22 23 Office Home Inpatient Hospital Outpatient Hospital Emergency Room – Hospital Horizon NJ Health Physician and Health Care Professional Manual, December 2007 9-5 Code Description 24 Ambulatory Surgical Center 25 Birthing Center 26 Military Treatment Facility 31 Skilled Nursing Facility 32 Nursing Facility 33 Custodial Care Facility 34 Hospice 41 Ambulance – Land 42 Ambulance – Air or Water 50 Federally Qualified Health Center 51 Inpatient Psychiatric Facility 52 Psychiatric Residential Treatment Center 53 Community Mental Health Center 54 Intermediate Care Facility/Mentally Retarded 55 Residential Substance Abuse Treatment Center 56 Psychiatric Residential Treatment Center 60 Mass Immunization Center 61 Comprehensive Inpatient Rehabilitation Facility 62 Comprehensive Outpatient Rehabilitation Facility 65 End Stage Renal Disease Treatment Facility 71 State or Local Public Health Clinic 72 Rural Health Clinic 81 Independent Laboratory 99 Other Unlisted Facility Type of Service Codes Code Description 1 2 3 4 5 6 7 8 9 D F Medical Services Surgery Consultations Radiology (total component) Laboratory (total component) Radiation therapy (total component) Anesthesia Assistant Surgery Other (e.g., prosthetic eyewear, contacts, ambulance) DME ASC Required and Conditional Field Indicator IMPORTANT – An Authorization Number and/or Referral Number must be included in Box #23 on a CMS 1500 (HCFA 1500) claim form or Box #63 on a UB-04 form. Required (R) fields must be completed on all claims. Conditional (C) fields must be completed if the information applies to the situation or the service provided. 9-6 Horizon NJ Health Physician and Health Care Professional Manual, December 2007 Horizon NJ Health Physician and Health Care Professional Manual, December 2007 9-7 1500 (HCFA 1500) Claim Form Field # 1 1a 2 3 4 5 Field Description INSURANCE PROGRAM IDENTIFICATION INSURED I.D. NUMBER PATIENT’S NAME (Last Name, First Name, Middle Initial) PATIENT’S BIRTH DATE/SEX Instructions and Comments Check only the type of health coverage applicable to the claim. This field indicates the payer to whom the claim is being filed. Select “D”, other. Plan’s member identification number Enter the patient’s name as it appears on the member’s Plan I.D. card MMDDYY/M or F Required or Conditional R R R R R R INSURED’S NAME (Last Name, First Enter the patient’s name as it appears on the member’s Horizon NJ Health Name, Middle Initial) I.D. card or enter the mother’s name when the patient is a newborn. PATIENT’S ADDRESS (Number, Street, City, State, Zip Code) Telephone (include area code) PATIENT RELATIONSHIP TO INSURED INSURED’S ADDRESS (Number, Street, City, State, Zip code) Telephone (include area code) PATIENT STATUS OTHER INSURED’S NAME (Last Name, First Name, Middle Initial) OTHER INSURED’S POLICY OR GROUP NUMBER OTHER INSURED’S BIRTH DATE/SEX EMPLOYER’S NAME OR SCHOOL NAME INSURANCE PLAN NAME OR PROGRAM NAME IS PATIENT’S CONDITION RELATED TO: RESERVED FOR LOCAL USE INSURED’S POLICY GROUP OR FECA NUMBER INSURED’S BIRTH DATE/SEX EMPLOYER’S NAME OR SCHOOL NAME INSURANCE PLAN NAME OR PROGRAM NAME IS THERE ANOTHER HEALTH BENEFIT PLAN? PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE INSURED’S OR AUTHORIZED PERSON’S SIGNATURE DATE OF CURRENT: ILLNESS (First MMDDYY symptom) OR INJURY (ACCIDENT) OR PREGNANCY (LMP) IF PATIENT HAS SAME OR SIMILAR MMDDYY ILLNESS. GIVE FIRST DATE DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION NAME OF REFERRING PHYSICIAN OR OTHER SOURCE MMDDYY REQUIRED if a physician other than the member’s primary care physician rendered invoiced services Required when other insurance is available Same as # 3 Required if employment is indicated in field # 10 Enter name of Horizon NJ Health Y or N by check box. If yes, complete # 9 a-d Enter the patient’s complete address and telephone number. (Do not punctuate the address or phone number.) Always indicate self Enter the patient’s complete address and telephone number. (Do not punctuate the address or phone number.) Enter the patient’s marital status, indicate if the patient is employed or is a student. Refers to someone other than the patient. REQUIRED if patient is covered by REQUIRED if # 9 is completed REQUIRED if # 9 is completed. MM DD YY/M or F by check box This field is related to the insured in field # 9. REQUIRED if # 9 is completed. Indicate Yes or No for each category 6 7 R R 8 9 9a 9b 9c 9d 10a,b,c 10d 11 11a 11b 11c 11d 12 13 14 R C C C C C R Not Required C C C C R Not Required Not Required C 15 16 17 C C 9-8 Horizon NJ Health Physician and Health Care Professional Manual, December 2007 1500 (HCFA 1500) Claim Form Field # 17a 17b 18 19 20 21 Field Description UNLABELED FIELD NPI HOSPITALIZATION DATES RELATED TO CURRENT SERVICES RESERVED FOR LOCAL USE OUTSIDE LAB CHARGES DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3, OR 4 TO ITEM 24E BY LINE) MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. PRIOR AUTHORIZATION NUMBER DATE (S) OF SERVICE PLACE OF SERVICE EMG PROCEDURES, SERVICES OR SUPPLIES CPT/HCPCS MODIFIER DIAGNOSIS POINTER Procedure codes (5 digits) and modifiers (2 digits) must be valid for date of service. Diagnosis Pointer - Indicate the associated diagnosis by referencing the pointers listed in field 21 (1,2,3, or 4). Diagnosis codes must be valid ICD-9 codes for the date of service. Enter charges Enter quantity. Anesthesia services are to be entered in true minutes. REQUIRED when place of service is in-patient. MMDDYY Enter the Individual Provider’s Medical Assistance I.D. (MAID) number C R Not Required Diagnosis codes must be valid ICD-9 codes for the date of service. “E” R codes are NOT acceptable as a primary diagnosis. NOTE: Paper claims with invalid diagnosis codes will be denied for payment. For re-submissions or adjustments, enter the DCN (Document Control Number) of the original claim. NOTE: Re-submissions may NOT currently be submitted via EDI. C Instructions and Comments Required or Conditional 22 23 24a 24b 24c 24d 24e Enter the referral or authorization number. Refer to Section 3.1.6, Benefit C Matrix, to determine if services rendered require an authorization or referral. From date: MMDDYY. If the service was performed on one day there is no need to complete the To Date. Enter the HCFA standard place of service code. R R R R R 24f 24g 24h 24i 24j 25 26 27 28 29 CHARGES DAYS OR UNITS EPSDT FAMILY PLAN ID QUAL RENDERING PROVIDER ID # FEDERAL TAX I.D. NUMBER SSN/EIN PATIENT’S ACCOUNT NO. ACCEPT ASSIGNMENT? TOTAL CHARGE AMOUNT PAID R R Not Required Not Required R Physician or Supplier’s Federal Tax ID numbers The physician’s billing account number Always indicate Yes. Refer to the back of the CMS 1500 (HCFA 1500-12-90) form for the section pertaining to Medicaid Payments. 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. REQUIRED when # 29 is completed R R R R C 30 31 BALANCE DUE SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS/DATE SERVICE FACILITY LOCATION INFORMATON C R 32 REQUIRED unless #33 is the same information. Enter the physical location. R (P.O. Box #’s are not acceptable here.) 32a 32b 33 NPI UNLABELED FIELD BILLING PROVIDER INFO AND PHONE # (include area code) Enter the complete name and address of the physician. Do not punctuate the address or phone number. PIN #: Enter Horizon NJ Health assigned individual physician ID. GRP #: Enter Horizon NJ Health assigned group physician ID. R 33a 33b NPI UNLABELED FIELD Horizon NJ Health Physician and Health Care Professional Manual, December 2007 9-9 9.2.2 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. Selected Codes Type of Bill Codes Code 111 112 113 114 115 117 121 131 211 212 213 214 321 Description Hospital/Inpatient(Part A)/Admit through Discharge Hospital/Inpatient(Part A)/Interim – First Claim Hospital/Inpatient(Part A)/Interim – Continuing Claims Hospital/Inpatient(Part A)/Interim – Last Claim Hospital/Inpatient(Part A)/Late Charge Only Hospital/Inpatient(Part A)/Replacement of Prior Claim Hospital/Hospital Based or Inpatient (Part B)/Admit Through Discharge Hospital/Outpatient/Admit Through Discharge Skilled Nursing/Inpatient (Part A)/Admit Through Discharge Skilled Nursing/Inpatient(Part A)/Interim – First Claim Skilled Nursing/Inpatient(Part A)/Interim – Continuing Claims Skilled Nursing/Inpatient(Part A)/Interim – Last Claim 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 01 02 03 04 05 06 07 9-10 Discharged to home or self care (routine discharge) Discharged/transferred to another short-term general hospital Discharged/transferred to SNF Discharged/transferred to ICF Discharged/transferred to another type of institution (including distinct parts) or referred for outpatient services to another institution Discharged/transferred to home under care of organized home health service organization Left against medical advice Horizon NJ Health Physician and Health Care Professional Manual, December 2007 Code 08 09 20 30 40 41 Description Discharged/transferred to home under care of a IV drug therapy provider Admitted as an inpatient to this hospital Expired (or did not recover – Christian Science Patient) Still Patient or expected to return for outpatient services Expired at home (Hospice claims only) 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 Commonly Used Revenue Codes Code Description 100 130 250 260 270 280 290 300 320 340 350 360 370 410 450 540 720 730 800 900 920 – – – – – – – – – – – – – – – – – – – – – 129 249 259 269 279 289 299 319 339 349 359 369 379 449 459 548 729 750 880 919 999 Room and board charges Semi-private; Private; Ward, Nursery, Subacute, ICU, CCU Pharmacy IV Therapy Medical/Surgical Supplies and Devices Oncology Durable Medical Equipment (DME) Laboratory/Laboratory Pathological Radiology Diagnostic/Therapeutic Nuclear Medicine CT Scan Operating Room Services Anesthesia Therapy Services Emergency Codes Ambulance Services Labor and Delivery Outpatient Surgery Radiology Psychiatric/Psychological Nuclear Medicine Required and Conditional Field Indicator Required (R) fields must be completed on all claims. Conditional (C) fields must be completed if the information applies to the services rendered to Horizon NJ Health members. IMPORTANT – When a referral form is required by Horizon NJ Health, please attach the original to the CMS 1500 (HCFA 1500) or the UB-04 claim form submitted for payment. Horizon NJ Health Physician and Health Care Professional Manual, December 2007 9-11 9-12 Horizon NJ Health Physician and Health Care Professional Manual, December 2007 Horizon NJ Health Physician and Health Care Professional Manual, December 2007 9-13 UB-04 Claim Form Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X Field # 1 Field Description UNLABELED FIELD Instructions and Comments Line a: Enter the complete physician name. Line b: Enter the complete address or post office number. Line c: city, state, and zip code Line d: Enter the area code, telephone number. Enter the Facility Medical Assistance I.D. (MAID) number. Physician’s patient account/control number Outpatient, Bill Types 13X, 23X, 33X Required or Required or Conditional Conditional R R 2 3a 3b 4 UNLABELED FIELD PATIENT CONTROL NO. MED REC NO. TYPE OF BILL R R R R Enter the appropriate three-digit code. 1st position indicates type of facility. 