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Horizon BCBSNJ Reimbursement Guidelines Changes in Outpatient Laboratory Claims

Outpatient Laboratory Claims: Referring Practitioner Required


In accordance with Centers for Medicare and Medicaid Services (CMS) guidelines, Horizon BCBSNJ requires that claims for clinical laboratory services report the referring practitioner on the claim submission. This applies to participating and non-participating providers.

Effective November 15, 2019 Horizon BCBSNJ will change the way consider and reimburse certain clinical laboratory claims that do not include information about the referring practitioner information. 

Based on the guidelines of this reimbursement policy, Horizon BCBSNJ will deny outpatient claims submitted by participating or nonparticipating clinical laboratories for services provided on and after November 15, 2019 if the referring practitioner information is not included.

To avoid claim outpatient clinical laboratory claim denials, include referring practitioner information as noted below,
  • In 837P transactions please include referring practitioner information in Loop 2310A
  • On CMS  1500 claim forms (per the Medicare Claims Processing Manual Chapter 26 - Completing and Processing Form CMS-1500 Data Set), please include the following referring practitioner information
    •  Field 17.    Enter a “DN” qualifier (to denote Referring Provider), and Enter the referring provider name
    •  Field 17b.   Enter the NPI of the referring provider
To address claims denied for no referring practitioner information, clinical laboratories will have to submit a corrected claim that includes this required information. Until such time as this corrected claim information can be submitted and processed, members cannot be held liable for services related to these claim denials.


Source: https://www.horizonblue.com/providers/news/news-legal-notices/reimbursement-policy-implementation-outpatient-laboratory-claims-referring-practitioner-required
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