1. NJAAHAM Semi Annual Billing Seminar April 12, 2017
Horizon NJ Health
NJAAHAM Semi Annual Billing Seminar
April 12, 2017

2. Agenda Horizon NJ TotalCare (HMO SNP) Billing
Taxonomy Codes
Electronic Billing COB
J&Q Codes
Corrected Claims
Paper Claims
Electronic Funds Transfer (EFT) Enrollment
Navinet Advanced Referral Module
Q&A

3. Horizon NJ TotalCare (HMO SNP)
Effective date of 1/1/2017
Providers are participating via contract amendment
This new plan combines all covered Medicare and Medicaid managed care benefits into one health plan
Member ID includes YKU prefix
Zero cost sharing for most covered services
PCP selection required

4. Horizon NJ TotalCare (HMO SNP) Service Area
Horizon NJ TotalCare (HMO SNP) serves the following counties: 1. Atlantic 2. Cumberland 3. Essex 4. Gloucester 5. Hudson 6. Hunterdon 7. Mercer 8. Monmouth 9. Morris 10. Passaic 11. Salem 12. Somerset 13. Sussex 14. Union 15. Warren

5. Horizon NJ TotalCare (HMO SNP)
All members are enrolled in the care management program
Referrals and prior authorizations for certain services
No out of network services except for emergencies
Members must reside in the 15 counties to be eligible to enroll
Members can receive services in any county where there are DSNP network providers

6. Horizon NJ Total Care Sample ID Card

7. Horizon NJ TotalCare (HMO SNP)
Contact Information
TotalCare (HMO SNP) Education Webinars
Available on the 2nd and 4th Wednesdays of each month, from February 22, 2017 through June 28, The seminars will run from a.m. and from 1-2 p.m. Where to register
Misc. Member/Provider Correspondence
Horizon NJ TotalCare Misc Member/Provider Correspondence PO Box Newark, NJ 
Provider Services
(available 8am to 6pm ET, M-F)
1 (855)
Member Services (Non-MLTSS)
(available 24/7)
1 (800)
Member Services (MLTSS)
1 (855)
Mailing Address for Paper Claims
Horizon NJ TotalCare Claims Processing Department PO Box Newark, NJ 
Participating providers for payment disputes must use Member Provider correspondence

8. Billing: Taxonomy Codes
All claims must be submitted with taxonomy, NPI and Tax Identification number. (Atypical providers are excluded)
Effective 4/1/17, claims that are submitted without this information will be denied
Additional claim submission guidance is available in Section 9 of the Physician and Health Care Professional Manual, located at horizonNJhealth.com
Submitting Claims with Taxonomy Codes:
Institutional Claims:
For paper UB04 institutional claims, the taxonomy code should be placed in box 81 and should be submitted with the “B3” qualifier.
UB-04 Paper Institutional Claim Form (for enumerated providers)
Billing Provider Taxonomy Code Locator 81
Professional Claims:
For paper CMS-1500 professional claims, the taxonomy code should be identified with the qualifier “ZZ” in the shaded portion of box 24i. The taxonomy code should be placed in the shaded portion of box 24j for the rendering level and in box 33b preceded with the “ZZ” qualifier for the billing level.
CMS 1500 (02/12) Professional Claim Form (for enumerated providers)
Please be sure that your claim software supports the revised 1500 claim form (02/12). Reference the 1500 Reference Instruction Service Facility Location NPI Field 32a. You can reference the 1500 Reference Instruction Manual at nucc.org for specific details on completing this form.  Additional claim submission guidance is available in Section 9 of the Physician and Health Care Professional Manual, located at horizonNJhealth.com.
Electronic Claims:
Taxonomy codes on electronic claim submissions with the ASC X12N 837P and 837I format are placed in segment PRV03 and loop 2000A for the billing level and segment PRV03 and loop 2420A for the rendering level.

9. Electronic Billing: Coordination of Benefits
Secondary/COB Claims do not need to be submitted via paper
Please use the following COB loops:
Loop
Description
Reported Data
2320
Other Subscriber Information
Name of Primary
Insurance
2330A
Other Subscriber Name
Name of Subscriber
2330B
Other Payer Name
Payment Date From
Other Insurance
2340
Line Adjudication Information
Payment

10. (Physician Administered Drugs - UMO)
Billing: J&Q Codes
When billing J and Q codes all three elements must be included:
NDC
Unit of measure
Quantity
Utilize the NJMMIS look up tool to verify information before submission of claims:
(Physician Administered Drugs - UMO)

11. Billing: Filing Corrected Claims
Electronic Claims:
This is the preferred method of submitting corrected claims
Use “7” for replacement of a prior claim utilizing bill type in loop 2300, CLM05-03 (837P)
Include the original claim number in segment REF01=F8 and REF02=the original claim number; no dashes or spaces
Include the Horizon NJ Health claim number in order to submit your claim with the 7
Bill all services, not just the services that need corrections
For guidance please refer 2017 Provider Manual Section 9.3.5

12. Horizon NJ Health does not accept handwritten or black & white claims
Billing: Paper Claims
Horizon NJ Health does not accept handwritten or black & white claims
REJECT
APPROVE
123 MAIN ST.
Can not be handwritten or altered in any way (this includes stamps)

13. EFT Enrollment - Electronic Fund Transfer
We encourage all Horizon NJ Health providers who have not yet begun to receive their payments using Electronic Funds Transfer (EFT) to sign up
Advantages:
With EFT, your reimbursement cycle will be accelerated, since providers can receive EFT payments more quickly than check payments sent through the mail
Payments can be distributed more securely by virtually eliminating check payments lost in the mail, and this can help increase cash flow. In most situations, funds are available on the date the payment is credited to the provider's bank account

14. EFT Enrollment - Electronic Fund Transfer
Administered by Change Healthcare
Dial , option 1 for more information
or visit the Horizon NJ Heath online to sign up
Link for form:

15. Navinet Advanced Referral Module
The Advanced Referral module, a new interface for providers who care for Horizon NJ Health Medicaid and Horizon NJ Total Care (HMO SNP) members, will be available for providers
This new interface will employ a form-based search which will allow you to search using any of the following criteria:
Address, City, State, ZIP
Group Name
NPI (Group or Individual)
Provider Name
Specialty

16. Q & A