2nd position indicates type of care. 3rd position indicates billing sequence. Enter the number assigned by the federal government for tax reporting purposes. Enter dates for the full ranges of services being invoiced. MMDDYY R R 5 6 7 8a FED. TAX NO. STATEMENT COVERS PERIOD FROM/THROUGH UNLABELED FIELD PATIENT NAME R R R R Last name, first name, and middle initial. Enter the patient name as it appears on Horizon NJ Health ID card. Use a comma or space to separate the last and first names. Titles (Mr., Mrs., etc.) should not be reported in this field. Prefix: No space should be left after the prefix of a name eg. McKendrick. Hyphenated names: Both names should be capitalized and separated by a hyphen (no space). Suffix: A space should separate a last name and suffix. R R 8b 9a 9b 9c 9d 9e 10 11 UNLABELED FIELD PATIENT ADDRESS UNLABELED FIELD UNLABELED FIELD UNLABELED FIELD UNLABELED FIELD BIRTHDATE SEX MMDDYY Enter the patient’s sex as recorded at the time of registration. Only M, F, and U are acceptable. R R R R Enter the complete mailing address of the patient. R R ADMISSION INFOR 12-17 12 13 14 15 16 17 DATE HR TYPE SRC DHR STAT MMDDYY Admission Hour Admission Type Source of Admission Discharge Hour Patient Status ( disposition ) R R R R R R R R Not Required Not Required R Not Required CONDITION CODES 18-28 18 19 20 21 22 23 24 25 9-14 CONDITION CODE CONDITION CODE CONDITION CODE CONDITION CODE CONDITION CODE CONDITION CODE CONDITION CODE CONDITION CODE REQUIRED when applicable REQUIRED when applicable REQUIRED when applicable REQUIRED when applicable REQUIRED when applicable REQUIRED when applicable REQUIRED when applicable REQUIRED when applicable C C C C C C C C C C C C C C C C Horizon NJ Health Physician and Health Care Professional Manual, December 2007 UB-04 Claim Form Inpatient, Outpatient, Bill Types Bill Types 11X, 12X, 13X, 23X, 33X 21X, 22X, 32X Field # 26 27 28 29 30 Field Description CONDITION CODE CONDITION CODE CONDITION CODE ACDT STATE UNLABELED FIELD Occurrence Codes. Enter the appropriate occurrence code and date. REQUIRED when applicable REQUIRED when applicable REQUIRED when applicable REQUIRED when applicable REQUIRED when applicable REQUIRED when applicable REQUIRED for re-submissions or adjustments. Enter the DCN (Document Control Number) of the original claim. Re-submissions may NOT currently be submitted via EDI. C C C C C C C C C C C C C C Instructions and Comments REQUIRED when applicable REQUIRED when applicable REQUIRED when applicable Required or Required or Conditional Conditional C C C C C C OCCURRENCE CODES AND DATES 31-34 31 32 33 34 35 36 37 CODE DATE CODE DATE CODE DATE CODE DATE OCCURRENCE SPAN CODE FROM/THROUGH OCCURRENCE SPAN CODE FROM/THROUGH UNLABELED FIELD 38 UNLABELED FIELD Value Codes and amounts. If more than one value code applies, list in alpha-numeric order. REQUIRED when applicable REQUIRED when applicable REQUIRED when applicable Revenue Code Revenue Code description Not Required Not Required VALUE CODES 39-41 39 40 41 42 43 44 45 46 47 48 49 50 CODE AMOUNT CODE AMOUNT CODE AMOUNT REV.CD. DESCRIPTION HCPCS/RATES/HIPPS CODE SERV. DATE SERV. UNITS TOTAL CHARGES NON-COVERED CHARGES UNLABELED FIELD PAYER C C C R R C C C R R R R R R C Enter the applicable rate, CPT, HCPCS, OR HIPPS code and modifier R based on the Bill Type of Inpatient or Outpatient. Report line item dates of service for each revenue code or HCPCS/CPT code. Report units of service Report grand total of submitted charges REQUIRED when Medicare is primary R R R C Not Required Not Required Enter the name for each payer being invoiced. When the patient has R other coverage, list the payers as indicated below. Line A refers to the primary payer; B, secondary; and C, tertiary. Report the Health Plan ID assigned by Horizon NJ Health. R R 51 52 HEALTH PLAN ID REL. INFO R R Release of Information Certification Indicator. This field is required R on paper and electronic invoices. Line A refers to the primary payer; B, secondary; and C, tertiary. It is expected that the physician have all necessary release information on file. It is expected that all released invoices contain “Y”. Valid entries are “Y” (yes) and “N” (no). The A, B, C indicators refer to the information in Field 50. Enter the estimated amount due (the difference between “Total Charges” and any deductions such as other coverage). R R C 53 54 55 56 ASG. BEN. PRIOR PAYMENTS EST. AMOUNT DUE NPI R R C Not Required Not Required 9-15 Horizon NJ Health Physician and Health Care Professional Manual, December 2007 UB-04 Claim Form Inpatient, Outpatient, Bill Types Bill Types 11X, 12X, 13X, 23X, 33X 21X, 22X, 32X Required or Required or Conditional Conditional Not Required Not Required Information refers to the payers listed in field 50. In most cases this will be the patient name. When other coverage is available, the insured is indicated here. Enter the patient’s relationship to insured. For Medicaid programs the patient is the insured. (Code 01: Patient is Insured) R R Field # 57 58 Field Description OTHER PROVIDER ID INSURED’S NAME Instructions and Comments 59 60 61 P. REL INSURED’S UNIQUE ID GROUP NAME R R R R C Use this field only when a patient has other insurance and group coverage applies. Do not use this field for individual coverage. Line A refers to the primary payer; B, secondary; and C, tertiary. Use this field only when a patient has other insurance and group coverage applies. Do not use this field for individual coverage. Line A refers to the primary payer; B, secondary; and C, tertiary. Enter Horizon NJ Health referral or authorization number. Line A refers to the primary payer; B, secondary; and C, tertiary. C 62 INSURANCE GROUP NO. C C 63 64 65 66 67 TREATMENT AUTHORIZATION CODES DOCUMENT CONTROL NUMBER EMPLOYER NAME DX A-Q R R R R C C R REQUIRED if field 64 contains 1, 2, or 4. Line A refers to the primary C payer; B, secondary; and C, tertiary. C Enter the complete ICD-9-CM diagnosis code. Include the 4th and 5th digits if applicable. Each diagnosis code must be valid for the date of service. R OTHER DIAG. CODES 68-75 68 69 70 71 UNLABELED FIELD ADMIT DX PATIENT REASON DX (a-c) PPS CODE Enter the complete ICD-9-CM diagnosis code. Include the 4th and 5th digits if applicable. Each diagnosis code must be valid for the date of service. R R R R R R R R 72 73 ECI UNLABELED FIELD R R 74 PRINCIPAL PROCEDURE CODE DATE Enter the procedure code for the principal procedure performed during the period covered by the invoice. Inpatient claims and all surgical procedures require ICD-9-CM codes. Outpatient claims require CPT/HCPCS codes. R R 74 a-e OTHER PROCEDURE CODE DATE Enter the procedure code for the other procedure performed during R the period covered by the invoice. Inpatient claims and all surgical procedures require ICD-9-CM codes. Outpatient claims require CPT/HCPCS codes. R 75 UNLABELED FIELD 76 ATTENDING PHYS. ID Enter the name of the physician who has primary responsibility for the patient’s medical care or treatment in the lower line, and the medical license # or UPIN # in the upper line. REQUIRED for reporting external cause of injury. Enter the complete ICD-9-CM diagnosis code. Include the 4th and 5th digits if applicable R R 77 OPERATING C C 78 79 OTHER OTHER Not Required Not Required R R 9-16 Horizon NJ Health Physician and Health Care Professional Manual, December 2007 UB-04 Claim Form Inpatient, Outpatient, Bill Types Bill Types 11X, 12X, 13X, 23X, 33X 21X, 22X, 32X Field # 80 81 a-d Field Description REMARKS CC Instructions and Comments Required or Required or Conditional Conditional C C 9.3 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 hospitals, physicians and health care professionals. 