Update on Horizon Blue Cross Blue Shield System Fix on Routine Eye Care/Refraction Denials

As reported previously, Horizon Blue Cross Blue Shield of New Jersey (HBCBSNJ) had experienced a systems error with regard to claims submitted for routine eye care and refraction services.

Claim were denying under denial code edits F027/F028, M670, 403, and 404.

After a series of communication with senior staff at HBCBSNJ, a meeting was held on this past week to address the Q Blue file updates required to accurately reflect the eligible diagnoses in accordance with the carrier’s medical policy.

As was noted in our last communication to NJAO members, the problem surfaced when updates were performed to the carrier files and diagnoses were inadvertently removed. This caused claims to deny as ineligible benefits, non-covered services and ineligible with the place of service billed. 

We have since been advised that carrier has corrected the problem and support staff performed testing based on the newly updated diagnosis listing, which now contains the diagnoses previously listed in the system along with the newly added diagnoses. The testing results are being reviewed to ensure the maintenance performed was successful.  If the results are a success, it will be rolled out into live production. 

In addition, a request of impacted claims has been requested (Q Blue only) to determine the volume of incorrectly denied claims.

It was identified that the high impact on Q Blue was on the Medicare Advantage products.

HBCBS should have a status no later than Wednesday, February 4, 2009 on the claims volume to be adjusted.  Keep an eye out for these claim adjustments if you have experienced this problem.

Once the testing is completed on both systems to acknowledge the eligible diagnoses against the member eligibility, it should address all of the denials that physicians received or are receiving under edits F027/F028, M670, 403, and 404.

However, please keep in mind that you may receive denials which are valid, as the members overall benefit package may not cover the billed services, that is, they have not purchased a routine eye care or vision rider.

The members benefit must clearly state that they have Vision Care services, in order for the refractions to be considered eligible. If the member’s policy does not state they have Vision Care services, the policy will only cover services which are considered medically necessary. 

For guidance on this issue, contact us through the Third Party Insurance Help Program.