Claims Payment Policies and Other Information

OUT-OF-NETWORK LIABILITY AND BALANCE BILLING

Horizon BCBSNJ is offering two types of medical plans on the Individual Marketplace for 2020 – Horizon Advantage EPO and OMNIA Health Plans. Horizon BCBSNJ is also offering three types of dental plans on the Individual Marketplace for 2020 – Horizon Young Grins, Horizon Family Grins and Horizon Family Plus.

Members in the medical plans must use doctors, other health care professionals and hospitals in the Horizon Managed Care Network. For eligible dental services to be covered, members must use participating dentists in the dental PPO Network. There are no out-of-network benefits, except in emergency situations, for Individual consumers enrolled in the Horizon Advantage EPO or OMNIA Health Plans. If you receive non-emergent services from a non-participating provider, you will have to pay the provider’s total charges out of your pocket. Additionally, non-participating providers can balance bill you up to their total charges.

Use our Doctor & Hospital Finder to look for a participating doctor, dentist, other health care professional or hospital.

Participating doctors, dentists, other health care professionals and hospitals are not permitted to “balance bill” you for any difference between their charges and Horizon BCBSNJ’s allowed amount for a covered service. For example, if your participating doctor charges $200 for a service, and our allowed amount is $100 for that service, the participating doctor is not permitted to charge you the remaining $100. Because your doctor has agreed to receive a discounted rate from Horizon BCBSNJ, the total amount your doctor can collect is our contracted payment, plus any applicable coinsurance or copayment from you. This amount will not exceed the $100 allowed amount. If you receive any services that are not covered under your plan, you will be responsible for paying the doctor’s total charges.

Learn more about the importance of staying in network.
Learn more about your dental plan.

ENROLLEE CLAIMS SUBMISSION

Filing a Medical Claim

Members filing a medical claim for an out-of-network service are required to complete a claim form and submit it within 12 months from the date of service. Remember, when you use a participating doctor, other health care professional or facility, you do not need to submit your claims. Participating doctors file claims directly to Horizon BCBSNJ on behalf of their patients.

To submit a medical claim for out-of-network services, you can download a claim form.

1. When you are submitting expenses for more than one family member, please use a separate claim form for each person.
2. Itemized bills for covered services or supplies must be attached to the claim form and include the following information:
   • Name and address of person or institution rendering the service or supplying the item
   • Health Care Professional’s Federal Tax Identification Number
   • Health Care Professional’s National Provider Identifier Number (NPI)
   • Patient’s full name
   • Type of service rendered/produced or item supplied
   • Date each service rendered or item supplied
   • Amount charged for each service rendered or item supplied
   • Diagnosis of ailment

(Note: Cash register receipts, cancelled checks, money order receipts, personal itemizations and bills only noting a "balance due" are not acceptable.)

3. Please mail the completed claim form within 12 months from the date of service to:

Horizon Managed Care Claims
Horizon Blue Cross Blue Shield of New Jersey
PO Box 820
Newark, NJ 07101-0820

For information or status about a claim, you can:

• Send your question through our secure Message Center. You will receive a status of your inquiry within two business days
• Chat live with a Member Services Representative during normal business hours.
• Call Member Services at 1-800-355-BLUE (2583), Monday through Wednesday and Friday, between 8 a.m. and 6 p.m., Eastern Time (ET) and Thursday, between 9 a.m. and 6 p.m., ET.
• https://www.horizonblue.com/claims-payment-policies-other-information

Filing a Dental Claim Form

Generally, since these dental plans require the use of in-network dentists for most covered dental services, there will be no need to file claims. New Jersey requires Providers to file claims on behalf of members, unless the person elects to file a claim themselves.

To submit a dental claim for out-of-network services, you can download a claim form. Then follow these guidelines:

• When you are submitting expenses for more than one family member, please use a separate claim form for each person.
• Itemized bills for covered services or supplies must be attached to the claim form and include the following information:

  1. Name and address of person or institution providing the service or supplying the item

  2. Health Care Professional’s Federal Tax Identification Number

  3. Health Care Professional’s National Provider Identifier Number (NPI)

  4. Patient’s full name

  5. Type of service provided/produced or item supplied

  6. Date each service was provided or item supplied

  7. Amount charged for each service provided or item supplied

Please mail the completed form within 12 months from the date of service to:

Horizon Blue Cross Blue Shield of NJ
Dental Programs
PO Box 1311
Minneapolis, MN 55440-1311

For information about the claim status or any other questions concerning your dental coverage, please call our dental customer service at 1-800-4DENTAL.