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 re-work (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 quicker. Reports have shown that a large percentage of EDI claims are processed within 10 to 15 days of their receipt. IMPORTANT – Referrals are valid for up to 180-days from the date indicated in Box 3 (date of service) of the Horizon NJ Health referral form. The referral number on the claim does not generate a payment. The actual referral must be submitted with each claim to avoid claim processing delays or denials. NOTE – Hospitals, physicians and health care professionals submitting claims electronically should make sure the referral number is present on the claim. Referral forms must be submitted separately, by mail to: Horizon NJ Health Claim Processing Department P. O. Box 7117 London, KY 40742 NOTE – EDI Technical Support Team is available during regular business hours 8:00 am through 5:00 pm, Monday through Friday. IMPORTANT – Requests for adjustments may be submitted by telephone to: The Physician and Health Care Hotline 1-800-682-9091 Horizon NJ Health Physician and Health Care Professional Manual, December 2007 9-17 9.3.1 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 Emdeon (formerly WebMD ), whether through direct submission or through another clearinghouse/vendor using payor number 22326. Currently, only Emdeon can submit claims electronically to Horizon NJ Health. Emdeon is the largest clearinghouse for EDI Healthcare transactions in the world. It has the capability to accept electronic data from numerous physicians in several standardized EDI formats and then forwards accepted information to carriers in an agreed upon format. Contracting with Emdeon 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 currently have Emdeon EDI Services, you can contact Emdeon’s Sales Department at 1-800-845-6592. You may also choose to contract with another EDI clearinghouse or vendor who already has access to Emdeon 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 Horizon NJ Health’s Hospitals, physicians and health care professionals ID numbers, the electronic payor number, Emdeon 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 material is received, proceed as follows: • Read over the materials carefully. • Transmission can begin upon receipt of your Horizon NJ Health individual hospitals, physicians and health care professionals ID. 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, regular mail, or e-mail on the effective day for EDI claim submission. No approval is necessary. • Contact your system vendor and/or Emdeon to inform them that you are now going to submit production claims to Horizon NJ Health electronically. You will be asked for the electronic payor address and the Emdeon specific edits included in your Horizon NJ Health documentation. NOTE – Contact EDI Technical Support at 1-877-234-4273 to notify them of your intention to begin EDI transmissions. 9.3.2 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 various Designated Standard Maintenance Organizations (DSMOs) responsible for each transaction. Additional information can be obtained through the Center for Medicare and Medicaid Services Web site at www.cms.hhs.gov. 9-18 Horizon NJ Health Physician and Health Care Professional Manual, December 2007 9.3.3 Electronic Claim Flow Description In order to send claims electronically to Horizon NJ Health, all EDI claims must first be forwarded to Emdeon using payor number 22326. This can be completed via a direct submission or through another EDI clearinghouse or vendor. Once Emdeon receives the transmitted claims, they are validated against Emdeon’s proprietary specifications and Horizon NJ Health specific requirements. Claims not meeting the requirements are immediately rejected and sent back to the sender via an Emdeon error report. The name of this report can vary based upon the physician’s contract with their intermediate EDI vendor or Emdeon. Claims are then passed to Horizon NJ Health and Emdeon returns a conditional acceptance report to the sender immediately. Claims forwarded to Horizon NJ Health by Emdeon are immediately validated against physician and member eligibility records. Claims that do not meet this requirement are rejected and sent back to Emdeon, 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 Emdeon or other contracted vendors, must be reviewed and validated against transmittal records daily. NOTE – For a detailed list of Emdeon data requirements, contact EDI Technical Support at 1-877-234-4273 or visit www.edi.hm@kmhp.com. 9.3.4 Invalid Electronic Claim Record Rejections/Denials All claim records sent to Horizon NJ Health must first pass Emdeon’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 re-submitted 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 Emdeon or your vendor in order to identify and re-submit these claims accurately. IMPORTANT – Missing/Invalid Member ID will result in claim rejection. Common Rejections • Invalid Electronic Claim Records – common rejections from Emdeon • 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-9, etc) • Claims without hospital, physician or health care professional numbers • Invalid Electronic Claim Records – common rejections from Horizon NJ Health (EDI edits within the claim system) • Claims received with invalid hospital, physician or health care professional numbers NOTE – Hospital, physician or health care professional identification number validation is not performed at Emdeon. Emdeon will reject claims for hospital, physician or health care professional information only if the hospital, physician or health care professional number fields are empty. Horizon NJ Health Physician and Health Care Professional Manual, December 2007 9-19 9.3.5 Action Electronic Billing Inquiries Contact Contact EDI Technical Support at: 1-877-234-4273 Contact EDI Technical Support at: 1-877-234-4273 Contact EDI Technical Support at: 1-877-234-4273 Contact your System Vendor or call the Emdeon Corporation Help Desk at: 1-800-845-6592 Contact Physician and Health Care Hotline at: 800-682-9091 Contact Physician and Health Care Hotline at: 800-682-9091 Contact Physician and Health Care Hotline at: 800-682-9091 Notify the Physician & Health Care Hotline in writing at: Member/Physician Services, Horizon NJ Health, 200 Stevens Drive, 1st Floor, Philadelphia, PA 19113-1570 or by fax: 1-215-937-5300 or by telephone: 1-800-682-9091 Notify the Physician & Health Care Hotline in writing at: Member/Physician Services, Horizon NJ Health, 200 Stevens Drive, 1st Floor, Philadelphia, PA 19113-1570 or by fax: 1-215-937-5300 or by telephone: 1-800-682-9091 Please direct inquiries as follows: If you would like to be authorized to transmit electronic claims If you have specific EDI technical questions If you have general EDI questions or questions on where to enter required data If you have questions about your claims transmissions or status reports If you have questions about your claim status (receipt or completion dates) If you have questions about claims that are reported on the Remittance Advice If you need to know a provider ID number If you would like to update provider, payee, UPIN, tax ID number or payment address information For questions about changing or verifying provider information 9.4 9.4.1 Common Coding Requirements Diagnosis Codes All claims must include the proper ICD-9-CM diagnostic code. The Centers for Medicare and Medicaid Services (CMS) provides specific guidelines to aid in standardizing U.S. coding practices. The guidelines for outpatient facilities, physician offices and ancillary care are summarized below: • Identify each service, procedure or supply with an ICD-9-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 for that visit or procedure as supplementary information. Do not code a diagnosis that is no longer applicable. 9-20 Horizon NJ Health Physician and Health Care Professional Manual, December 2007 • 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-9-CM codes require additional digits. • Code a chronic diagnosis when it is applicable to the patient’s treatment or when follow-up on the condition is requested during the visit. • 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. • For surgical procedures, code the diagnosis applicable to the procedure. If, after the procedure has been done, the condition necessitating the surgery is more specifically identified, or even determined to be different than the preoperative diagnosis, code the most specific diagnosis determined to be the reason for the surgery. Note – ICD-9 surgical procedures must be listed in Box 80 of the CMS -1450 or UB 04 claim form. Horizon NJ Health has adopted these diagnosis guidelines for its health plan and recommends that hospitals, physicians and health care professionals remain informed about these requirements through updated ICD-9-CM coding manuals. 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-9 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 hospitals, physicians and health care professionals with zeros (00000) and an explanation that the codes are not valid. 9.4.2 Procedure Codes Common Procedure Terminology CPT is a standardized system of five-digit codes and descriptive terms used to report the medical services and procedures performed by physicians or health care professionals. It was developed and is updated and published annually by the American Medical Association (AMA). CPT codes communicate to physicians, health care professionals, patients, and payors the procedures performed during a medical encounter. Accurate CPT 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 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 physicians and health care professionals must use the appropriate procedure codes from the most recent HCPCS and CPT coding manuals. 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 American Medical Association (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 hospitals, physicians and health care professionals with zeros (00000) and an explanation that the codes are not valid. Horizon NJ Health Physician and Health Care Professional Manual, December 2007 9-21 9.4.3 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 for 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 – 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 may result in inaccurate reimbursements or inaccurate denials for duplicate services. IMPORTANT – All Family Planning procedures must be reported using the FP modifier. Claims submitted without the modifier will be denied and returned to the submitter to be re-coded. 9.4.4 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. 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. 9.4.5 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 overpayments or claim payment delays. 9-22 Horizon NJ Health Physician and Health Care Professional Manual, December 2007 9.5 Common Billing Modifiers Description Prolonged Evaluation and Management Services – Use if the face-to-face or floor/unit service(s) provided is prolonged or greater than usually required. Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service – Use if the condition of the patient requires a significant, separate and identified E/M service above and beyond the other service provided. Professional Component - Use when billing for the physician component only. Bilateral Procedures – Use when billing for bilateral procedures performed in the same session. Procedure code must indicate the appropriate body part and the description must indicate the applicable side (RT/LT). Multiple Procedures – Use when additional procedures are performed at the same session by the physician. Reduced Services – Use when a service or procedure is partially reduced or eliminated at the physician’s discretion. Decision for Surgery – Use when the evaluation and management service resulted in the initial decision to perform the surgery. Distinct Procedural Service – Use when indication is needed that a procedure or services was distinct or independent from other services performed. Two Surgeons – Use when two surgeons work together as primary surgeons performing distinct part(s) of a single reportable procedure. Repeat Procedure by Same Physician - Use if the same procedure is performed subsequent to the original procedure. Repeat Procedure by Another Physician - Use if the same procedure is performed again by a second physician. Return to the Operating Room for a Related Procedure During the Postoperative Period – Use when another procedure was performed during the postoperative period of the initial procedure. Assistant Surgeon – Use when billing for surgical assistant services. Minimum Assistant Surgeon – Use when billing for minimum surgical assistant services. Assistant Surgeon (when qualified resident surgeon not available) – Use when the unavailability of a qualified resident surgeon is a prerequisite. Modifier 21 25 26 50 51 52 57 59 62 76 77 78 80 81 82 9.5.1 Requirements Use the appropriate modifier from the most recent HCPCS and/or CPT coding manuals. Using deleted or incorrect codes and failing to use a modifier will result in claim payment delays, rejections, denials or incorrect payments. 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 may result in inaccurate reimbursements or denials for duplicate services. Horizon NJ Health Physician and Health Care Professional Manual, December 2007 9-23 NOTE – These modifiers are subject to change. Consult the current CPT or HCPCS publications for the most up-todate modifier list. 9.5.2 Pharmacy (HCPC Codes) Effective January 1, 2008, when billing for all “J” code or HCPCS codes for drugs, injectables, and eneteral nutrition solutions (J0120-J8999) the appropriate National Drug Codes (NDC) number should be submitted as well. Failure to submit the NDC number along with the “J” code will result in the claim being rejected. 9.6 9.6.1 Common Causes of Claim Processing Delays, Rejections or Denials Authorization or Referral Number Invalid or Missing A valid authorization number must be included on the claim for all services requiring prior authorization. For all services requiring a referral, a valid referral number should be indicated on the CMS 1500 (HCFA 1500) form in Box #23 or on the UB-04 form in Box #63 or indicated in the appropriate section designated in the HIPAA Implementation Guide for the 837 transaction. A copy of the referral must be submitted for all claims. IMPORTANT – Missing or invalid authorization numbers and missing referrals for specialist, health care professionals or non-participating physician claims may result in processing delays or denials. IMPORTANT – Only services specifically identified in the authorization will be reimbursed. NOTE – The PCP recommending the service must forward Referral forms to Horizon NJ Health. However, to expedite processing, specialists, health care professionals or non-participating physicians must submit a copy of the original referral form when submitting each claim. 9.6.2 Billed Charges Missing or Incomplete A billed charge amount must be included for each service/procedure/supply on the claim. IMPORTANT – Regardless of whether reimbursement is expected, the billed amount of the service must be documented on the claim. Missing charges will result in rejections or denials. 9.6.3 Claim Information Does Not Match Authorization Authorized services provided to the member must be reflected on the claim as agreed to during the authorization process. Procedure codes, frequency, amount, and duration of services must exactly match the information in the authorization. If a medical need for a different service is identified, contact Utilization Management to change or update the authorization prior to the provision of services. IMPORTANT: Only services specifically authorized will be considered for reimbursement. hospitals, physicians and health care professionals may include a written description of services in addition to the appropriate HCPCS or CPT codes as an aid in identifying authorized services. Although an authorization number is indicated on the claim, if the services billed do not match the authorization, the claim will be denied. IMPORTANT – The service provider (i.e., the physician, health care professional or facility) on the claim must match the practitioner of facility authorized for the service. Inconsistencies may result in inaccurate payments or denials. 9-24 Horizon NJ Health Physician and Health Care Professional Manual, December 2007 9.6.4 Coordination of Benefits (COB) Information Missing or Incomplete See Section 9.6.10, Explanation of Benefits (EOB) Missing or Incomplete IMPORTANT – The services billed on the claim should exactly match the services and charges detailed on the accompanying EOB. If the EOB charges appear different due to global coding requirements of the primary insurer, submit the claim with the appropriate coding which matches charges for services reflected on the EOB. REFER TO Section 9.7, Coordination of Benefits, for specific billing guidelines. 9.6.5 Diagnosis Code Missing 4th or 5th Digit Precise coding sequences must be used in order to accurately complete processing. Review the ICD-9-CM manual for the 4th and 5th digit extensions. The ÷ 5th symbol indicates a 5th digit must be included. IMPORTANT – The 4th and 5th digit of diagnosis codes must be used if listed in the most current ICD-9 CM coding manual in order to be considered a valid code. Claims without valid diagnoses will be denied. IMPORTANT – Where an “E” code is applicable, use it in addition to the primary ICD-9 CM indicating the nature of the condition. 9.6.6 Diagnosis, Procedure or Modifier Codes Invalid or Missing Coding from the most current coding manuals (ICD-9-CM, CPT or HCPCS) is required in order to accurately complete claim processing. All applicable diagnosis, procedures and modifier fields must be completed. IMPORTANT – All codes billed must be valid for the date of service. Invalid coding will result in claim rejections or denials. 9.6.7 DRG Codes Missing or Invalid All claims submitted for inpatient services must include the Diagnostic Related Group (DRG). Review the CMS UB-04 form field requirements for the appropriate placement of the DRG code. 9.6.8 Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Information Missing or Incomplete All tests and services listed on the New Jersey EPSDT Program Periodic and Screening Schedule must be performed within the indicated time periods and recorded on the EPSDT form. All supporting documentation must be kept on file in the provider’s office for audit verification. When submitting claims for payment for professional services, the physician or health care professional must use a CMS 1500 (HCFA 1500) claim form. For hospital and/or facility charges, a UB-04 claim form is required. Electronic claim submissions are preferred and the acceptable transaction set is the appropriate HIPAA designated 837 format. Procedure Code 99381 99382 99383 99384 99385 Procedure Code Description New New New New New Patient, Patient, Patient, Patient, Patient, Initial Initial Initial Initial Initial Preventive Preventive Preventive Preventive Preventive Medicine; Medicine; Medicine; Medicine; Medicine; infant (age under 1 year) early childhood (age 1-4 years) late childhood (age 5-11 year) (adolescent (age 12-17 years) (18-39 years)* 9-25 Horizon NJ Health Physician and Health Care Professional Manual, December 2007 Procedure Code 99391 99392 99393 99394 99395 Procedure Code Description Established Patient; Periodic Preventive Medicine; infant (age under 1 year) Established Patient; Periodic Preventive Medicine; early childhood (age 1-4 years) Established Patient; Periodic Preventive Medicine; late childhood (5-11 years) Established Patient; Periodic Preventive Medicine; adolescent (age 12-17 years) Established Patient; Periodic Preventive Medicine; (18-39 years)* Diagnosis Code Description Health supervision of infant or child Other health infant or child receiving care Routine infant or child health check Procedure Code Description Primary Diagnosis Code V20.0 V20.1 V20.2 Procedure Code 99431 Normal Newborn, Inpatient Care; History and Examination CPT Procedure Code 99431 is an inpatient code that should be linked to a Primary V30 series ICD-9 code which are inpatient diagnosis codes. The V30 series codes are: V30.01, V31.01, V32.01, V33.01, V34.01, V30.1, V31.1, V32.1, V33.1, V34.1, V30.2 V31.2 V32.2 V33.2 V34.2 IMPORTANT – Physicians, hospitals and health care professionals must use the appropriate CPT and diagnosis codes in order to be considered for payment. Submission of claims for EPSDT services without the specified CPT and diagnosis coding cannot be processed or paid by Horizon NJ Health. 9.6.9 Eligibility/Enrollment Hospitals, Physicians, and Health Care Professionals must verify eligibility before providing services to a member. PCPs should reference their most current panel listing utilizing Horizon NJ Health’s Physician & Health Care Center Web site at www.horizonnjhealth.com or contact the Physician and Health Care Hotline to verify current eligibility. Always verify new patient eligibility and PCP designation by calling the Physician & Health Care Hotline at 1-800-682-9091. IMPORTANT – Horizon NJ Health updates eligibility records when the State’s eligibility file updates are released to Horizon NJ Health. Consequently, the physician must verify that the member is eligible each time a service or item is dispensed as eligibility can change from day to day. Failure to verify eligibility prior to rendering initial or repeat services could result in denials. 