Horizon NJ Health Downcoding Claims

[Biller2023]

Horizon NJ Health is downcoding our claims even without reviewing the documentation. Is anyone experiencing the same issue and what are the steps to handle this?

 

[shanamarie]

Horizon NJ Health is downcoding our claims even without reviewing the documentation. Is anyone experiencing the same issue and what are the steps to handle this?

Several payers are currently doing this, using an AI edit or something like that. We appeal all of these with records, and end up getting paid.

 

[Biller2023]

We appeal with records but our claims are still not getting paid. Our records clearly show the visit time based on the E&M (please see below) but still Horizon NJ Health denies and they directed us to these notices on their website (provided links below). Can someone tell us how to handle this situation and how to make Horizon NJ Health pay for the code we billed without downcoding.

• • 99212: 10 minutes (met or exceeded)
  • 99213: 20 minutes (met or exceeded)
  • 99214: 30 minutes (met or exceeded)
  • 99215: 40 minutes (met or exceeded)

New Patient Office Visit Time Thresholds

• • 99202: 15 minutes (met or exceeded)
  • 99203: 30 minutes (met or exceeded)
  • 99204: 45 minutes (met or exceeded)
  • 99205: 60 minutes (met or exceeded) [1, 2, 3]

https://www.horizonblue.com/providers/news/news-legal-notices/outlier-program-expansion-high-level-e-m-coding

https://www.horizonnjhealth.com/for-providers/news/updates-and-announcements/outlier-program-expansion-high-level-em-coding

https://www.horizonnjhealth.com/for-providers/news/updates-and-announcements/outlier-program-expansion-update-high-level-em-coding

https://www.horizonblue.com/providers/policies-procedures/claim-submission-billing/pre-payment-correct-coding-reviews/high-level-evaluation-management-e-m-prepayment-coding-review

https://www.horizonblue.com/providers/news/news-legal-notices/outlier-program-expansion-update-high-level-e-m-coding