GRACE PERIODS AND CLAIMS PENDING POLICIES DURING THE GRACE PERIOD

It’s important for you to pay to your premium on time. Members who receive a tax subsidy from the federal government to use towards the cost of health insurance and possibly towards their dental insurance, and who have previously paid at least one full month’s premium during the benefit year, have a three month grace period to pay their past due premiums before being terminated for non-payment. Learn more about the three month grace period.

RETROACTIVE DENIALS

If you do not pay your premiums on time, your claims for services you received will be held for processing and payment. Once the grace period is over, your claims will be denied and you will be responsible for paying the provider’s total charges. Learn more about what happens to your claims if you do not pay your premium on time.

ENROLLEE RECOUPMENT OF OVERPAYMENTS

Requesting a Premium Refund

To request a refund for overpayment of premiums, please call Member Services at 1-800-355-BLUE (2583), Monday through Wednesday and Friday from 8 a.m. to 6 p.m., ET, and Thursday, from 9 a.m. to 6 p.m., ET. You will need to provide the following information:

• Name

• Date of birth

• Member ID number

• Amount of money to be refunded

• Reason for refund request

Premium refunds take approximately three business days for a wire transfer and 30 business days for a check.

MEDICAL NECESSITY AND PRIOR AUTHORIZATION TIMEFRAMES AND MEMBER RESPONSIBILITIES

The Horizon BCBSNJ Utilization Management (UM) program helps doctors manage the level and setting of the care they provide. Through the UM program, Horizon BCBSNJ looks for best practices that produce high-quality care and health outcomes, and shares that information with members, participating doctors, other health care professionals and employers.

Horizon BCBSNJ watches for:

• Underutilization — This occurs when members do not get annual checkups or preventive vaccinations, as recommended.
• Overutilization — This occurs when members get medical care, medications, laboratory testing or surgical procedures when they are not medically necessary.

What is prior authorization or prior approval?

Some non-emergency medical services, procedures or supplies/equipment may require prior authorization or prior-approval. This means that Horizon BCBSNJ must approve certain services before you receive them.

Under your medical plan, Horizon BCBSNJ must approve all non-emergency hospitalizations, hospital stays and some specialty care services (except for routine OB/GYN services) before you receive these types of services.

Under your dental plan, the following services require prior authorization:

• Any and all orthodontic treatment;
• Any and all dental services required to be performed in a hospital or Ambulatory Surgical Center; and
• Behavioral Management Services associated with your dental services

Requesting prior authorization

Requests for prior authorization of some services and medical supplies before a member receives the service or charges are incurred need to be submitted to Horizon BCBSNJ by phone or electronically.

The approval process is based on the member’s benefits/policy and the medical necessity of the service.

The fact that a doctor, dentist or health care professional prescribes, orders, suggests or approves the care, the level of care or the length of time care is to be received, does not make the services medically necessary and appropriate, or a covered benefit under the member’s Horizon BCBSNJ plan.

Medically necessary and appropriate means that a service or supply is provided by a recognized doctor or other health care professional, and Horizon BCBSNJ determines that it is:

• Necessary for the symptoms and diagnosis or treatment of the condition, illness or injury;
• Provided for the diagnosis, or the direct care and treatment, of the condition, illness or injury;
• Generally accepted medical practice;
• Not for the convenience of the member;
• The most appropriate level of medical care the member needs; and
• Within the framework of generally accepted methods of medical management currently used in the United States.

If you receive care without proper authorization when required under your plan, you may be responsible to pay the total cost of care out of your pocket.

How is medical necessity determined?

To determine medical necessity, Horizon BCBSNJ uses the clinical information provided, nationally recognized guidelines, Horizon Uniform Medical policy, Horizon Dental Policies and evidence based criteria.