9.6.10 Explanation of Benefits (EOB) Missing or Incomplete A complete EOB (all pages) must be submitted with all claims for members who have additional medical insurance coverage. Since all other medical insurance carriers are considered primary 9-26 Horizon NJ Health Physician and Health Care Professional Manual, December 2007 payors for Horizon NJ Health members, each primary insurance carrier’s EOB must be submitted for coordination of benefits. The information provided on the EOB is used to identify the remaining medical service costs to be covered by Horizon NJ Health. NOTE – Do not attach notes to the face of the claim. This will obscure information or become separated if removed from the claim. 9.6.11 Illegible Claim Information Information on the claim must be legible in order to avoid delays or inaccuracies in processing. Review billing processes to ensure that forms are typed or printed in black ink, that no fields are highlighted (this causes information to darken when scanned or filmed), and that spacing and alignment are appropriate. Handwritten information often causes delays or inaccuracies due to reduced clarity. Handwritten corrections on previously submitted claims are not accepted and will be returned. NOTE – Do not highlight any information on the claim form or accompanying documentation. Highlighted information will become illegible when scanned or filmed. NOTE – Submitting the original copy of the claim form will assist in assuring claim information is legible. 9.6.12 Incomplete Forms All required information as specified within this manual or the appropriate CMS claims form instruction guides must be included on the claim form in order to ensure prompt and accurate processing. 9.6.13 Newborn Claim Information Missing or Invalid All newborns receive an individual member number. Always include the first and last name of the mother and baby on the claim. If the baby has not been named, insert “Girl” or “Boy” in front of the mother’s last name as the baby’s first name. Verify that the appropriate last name is recorded for the mother and baby. IMPORTANT – The claim for baby must include the baby’s date of birth. IMPORTANT – On claims for twins or other multiple births, indicate the birth order in the patient name field e.g. Baby Girl Smith A, Baby Girl Smith B, etc. 9.6.14 Payor or Other Insurer Information Missing or Incomplete Include the name, address and policy number for all insurers covering the Horizon NJ Health member. 9.6.15 Place of Service Code Missing or Invalid A valid and appropriate two digit numeric place of service code must be included on all claims. Since the place of service can alter the qualification of, or reimbursement structure used for some procedure codes, it is required that this information be accurately documented on the claim. IMPORTANT – The place of service code must correspond to the service address listed in box #32 of the CMS 1500 (HCFA 1500) claim form if services were performed other than in the office or at home. Incorrect coding may result in inaccurate payments or denials. Horizon NJ Health Physician and Health Care Professional Manual, December 2007 9-27 9.6.16 Procedure/Service Code Does Not Match Authorization The procedure/service code must exactly match the service identified in the authorization. Coding from the most current coding manuals (ICD-9-CM, CPT or HCPCS) is required to accurately complete processing. IMPORTANT – Only use the miscellaneous procedure code when a specific procedure code does not exist, and the authorization unit authorizes the service or item and negotiates a reimbursement rate. If the miscellaneous procedure code must be used, a full description of the item or service must be documented on the claim. The hospital, physician or health care professional must also send a copy of the invoice with the claim for any miscellaneous codes submitted for reimbursement. Horizon NJ Health retains the right to deny miscellaneous codes if there is a recognized code for that item or if an invoice is not submitted with the claim. 9.6.17 Physician Name Missing or Invalid The hospital, physician or health care professional’s name and Horizon NJ Health identification number for that hospital, physician or health care professional must be listed in the appropriate fields on the claim. The name listed must be the hospitals physician or health care professional that performed the service. The name and number must accurately represent the service practitioner or facility’s name and Tax Identification Number (TIN) and must exactly match the information documented in Horizon NJ Health’s records. IMPORTANT – An individual physician’s or health care professional’s name is required on all claims whether submitted on paper or electronically. Claims without an individual physician’s or health care professional’s name in Box 31 of the CMS 1500 (HCFA 1500) claim form or Boxes 82 to 83 of the UB-04 claim form cannot be processed for payment. IMPORTANT – The individual service practitioner’s name and number must be indicated on all claims for professional services, including outpatient clinic claims. Using only the group or billing entity name and number will not be processed for payment by Horizon NJ Health. 9.6.18 Hospital, Physician or Health Care Professional Identification Number Missing or Invalid All of the appropriate hospital, physician or health care professional identification numbers must be included on the claim. Those numbers include Horizon NJ Health’s assigned individual and group identification numbers and the TIN. Review the CMS 1500 (HCFA 1500) claim form and the UB-04 claim form required fields documents in this manual for specific placement of these identification numbers. The HIPAA Implementation Guide for the 837 transaction will indicate where this information should be placed on electronic claims. IMPORTANT – When the physician, facility or other health care professional has more than one Horizon NJ Health identification number, use the number that matches the services submitted on the claim. Imprecise use of identification numbers may result in rejections, inaccurate payments or denials. IMPORTANT – All the information submitted on the claim identifying the service practitioner must exactly match the information documented in Horizon NJ Health’s file. Failure to notify Horizon NJ Health of EIN, address or group affiliation changes can result in processing or payment errors. 9.6.19 Revenue Codes Missing or Invalid Facility claims must include a valid three digit numeric revenue code. Refer to UB-04 reference material for a complete list of revenue codes. 9-28 Horizon NJ Health Physician and Health Care Professional Manual, December 2007 9.6.20 Spanning Dates of Service Do Not Match the Listed Days/Units Spanning dates of service(s) is only appropriate when the services have been provided on consecutive days without interruption and have remained identical for the indicated time span. Always enter the corresponding number of days in the days/unit field. The Service date must not exceed the Statement Covers Period From / Through Date. IMPORTANT – If services were not provided on consecutive days, each date or group of consecutive days must be listed separately. IMPORTANT – If multiple services were provided on any or each day billed, list each service on a separate line or submit an itemized bill along with the claim. 9.6.21 Signature Missing The signature of the provider of service must be present on the claim form and must match the service physician or health care professional name and EIN on file with Horizon NJ Health. IMPORTANT – Claims without the physician or health care professional signature will be rejected. The physician or health care professional is responsible for re-submitting these claims within 180 calendar days from the date of service. IMPORTANT – Signatures other than the physician’s or supplier’s are not valid for claims submitted to Horizon NJ Health and could cause payment delays, inaccuracies, rejections or denials. 9.6.22 Employer Identification Number (EIN) Missing or Invalid The Employer/Tax Identification Number must be present and must match the service hospital, physician or health care professional name and payment entity on file with Horizon NJ Health. IMPORTANT – Any changes in a participating physician’s name, address or employer/tax identification number(s) must be immediately reported to: Horizon NJ Health Professional Contracting & Servicing Department Phone: 1-800-682-9094 Fax: 609-583-3004 IMPORTANT – Notify Horizon NJ Health at least forty-five (45) days prior to a change in your name, address, billing address, employer/tax identification number or other critical information. Late notification of these changes may result in incorrect payment or denial of services. 9.6.23 Third Party Liability (TPL) Information Missing or Incomplete See EOB from Primary Insurer Missing or Incomplete - Any information indicating a work related illness/injury, no fault, or other liability condition must be included on the claim. Additionally, a copy of the primary insurer’s explanation of benefits (EOB) or applicable documentation must be forwarded along with the claim. 