General Requirements
We will pay claims based only on eligible charges. Unless the provider contract states otherwise, claims will be paid on the lesser of billed charges or the contracted rate (fee schedule). Claims submitted by nonparticipating providers will be paid on the lesser of billed charges or the nonparticipating provider fee schedule. Consistent with CFR 42 Part § 447.45: the following definition shall apply to clean claims as used within the Billing Guide.
Under the New Jersey Health Claims Authorization, Processing and Payment Act (HCAPPA), 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).
- The payor has no reason to believe that the claim has been submitted fraudulently.
- We must receive all claims within 180 calendar days from the initial date of services. If claims are not received within 180 calendar days from the initial date of service, claims will be denied for untimely filing.
Taxonomy
Taxonomy codes are required on all claim submissions. Review the Use of Taxonomy Codes for more information.
Electronic Claim Submission
We are required by state and federal regulations to capture and report specific data regarding services rendered to our members. All services rendered, including capitated encounters and fee-for-service claims, must be submitted on the CMS 1500 (HCFA 1500) version 02/12 or UB-04 claims 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.
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, we cannot process the claims.
Corrected Claims
The following instructions explain how to bill and submit a corrected claim. Both paper and electronic claims must be submitted within 365 calendar days from the initial date of service.
For paper claims:
CMS-1500 should be submitted with the appropriate resubmission code (value of 7) in Box 22 of the paper claim with the original claim number of the corrected claim. Include a copy of the original Explanation of Payment (EOP) with the original claim number for which the corrected claim is being submitted.
For UB-04 claims:
UB-04 claims should be submitted with the appropriate resubmission code in the third digit of the bill type (for corrected claims this will be 7), the original claim number in Box 64 of the paper claim and a copy of the original EOP.
Send red and white paper corrected claims to:
Horizon NJ Health
Claims Processing Department
PO Box 24078
Newark, NJ 07101-0406
Correcting electronic HCFA 1500 claims:
EDI 837P data should be sent in the 2300 loop, segment CLM05 (with value of 7) along with an additional loop in the 2300 loop, segment REF *F8* with the original claim number for which the corrected claim is being submitted.
Correcting electronic UB-04 claims:
EDI 837I data should be sent in the 2300 loop, segment CLM05 (with value of 7) along with an additional loop in the 2300 loop, segment REF * F8 * with the original claim number for which the corrected claim is being submitted.
Coordination of Benefits/Medicare
Any services provided to a member are reviewed against benefits provided for that same individual under other insurance carriers with whom the member has coverage. We are 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.
Primary payors include (but are not limited to):
- Private health insurance, including assignable indemnity contracts
- Health maintenance organizations (HMOs)
- Public health programs, such as Medicare
- Profit and nonprofit health plans
- Self-insured plans
- No-fault automobile medical insurance
- Liability insurance
- Workers’ compensation
- Long-term care insurance
- Other liable third parties
For more information, refer to sections 9.8 and 12.28 or the Provider Administrative Manual.
Complaints and Appeals
When you are dissatisfied with services, a complaint can be initiated through any of the following:
- Call a representative at 1-800-682-9090 (TTY 711) for members; physicians can call 1-800-682-9091.
- Send a written letter to:
Horizon NJ Health Member/Provider Correspondence
PO Box 24077
Newark, NJ 07101-0406
All claim appeals must be submitted on the New Jersey Department of Banking and Insurance Health Care Provider Application to Appeal a Claims Determination Form.
Appeals must be received within 90 days from the date of denial or remittance advice.
- Call: 1-800-682-9094
- Mail:
Horizon NJ Health
Claim Appeals
PO Box 63000
Newark, NJ 07101-8064 - Fax: 1-973-522-4678
IMPORTANT - Please do not send medical records with administrative claim appeals. Supporting documentation (e.g., proof of timely filing) may be submitted. Please follow all appropriate procedures as defined in section 10 of the Provider Administrative Manual before submitting an appeal.
Corrected claims should be sent to:
Horizon NJ Health
Claims Processing Department
PO Box 24078
Newark, NJ 07101-0406br>
These claims should not be submitted through the appeals process, unless the original submission is considered to be correct.
Utilization Management (UM) Medical Appeals
Providers can submit UM medical appeals to the following address:
Medicaid: Horizon NJ TotalCare (HMO D-SNP):
Horizon NJ Health UM Appeals
PO Box 10194
Newark, NJ 07101
Horizon NJ TotalCare (HMO D-SNP) UM Appeals
PO Box 10196
Newark, NJ 07101