Prior authorization timeframes

You or your doctor/dentist/health care professional, acting on your behalf, will be notified of Horizon BCBSNJ’s initial decision as quickly as possible based on the medical circumstances, but in no event later than¹:

• 72 hours from receipt of an urgent care prior authorization/claim;
• 15 days from receipt of a prior authorization/claim;
• 30 days from receipt of a post service authorization request/claim

¹These timeframes may be extended to get additional clinical information from the health care professional.

Horizon BCBSNJ provides different levels of coverage depending on your plan. Some plans may require you to choose a Primary Care Physician (PCP) from our network of participating doctors and other health care professionals. If your Horizon BCBSNJ plan requires you to choose a PCP and you choose a participating PCP, you will have a lower copayment when you see that doctor. If your Horizon BCBSNJ plan does not provide out-of-network benefits, and you receive care from a nonparticipating doctor, other health care professional or hospital, when it’s not an emergency, you may be responsible for the total cost, depending on the plan you have.

If your plan has out-of-network benefits and you decide to receive care from a hospital or health care professional who is out-of-network, your out-of-pocket costs will be higher than if you had received the care from a health care professional who participates with your Horizon BCBSNJ plan. If your plan has tiered health care professionals/hospitals, your out-of-pocket cost will be higher when using a Tier 2 health care professional or hospital. You can sign in to Member Online Services and refer to the cost calculator for an estimate of your out-of-pocket costs. You can also call Member Services at the number below.

For more information about prior authorization

Not all services require prior authorization. You can sign in to Member Online Services or call Member Services at 1-800-355-BLUE (2583) for information about your plan and services.

Your Horizon BCBSNJ plan does not pay for services or supplies that are not covered under your policy.

What happens if there is no prior authorization?

If prior authorization is required, but not received, Horizon BCBSNJ will reduce benefits that would otherwise be payable under your plan by 50 percent with respect to charges for treatment, services and supplies.

Requesting Prior Authorization / Medical Necessity / Coverage Exception for Certain Prescription Drugs

Coverage under Horizon BCBSNJ plans is limited to services, including covered drugs and supplies, which Horizon BCBSNJ determines to be medically necessary. Certain drugs are subject to the prior authorization/medical necessity determination process. This means Horizon BCBSNJ will determine in advance whether the drugs are medically necessary in the member’s medical circumstances and therefore covered. In instances in which the prior authorization/medical necessity determination process is not followed, the drug will not be covered under the member’s plan and the member will be responsible to pay for the total cost of the drug. When prior authorization/medical necessity determination for a requested drug is not demonstrated, authorization will not be granted. The member and ordering doctor will receive a written letter advising them of Horizon BCBSNJ’s decision. The letter will include instructions on how the member or participating doctor can appeal the decision.

The drugs that are subject to a prior authorization/medical necessity determination are posted on Horizon BCBSNJ’s contracted Pharmacy Benefits Manager’s (PBM) website and available upon request from Horizon BCBSNJ Pharmacy Services. Horizon BCBSNJ’s PBM is Prime Therapeutics LLC.

If a drug is not on the formulary, a member and/or his/her prescribing doctor can submit a request for drug coverage exception. Below are the links for the coverage exception criteria and forms for both members and prescribing doctors.

Coverage exception criteria form

Coverage exception member online form

Coverage exception prescribing doctor fax form

Time frames for Pharmaceutical Prior Authorization / Medical Necessity / Coverage Exception Decisions

Decisions on prior authorization / medical necessity requests for medications and other pharmaceuticals will be made as follows:

• Urgent/expedited requests – within 24 hours from the time the request is made
• Standard requests – within 72 hours from the time the request is made

DRUG EXCEPTIONS TIMEFRAMES AND ENROLLEE RESPONSIBILITIES

Requesting an Exception from the Prescription Drug Tiers

Certain Horizon BCBSNJ plans employ tiered copayment structures in connection with its prescription drug benefits. When obtaining a prescription drug under a tiered copayment structure, a member’s copayment will vary depending on how the prescription drug is classified, and whether it is considered a preferred generic drug, preferred brand name drug or non-preferred drug. In the event a non-preferred drug or a multisource brand is determined to be medically necessary by the prescribing doctor due to the ineffectiveness or documented intolerance to a preferred drug or a generic equivalent, a member or the prescribing doctor may request that the drug be covered at the preferred drug level by following the Prescription Drug Tier Exceptions Approval Policy process.