9.6.24 Type of Service Code Missing or Invalid A valid alpha or numeric code must be included on the claim. Since the type of service can alter the qualification of, or reimbursement structure used for, some procedure codes, it is important that this information be accurately documented on the claim. IMPORTANT – Missing or invalid information or incomplete billing forms may cause claim processing delays or rejections. Horizon NJ Health Physician and Health Care Professional Manual, December 2007 9-29 9.6.25 Unbundled Services Invalid Services deemed to be a part of a more complex service as defined by the appropriate National Correct Coding Institute (NCCI) will be re-bundled or denied as established by current criteria set by CMS and the American Medical Association (AMA) for medical practice norms. Horizon NJ Health currently uses CodeReview criteria in it claims editing process. This proprietary editing system provides for the identification of itemized services that are considered inappropriate or part of another global procedure. These items are identified on the remittance advice provided with denial and payment information. In accordance with CMS rules, Horizon NJ Health will not pay for items that meet the following CMS criteria: Unbundled codes Codes that are not valid for Medicaid purposes Non-covered services Excluded codes Restricted coverage codes, unless approved in advance by the Utilization Management Department • Incidental services • Mutually exclusive services • • • • • 9.6.26 – Attachments Missing From Original Claim Hospitals, physicians and health care professionals are required to submit an invoice for implantable items, referrals and other insurance EOBs. If these items are not submitted with the claim, or are submitted separately (EDI and Paper), incorrect payment or denials may occur. Corrections to these payments or denials should be submitted as adjustments not as a resubmission of the original claim. Please submit to the correspondence address below: Horizon NJ Health Physician Claim Services 200 Stevens Drive Philadelphia, PA 19113 Consent form for sterilization are required for payment under Federal requirements. These forms should be submitted to the address below: Horizon NJ Health P.O. Box 789 Newark, NJ 07101-0789 9.7 Coordination of Benefits Any services provided to a Horizon NJ Health member is 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 New Jersey 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): • • • • • 9-30 Private health insurance including assignable indemnity contracts Health Maintenance Organizations (HMOs) Public health programs such as Medicare Profit and non-profit health plans Self insured plans Horizon NJ Health Physician and Health Care Professional Manual, December 2007 • • • • No-fault automobile medical insurance Liability insurance Worker’s compensation Other liable third parties In cases where another insurer, other than Medicare, is deemed responsible for payment, Horizon NJ Health will pay the difference between our maximum allowable expense and the amount paid by the primary insurer provided this amount does not exceed the lowest contractually agreed amount and does not exceed the normal Horizon NJ Health benefits which would have been payable had no other insurance existed. When you provide services to a member who has any other coverage, bill the member’s primary insurer directly. Make sure that you follow that insurer’s 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, PCP referral and the primary insurer’s Explanation of Benefits (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. IMPORTANT – All Coordination of Benefit (COB) claims must be submitted with a copy of the EOB from the primary insurer. Submit Coordination of Benefit claims for all medical services, except Family Planning, to Horizon NJ Health at the following address: Horizon NJ Health PO Box 7117 London, KY 40742 Phone 1-800-682-9091 Submit Coordination of Benefit claims for Family Planning to Horizon HMO at the following address: Horizon NJ Health P.O. Box 789 Newark, NJ 07101-0789 1-800-833-3344 NOTE – Although a primary insurer may have unique coding specific to their business, providers must bill with valid ICD-9CM, CPT-4, and HCPCS codes. Unique or invalid codes specific to other insurers will cause claim processing delays or denials. IMPORTANT – The hospital, physician or health care professional 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 primary or additional insurer’s EOB. IMPORTANT – The primary or additional insurer’s EOB must include member name, billed amounts, paid amounts, adjustments, co-insurance amounts and all associated messages and notes. Incomplete information may result in a claim processing delay or denial. Horizon NJ Health Physician and Health Care Professional Manual, December 2007 9-31 9.7.1 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. Hospitals, physicians and health care professionals 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 health care professional, unless Medicare does not cover the service. When Horizon NJ Health, by default, becomes the primary payor, the hospital, physician or health care professional must comply with all coverage requirements indicated by Horizon NJ Health to be considered for payment. 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 or referral is not needed by Horizon NJ Health even if one is normally required by Horizon NJ Health. • and the procedure is not covered by Medicare, an authorization or referral is needed by Horizon NJ Health if one is normally required by Horizon NJ Health. IMPORTANT – The hospital, physician or health care professional may re-bill for services originally denied by Medicare when Medicare overturns the denial. The hospital, physician or health care professional must submit the re-bill within 60 days of the date of Medicare’s EOB. 9.7.2 Other Third Party Medical Insurance Members covered by a primary insurer other than 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 hospital, physician or health care professional must submit a copy of the primary insurer’s EOB or 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 hospitals, physicians or health care professionals may not bill Horizon NJ Health members for deductibles and co-insurance, or balances above our allowable fees. Medicaid is the “payer of last resort,” therefore, the payments received from the primary insurer and Horizon NJ Health must be considered payment in full. REFER TO – Section 10.0, Complaint 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, hospitals, physicians or health care professionals should obtain the appropriate referrals or prior authorizations needed to obtain coverage under Horizon NJ Health. Failure to do so may result in denial for 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 9-32 Horizon NJ Health Physician and Health Care Professional Manual, December 2007 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 explanation of benefits or a denial letter in order to be considered for payment. In all cases, Horizon NJ Health’s referral, 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 hospital, physician or health care professional 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 any applicable co-payments and deductibles up to Horizon NJ Health’s contracted rate. In all cases, Horizon NJ Health’s referral, 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 explanation of benefits must be included when submitting the claim for payment. Worker’s Compensation Worker’s compensation covers any injury that is the result of a work-related accident. If Horizon NJ Health is aware of a worker’s compensation carrier, Horizon NJ Health will reject the hospital, physician or health care professional’s claim and direct that the claim be submitted first to the primary worker’s compensation carrier. If insurance coverage is not available at the time the claim is submitted, or if the worker’s 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 hospital, physician or health care professional 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. For more information on the Referral form, refer to Section 6.0, Referrals to Specialty Care Physicians. 9.7.3 Reimbursement Medicare If a member has Medicaid and Medicare coverage, the hospital, physician or health care professional may bill for charges Medicare applied to the deductible or co-insurance, or both. Horizon NJ Health will make payment in the full amount of the Medicare Part A deductible and co-insurance for inpatient hospital services and for Part B outpatient hospital services. For all other non-hospital services Horizon NJ Health will pay only up to the lowest contracted rate. NOTE – Horizon NJ Health considers the deductible and co-insurance a component of the total primary care capitation for primary care reimbursement for services which are capitated. 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 coordination of benefits. Incomplete information could result in processing delays or denials. Horizon NJ Health Physician and Health Care Professional Manual, December 2007 9-33 Other Third Party Medical Insurance Horizon NJ Health pays the difference between our maximum allowable expense and the amount paid by the primary insurance carrier, provided this difference does not exceed the lowest agreed contracted amount and does not exceed the normal Horizon NJ Health benefits which would have been payable had no other insurance existed. 9.7.4 Services Which Do Not Require A Primary Insurer EOB Medicare Services Not Covered By Medicare • Hearing aids • Diapers/Under-pads/Incontinence items • EPSDT • Transportation Physician and health care professionals may bill Horizon NJ Health for these services without submission of a primary insurer’s EOB. IMPORTANT – If billing for room and board only at a Skilled Nursing Facility, 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 insurers’ claims. 9.7.5 Denials from Primary Insurers If the primary insurer denies payment to the hospital, physician or health care professional 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 for payment. Services denied by the primary insurer for non-compliance 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 – A copy of the refusal documentation must accompany current and subsequent submissions for the same member and service episode. NOTE – The hospital, physician or health care professional 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 hospital, physician or health care professional will have 60 days from the date of the letter to submit the claim. 9.8 Processing Rules Unless specifically stated to the contrary in contractual arrangement between the hospital, physician and/or health care professional and Horizon NJ Health, claims will be processed according to CMS guidelines. Where there are no specific guidelines stated in regulations (42 CFR), the plan will default to the CMS Claims Processing Manual, which is available at 9-34 Horizon NJ Health Physician and Health Care Professional Manual, December 2007 www.cms.hhs.gov/Manuals/. In conjunction with these requirements, Horizon NJ Health will also use the current National Correct Coding Institute’s editing criteria to determine appropriate reimbursement for claims. The specific areas covered by the CMS Claims Processing Manual include, but are not limited to, inpatient non-facility services, ambulance, ambulatory surgical centers, drugs and biologicals, durable medical equipment, prosthetics, orthotics, medical supplies, home health agency and physician practitioner claims. EPSDT claims are paid based on the periodicity schedule. The biological component of immunizations is only paid where the Vaccine For Children (VFC) program does not offer the biological or the supply is not available. Administration of immunizations for VFC sponsored immunizations are paid on a per visit basis, therefore multiple shots given on a single visit will result in a per vaccine administration payment. Physicians and health care professionals are encouraged to use combination immunizations where available. 9.9 Encounter Data Submissions Horizon NJ Health is required by the State of New Jersey to report encounter data regarding all services rendered to our members, including Capitated and Fee-For-Service activities. All hospitals, physicians and healthcare professionals are required to submit timely, accurate and complete encounter data. The encounter data you supply us is important, as it contributes to multiple functions that enable Horizon NJ Health and the State to: • • • • Document our members’ use of the health care system and the services provided. Monitor the quality of care provided to our members. Identify patterns of care and target disease management and case management programs. Submit data that facilitates the State’s rate setting process. All services must be submitted on the CMS 1500 (HCFA 1500) or the UB-04 claim form, or via electronic submission in a HIPAA compliant 837I, 837P or NCPDP format. Horizon NJ Health is required to submit this data in an HIPAA standard file format to the State. Any coded field or data element contained in a HIPAA transaction must adhere to the national set of codes, including medical services and diagnosis. The State of New Jersey will reject encounter data if it does not meet their processing criteria. In some instances Horizon NJ Health will be required to reverse payment already made to the provider if the encounter does not meet the State’s criteria. The following are some causes for rejections. Facility Services • When billing for any physician-administered drug, DME, or medical supply, the full 11 digit NDC number will need to be be captured along with the proper Unit of Measure. This information will be reported to the State. • The bill type must be consistent with the type of service rendered with the applicable revenue codes and corresponding HCPCS codes. • The Statement Covers Period – From and through dates must coincide with the service date (when applicable). The surgical procedure code dates must also fall within the Statement Covers Period. • The revenue codes must be valid for the type of claim being billed. • When billing revenue codes for laboratory services (300-319) procedure codes are required. • When billing the following revenue codes: 099, 360, 361, 362, 367, 369, 370, 374, 379, 490, 499, 710, 719, the surgical procedure code is required. • All diagnosis must be reported and coded to the 4th and 5th digit. Horizon NJ Health Physician and Health Care Professional Manual, December 2007 9-35 Professional Services • When billing for any physician-administered drug, DME, or medical supply, the full 11 digit NDC number will need to be captured along with the proper Unit of Measure. This information will be reported to the State. • Transportation services are required to report the origin and destination modifiers. • All codes are to be in HIPAA compliant format. The use of CPT Level III codes (local codes) are not valid. • All diagnosis must be reported and coded to the 4th and 5th digit. Some important things to remember: • Encounter data must be submitted for every visit and service, even if the service is capitated. • It is important to make sure that all relevant ICD-9 diagnosis codes are included on the encounter record. • HIPAA standard coding should be used to document the actual service provided. 9.10 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 hospitals, physicians or health care professionals 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. If, after reviewing the Remittance Advice, you have questions or want to request a reconsideration contact the Physician and Health Care Hotline at 1-800-682-9091 for assistance. Remark and Denial Codes Remark Code Denial Code CDD CRS CRT F47 F50 I02 I04 I05 I06 I08 I10 I11 9-36 Description DEFINITE DUPLICATE CLAIM CODE SUPERCEDED-AMA CPT GUIDELINES CODE SUPERCEDED-AMA CPT GUIDELINES-DENIED PAYMENT REFLECTS COB, IF $0, MAXIMUM LIABILITY WAS MET CLAIM ADJ - THIRD PARTY DENIED OR BENEFITS EXHAUSTED ILLEGIBLE RECORDS SUBMITTED; REFILE CORRECT NDC CODE REQUIRED FOR CONSIDERATION INVALID/DELETED CODE, MODIFIER OR DESCRIPTION ITEMIZED BILL/DATES OF SERVICE/CHARGES/ INVOICE REQUIRED DIAGNOSIS INVALID/MISSING/DELETED REQUIRED 4TH/5TH DIGIT E-CODE CANNOT BE USED AS PRIMARY DIAGNOSIS EOB FROM PRIMARY CARRIER REQUIRED Horizon NJ Health Physician and Health Care Professional Manual, December 2007 X02 X04 X05 X06 X08 X11 Remark Code I18 I19 I22 I24 I26 I27 I28 I30 I37 I42 I43 I44 I47 I48 I64 I65 I68 I83 I98 Denial Code X19 X22 X24 X26 X27 Description PAID BILLED CHARGES CARRIER OF SERVICE-HORIZON HEALTHCARE DENTAL SERVICE RESUBMIT WITH VISIT CODES & CHARGES CARRIER OF SERVICE-DAVIS VISION EXHAUSTION OF BENEFITS SUBMIT MEDICAL RECORDS TO HORIZON NJ HEALTH APPEALS UNIT REPROCESSED-CLAIM SUBJECT TO INTEREST SERVICE EXCEEDS LIFETIME LIMITATION RESUBMIT WITH APPROPRIATE MODIFIER AND/OR TIME UNITS ILLEGIBLE/INCOMPLETE/INAPPROPRIATE REFERRAL RECEIVED BI-LATERAL PROCEDURE PREVIOUSLY PAID WITH MODIFIER “50” RESUBMIT WITH ICD/9 PRINCIPLE PROCEDURE CODE NON CONTRACED LEVEL OF CARE RESUBMIT TO PRIMARY CARRIER FOR APPEALS PROCESS CAPITATED TO ANOTHER PROVIDER DUPLICATE CLAIM-PREVIOUSLY DENIED APPROPRIATELY INVALID PLACE OF SERVICE FOR PROCEDURE MOTHER’S BILL NOT RECEIVED – REFILE TOTAL BILLED STILL UNDER CONSIDERATION REDUNDANT PROCEDURE DISALLOW ASSISTANT SURGEON DISALLOW ADMINISTRATIVE OVERTURN PAYMENT INCLUDED IN OTHER BILLED SERVICES NO PRECERT/AUTHORIZATION OR REFERRAL RECEIVED AFTER TIMELY FILING TIME LIMIT REQUESTED HOSPITAL DOCUMENTS NOT RECEIVED NOT ENROLLED ON DATE OF SERVICE SUBSET/INCIDENTAL PROCEDURE DISALLOW RESUBMIT WITH ICD PRINCIPAL PROCEDURE, HCPCS OR CPT CODE COMBINED PAYMENT-MOTHER & BABY CONTRACTED FEE DUPLICATE CLAIM PREVIOUSLY PAID AT CORRECT RATE OR CAPITATION DUPLICATE CLAIM-ORIGINAL STILL UNDER CONSIDERATION DRG PAYMENT 9-37 X30 X37 X42 X43 X44 X47 Z48 X64 X83 N02 N06 Q17 X00 X01 X07 X09 X10 R00 R01 R07 R09 R10 R15 R18 R37 R38 R39 R40 R42 X39 X40 Horizon NJ Health Physician and Health Care Professional Manual, December 2007 Remark Code R43 R44 R45 R46 R47 R49 R50 R51 R53 R55 R56 R59 R60 R61 R65 R66 R67 R70 R71 R72 R78 R79 R81 R84 R86 R89 R91 R95 R96 R97 Denial Code Description INTERIM BILL PAYMENT MULTIPLE SURGICAL REDUCTION COMPLETE MED RECORDS REQUIRED FOR CONSIDERATION; REFILE OVER MAX PROCEDURE/BENEFIT LIMIT (All LOBs) PAYMENT REFLECTS COORDINATION OF BENEFITS, IF $0, MAX LIABILITY MET PREVIOUS PYMTS EQUAL TO PURCHASE PRICE SAME PROCEDURE PAID TO A DIFFERENT PROVIDER SERVICE NOT COVERED SERVICES WERE NOT PROVIDED BILLED INFORMATION REFLECTS LOWER DEGREE ACUITY/TREATMENT ADMINISTRATIVE APPROVAL AUTHORIZATION/REFERRAL EXPIRED DATES AND/OR SERVICES OUTSIDE REFERRAL/ AUTHORATION NO PCP REFERRAL INTERIM BILL 2ND CYCLE PAYMENT INTERIM BILL FINAL CYCLE PAYMENT DISCREPANCY WITH LEVEL OF CARE-APPEAL REQUIRED EPSDT SCREENING DID NOT COMPLY WITH PERIODICITY SCHEDULE DUPLICATE OF PREVIOUSLY SUBMITTED EPSDT SCREENING PROVIDER WAS NOT MEMBER’S PCP MEMBER’S AGE NOT VALID FOR [PROCEDURE CODE SPECIAL PROJECT-ADJUSTMENT CHARGES CONSIDERED INCLUDED IN INPATIENT ADMISSION PLEASE OBTAIN INDIVIDUAL PROVIDER ID # INVALID/MISSING REVENUE CODE ON CLAIM AUTHORIZATION ON FILE FOR TECHNICAL COMPONENT INAPPROPRIATE CODING FOR CONTRACT AGREEMENT CLAIM SUBMITTED WITHOUT PHYSICIAN NAME EOB/ATTACHMENTS WERE INCOMPLETE/ILLEGIBLE DATE OF SERVICE CANNOT BE GREATER THAN THE RECEIVED DATE MOTOR VEHICLE ACCIDENT - AUTO CARRIER PRIMARY WORKERS COMPENSATION PRIMARY CARRIER BILL THROUGH PHARMACY PROGRAM INCLUDED IN SETTLEMENT PAYMENT Horizon NJ Health Physician and Health Care Professional Manual, December 2007 X45 X46 X49 X50 X51 X53 X59 X60 X61 Z34 X67 X70 X71 X72 R78 X79 X81 X84 X85 X91 X95 X96 X97 X12 X13 X21 X25 9-38 Remark Code Denial Code X32 X33 X35 X55 X56 X57 X62 X68 X77 X94 Description APPEAL – DENIAL UPHELD APPEAL – ORIGINAL CLAIM PAYMENT UPHELD AUTHORIZATION DENIED FOR THIS DATE OF SERVICE MEMBER AGE NOT VALID FOR DIAGNOSIS CODE CLINIC CLAIM SUBMITTED WITH OUT PHYSICIAN NAME THIS “V” DIAGNOSIS CANNOT BE BILLED ALONE INVALID/MISSING DRG INVALID UNITS SUBMITTED INCORRECT PROVIDER NAME/TIN IDENTIFICATION # SUBMITTED PROVIDER NUMBER SUBMITTED VIA EDI INCORRECT/TERMINATED COMBINED PAYMENT – MOTHER AND BABY CARRIER FOR SERVICE-HORIZON BLUE SUBMIT CHARGES TO MA FEE-FOR-SERVICE PROGRAM SUBMIT CHARGES TO MEDICAID FEE FOR SERVICE PROGRAM INVALID OR MISSING PLACE OF SERVICE CODE NOT PAYABLE FOR PROVIDER SPECIALTY NO FEE ON FILE NOT AUTHORIZED UNDER CONTRACT TO PROVIDE THIS SERVICE X68 