A non-preferred drug or multisource brand shall be deemed to be medically necessary and eligible for coverage at the preferred brand drug level if the health care professional certifies that it is approved under the Federal Food, Drug and Cosmetic Act. For non-preferred brand or multisource brand requests, the prescribing doctor or health care professional states that at least two preferred drugs or generic equivalents, if two or more are available, have been tried prior to the requested brand product used to treat the disease have been proven ineffective in the treatment of the member’s disease or condition, or all such drugs have caused or are reasonably expected to cause, adverse or harmful reactions in the member/covered person, and medical records or other documentation that supports this view are supplied to the plan. The prescribing doctor can complete and fax this form to request for tier exception.

Time frames for Drug Tier Exception Decisions

The time frames for initial determinations are as follows:

• Urgent/expedited requests – within 24 hours from the time the request is made
• Standard requests – within 72 hours from the time the request is made

Initial denials will be communicated to the prescriber and the member in writing. In the event that the request is approved, the non-preferred drug will be covered at the appropriate preferred level, depending on whether the drug is a generic drug or a brand name drug.

Time frames for Pharmaceutical Prior Authorization/ Medical Necessity Decisions

Decisions on prior authorization / medical necessity requests for medications and other pharmaceuticals will be made as follows:

• Urgent/expedited requests – within 24 hours from the time the request is made
• Standard requests – within 72 hours from the time the request is made

DRUG EXCEPTIONS TIMEFRAMES AND ENROLLEE RESPONSIBILITIES

Requesting an Exception from the Prescription Drug Tiers

Certain Horizon BCBSNJ plans employ tiered copayment structures in connection with its prescription drug benefits. When obtaining a prescription drug under a tiered copayment structure, a member’s copayment will vary depending on how the prescription drug is classified, and whether it is considered a preferred generic drug, preferred brand name drug or non-preferred drug. In the event a non-preferred drug or a multisource brand is determined to be medically necessary by the prescribing doctor due to the ineffectiveness or documented intolerance to a preferred drug or a generic equivalent, a member or the prescribing doctor may request that the drug be covered at the preferred drug level by following the Prescription Drug Tier Exceptions Approval Policy process.

A non-preferred drug or multisource brand shall be deemed to be medically necessary and eligible for coverage at the preferred brand drug level if the health care professional certifies that it is approved under the Federal Food, Drug and Cosmetic Act. For non-preferred brand or multisource brand requests, the prescribing doctor or health care professional states that at least two preferred drugs or generic equivalents, if two or more are available, have been tried prior to the requested brand product used to treat the disease have been proven ineffective in the treatment of the member’s disease or condition, or all such drugs have caused or are reasonably expected to cause, adverse or harmful reactions in the member/covered person, and medical records or other documentation that supports this view are supplied to the plan.

Time frames for Drug Exception Decisions

The time frames for initial determinations are as follows:

• Urgent/expedited requests – within 24 hours from the time the request is made
• Standard requests – within 72 hours from the time the request is made

Initial denials will be communicated to the prescriber and the member in writing. In the event that the request is approved, the non-preferred drug will be covered at the appropriate preferred level, depending on whether the drug is a generic drug or a brand name drug.

INFORMATION ON EXPLANATION OF BENEFITS (EOBS)

An Explanation of Benefits (EOB) is a statement generated once Horizon BCBSNJ receives a claim and processes it. Learn more about how to read and understand your medical EOBs. To view your medical and dental EOBs, sign in to Member Online Services.

COORDINATION OF BENEFITS – MEDICAL ONLY

If you or a covered member of your family also has health coverage under Medicare or with any other insurance company, you must let us know. This is Coordination of Benefits (COB). COB applies when expenses for covered services are eligible for payment under more than one insurance program. To avoid duplication of coverage, we coordinate your Horizon BCBSNJ plan benefits with those provided by the other insurer.

Usually, one health insurance company has primary responsibility and there is at least one other health insurance company with responsibility for any remaining patient liability. On occasion, an automobile insurance or workers’ compensation insurance carrier will be involved. Regardless of which insurance carriers are responsible for payment, the combined payments are never greater than the actual charges of services and generally are not more than the primary carrier’s contracted rate.

Generally, you will need to let Horizon BCBSNJ know annually whether or not you have other health insurance coverage. To update your information, sign in to Member Online Services.