X78 Z19 Z47 X78 Z19 Z47 Z50 Z92 Z99 Z99 These explanation codes represent the current set of codes that are returned to the hospital, physician or health care professional on the remittance advice. Please review the translation grid above before calling the Physician & Health Care Hotline for questions about remittance advice codes. If an electronic Remittance Advice is requested, it will be submitted in the HIPAA compliant 835 format. The above explanation codes do not apply to an electronic Remittance Advice transaction. Horizon NJ Health Physician and Health Care Professional Manual, December 2007 9-39 Sample Remittance Advice 9-40 Horizon NJ Health Physician and Health Care Professional Manual, December 2007 Horizon NJ Health Physician and Health Care Professional Manual, December 2007 9-41 9.11 LabCorp Billing The following CPT are not available through LabCorp. These procedures are to be completed at a hospital or clinical setting and billed accordingly. More information on LabCorp services may be received from LabCorp Customer Service. LabCorp Customer Service 1-800-631-5250 CPTs Not Performed by LabCorp CPT 06 Procedure Name 80103 81007 81020 82075 82805 82810 82820 83014 84830 85348 86077 86078 86079 86485 86490 86510 86580 86588 86805 86806 86890 86891 86903 86904 86911 86920 86921 86922 86923 86927 86930 86931 86932 86945 86950 9-42 Drug Prep,Tissue UA; bacteriuria screen UA; two or three glass test Alcohol,Breath Blood Gas+Anal+O2 sat Blood Gas,O2 sat Hemoglobin Sat Helicobacter pylori, breath test;drug admin Ovulation tests Coagulation time; Lee and White, other methods Path Review,Crossmatch Path Review,Transfuse Rx Path Review,BldBank Polcy Candida Test,Skn Cocci Test,Skn Histo Test,Skn TB Test,Intraderm Strep Scn,Dir Lymphocytox + Titration Lymphocytox - Titration+E783 Autologous Bld,Prep+Store Autologous Bld,Salvage Bld Typing,Reagent Serum Bld Typing,Patient Serum Bld Paternity,2+ Ag,each Crossmatch, Immed Spin Crossmatch, Incubate Crossmatch, AHG Crossmatch, electronic Frz Plasma, Thawing Frz Blood, Preparation Frz Blood, Prep + Thaw Frz Blood, Freeze/Thaw Bld Irradiation,each unit WBC Transfusion Horizon NJ Health Physician and Health Care Professional Manual, December 2007 CPT 06 86960 86965 86970 86971 86972 86975 86976 86978 86985 86999 87001 87003 87071 87073 87158 87164 87166 88000 88005 88007 88012 88014 88016 88020 88025 88027 88028 88029 88036 88037 88040 88045 88099 88125 88130 88140 88143 88147 88148 88150 88152 88153 88154 Procedure Name Volume reduction of blood product, each unit Platelets, Pool RBC, Pretreat for ABID RBC,Enzy Pretreat, ABID RBC,Separation for ABID Serum,Pretreat for ABID Serum,Dil Pretreat,ABID Serum,Diff Abs Pretreat Bld,Pool,each Unit Unlisted transfusion medicine procedure Animal,Inoculate + Obs Animal,Dissect + Obs Culture bacteri aerobic othr Culture bacteria anaerobic Culture typing, added method Dark field examination Dark field examination Autopsy,w/o CNS Autopsy,with Brain Autopsy,with Brain+Cord Autopsy,Infant Autopsy,Stillborn,Comp Autopsy,Stillborn,Parts Autospy,Gross+Micro Autopsy,G+M,Brain Autopsy,G+M,Brain+Cord Autopsy,G+M,Infant+Brain Autopsy,G+M,Stillborn Autopsy,G+M,Limited Autopsy,G+M,Organ,each Autopsy,G+M,Forensic Autopsy,G+M,Coroner Autopsy,Unlisted Cytopath,Forensic Exam Sex chromatin ID; Barr bodies peripheral blood smear, polymorphonuclear drumsticks Cytopath c/v thin layer redo Cytopath, c/v, automated Cytopath, c/v, auto rescreen Cytopath, c/v, manual Cytopath, c/v, auto redo Cytopath, c/v, redo Cytopath, c/v, select 9-43 Horizon NJ Health Physician and Health Care Professional Manual, December 2007 CPT 06 88160 88166 88167 88245 88261 88263 88283 88299 88349 88355 88356 88362 88367 88371 88380 88384 88385 88386 88399 88400 89049 89100 89105 89130 89132 89135 89136 89140 89141 89220 89230 89235 89250 89251 89253 89254 89255 89257 89258 89259 89261 89264 89268 9-44 Procedure Name Cytopath, smears, any othr source Cytopath tbs, c/v, auto redo Cytopath tbs, c/v, select Chromosome analysis, for breakage synd, 20-25 Chromosome analysis, 5 cells, 1 karyotye w/banding Chromosome analysis, 45 cells for mosaicism Chromosome add'l specialized banding technique Unlisted cytogenetic study Electron Micro,Scanning Morphometric Anal, Skeletal Muscle Morphometric Anal,Nerve Nerve,Teasing Prep Morphometric Anal, in situ, each probe, comp-assist Protein, western blot tissue w/interp & report Miccrodissection Array-based eval of mult. Molecular probes; 11-50 Array-based eval of mult. Molecular probes; 51-250 Array-based eval of mult. Molecular probes; 251-500 Unlisted surg path procedure Bilirubin, total, transcutaneous CHCT for malignant hyperthermia suscept. W/interp Duodenal Asp,Single Spec Duodenal Asp,Multi Spec Gastric Asp,each Gastric Asp,Stimulated Gastric Asp,1Hr Gastric Asp,2 Hr Gastric Asp,Stim,2 Hr Gastric Asp,Stim,3 Hr Sputum, obtaining specimen Sweat collection by iontophoresis Water load test Ooctypes,Cult+Fertilize Ooctyes, Culture & Fertilization Assisted Embryo Hatching, micro Oocytes ID from folliculzr fld. Preperation Embyro for transfer Sperm ID, aspiration Crypreservation, Embryo Crypreservation, Sperm Sperm isolation complex prep Sperm ID from testis tissue Insemination of oocytes Horizon NJ Health Physician and Health Care Professional Manual, December 2007 CPT 06 89272 89280 89281 89290 89291 89300 89329 89330 89335 89342 89343 89344 89346 89352 89353 89354 89356 Procedure Name Ext. culture of oocytes, embryos Asst. oocyte fertilization, microtechnique, < or = 10 Asst. oocyte fertilization, greater than 10 oocytes Biopsy, oocyte polar body or embryo blastomere Biopsy, oocyte polar body or embryo blastomere >5 Semen analysis; presence +/or motility including Huhner test Sperm eval; hamster penetration test Sperm eval; cerv mucus penetration test Cryopreservation, reproductive tissue, testicular Storage, per year; embryo(s) Storage, per year; sperm/semen Storage, per year; rep. tissue, testicular/ovarian Storage, per year; oocyte(s) Thawing of cryopreserved; embryo(s) Thawing of cryopreserved; sperm/semen, each aliquot Thawing of cryopreserved; rep. tissue, testicular/ovarian Thawing of cryopreserved; oocytes, each aliquot Testing Not Available Through LabCorp Lab Name Test Name ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ADmark ApoE Genotype ADmark Profile (Tau/AB42 & ApoE) ADmark PS1 (Presenilin 1 only) S or A ADMARK TAU/AMY/BETA42 ANALYSIS Asialo GM1 AUTOSOMAL DOMINANT CMT-EVALUATION Autosomal Doninant Ataxia Evaluation AXONAL HMSN EVALUATION Botulinum Toxin Type A (Botox) CAR Autoantibody (Cancer Assoc Ret) CARPAL TUNNEL SYNDROME EVALUATION CHOREA DIFFERENTIAL EVALUATION CHRONIC DEMYELINATIVE NEUROPATHY CMT 2 EVALUATION PROFILE CO-GM1 TRIAD Complete Ataxia Evaluation COMPLETE CMT EVALUATION (WITH PRX) Complete Dejerine-Sottas(DDS) Neuropathy Evaluation COMPLETE HEREDITARY SPASTIC PARAPLEGIA COMPLETE HNPP EVALUATION COMPLETE MYOTONIC DYSTROPHY (DM) EVALUATION COMPLETE TUBEROUS SCLEROSIS COMPREHENSIVE CMT EVALUATION 9-45 Horizon NJ Health Physician and Health Care Professional Manual, December 2007 Lab Name ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA ATHENA 9-46 Test Name CV2 AUTOANTIBODY DMD/BMD DNA Deletion (Carrier) DMD/BMD DNA Deletion (Proband) DRPLA DNA DYSTONIA (DYT1) EPM1 DNS Familial ALS (SOD1) Friedreich's Ataxia FSH DYSTROPHY DNA DELETION TEST Galop Autoantibody GD1b Antibody GM1 TRIAD (GM1, ASIALO, GD1B,GQ1B) GQ1b Autoantibody HU Autoantibody Huntington Disease DNA (Symptoms ?) Kennedy Disease DNA LEMS AUTOANTIBODY LHON MtDNA LIMB GRIDLE MUSCULAR DYSTROPHY Ma/Ta Autoantibody MAG Dual Antigen (SGPS & MAG) MAG Single Antigen MELAS MtDNA MERRF 8344 MERRF 8344 MtDNA WHOLE BLOOD Mitochondrial Enzyme Deficiency Mitochondrial Myopathy mtDNA Evaluation MJD- Machado-Joseph-Disease -SCA3 Motor Neuropathy (MAG & GM1) MOTOR NEUROPATHY PROFILE MERRF mtDNA Evaluation MULTIFOCAL NEUROPATHY EVALUATION MUSK ANTIBODY TEST Myotonic Dystrophy MYOTONIC DYSTROPHY TYPE 2 (DM2) NabFeron (Neutralizing Antibody) NEO COMPLETE PARANEOPLASTIC PROFILE NeoEncephalitis Paraneoplastic Profile with Recombx NEOCEREBELLAR DEGENERATION PARANEOPLASTIC PROFILE NeoComplete Paraneoplastic Profile with Recombx NeoSeM Basic Paraneoplastic Profile NEOSENSORY NEUROPATHY PARANEOPLASTIC OCULOPHARYNGEAL MUSCULAR DYSTROPHY (OPMD DNA TEST) Horizon NJ Health Physician and Health Care Professional Manual, December 2007 Lab Name Test Name ATHENA PEROXISOMAL DISORDERS (VLCFA & PHYTANIC ACID) ATHENA PMP22 (DUPL./DELETION) DNA TEST ATHENA PMP22 DNA SEQUENCING TEST ATHENA RI Autoantibody ATHENA SCA2 DNA ATHENA SCA7 DNA ATHENA SENSORIMOTOR NEUROPATHY ATHENA SENSORIMOTOR NEUROPATHY PROFILE ATHENA SensoriMotor Neuropathy Profile-Complete ATHENA SENSORY NEUROPATHY PROFILE ATHENA SGPG Single Antigen ATHENA Small Fiber Painful Axonal Neuropathy Profile ATHENA SPASTIN/SPG4 ATHENA Spinal Muscular Atrophy (SMA) NO CARRIER TESTING ATHENA SPINOCEREBELLAR ATAXIA TYPE 1 UPGRADE ATHENA SPINOCEREBELLAR ATAXIA TYPE 8 TEST ATHENA Sulfatide ATHENA Thrombix Profile II ATHENA Thrombx Profile I ATHENA TRANSTHYRETIN DNA SEQUENCING ATHENA YO Autoantibody PROMETHEUS ANTI-CHIMERIC ANTIBODY (HACA) PROMETHEUS FIBROSPECT PROMETHEUS IBD DIAGNOSTIC SYSTEM GENERATION II PROMETHEUS IBD FIRST STEP GENERATION II PROMETHEUS INFLIXIMAB PROMETHEUS PRO-PREDICT ENZ-ACT PROMETHEUS PRO-PREDICT TPMT PROMETHEUS Pro-PredictR 6MP Metabolites PROMETHEUS 6 GT (6-Thioguanine) PROMETHEUS 6 MMP (6-methyl mercaptopurine) MYRIAD GENETICS BRCA 1&2 (Breast Cancer Antigen 1&2 Full Sequencing) - Specimen no longer collected by LabCorp and forwarded to Myriad. Note: BRCA 1&2 Single Mutation is performed at LabCorp MYRIAD GENETICS COLARIS-HNPCC (Hereditary Nonplypoidal Colon Cancer) NOTE – For all testing listed above, providers must submit to the lab named in left column directly, and that lab will bill Horizon NJ Health. Horizon NJ Health Physician and Health Care Professional Manual, December 2007 9-47 This page intentionally blank. 9-48 Horizon NJ Health Physician and Health Care Professional Manual, December 2007