Horizon Casualty Services, Inc. (HCS), a subsidiary of Horizon Blue Cross Blue Shield of New Jersey, is an approved New Jersey workers’ compensation managed care organization (WCMCO) and provides personal injury protection services (PIP) for automobile insurers.
Our mission is to provide managed medical care services that generate optimal medical and return-to-work outcomes, while containing workers’ compensation and personal Injury protection (PIP) costs.
Workers’ compensation insurers, self-insured employers and automobile insurers and their claimants can benefit significantly by using HCS. We provide an array of administrative, medical network and medical management services to achieve optimal medical and return-to-work outcomes. HCS helps claimants return to work, and contain workers’ compensation and PIP costs.
- Publication and distribution of the network directory
- Annual demographic and provider affiliation verification
- Referral of claimants to in-network facilities for their entire course of treatment of the injury
- Utilization Management (UM)
- Customer Service for questions about reimbursement and precertification
- Resolution of complaints and appeals
- Medical bill processing
- Issuance of payment checks on behalf of clients
- Appointment Scheduling for certain diagnostic procedures
The HCS network includes:
- Initial treating physicians (initial treaters)
- Physical therapy centers
- Ambulatory surgical centers (ASCs)
- Urgent Care Providers
- Diagnostic centers
- Sub-acute and skilled nursing facilities
- Home care providers
- Durable medical equipment (DME) providers
- Laboratory services providers
- Other services and health care professionals
Initial treaters function as Care Coordinator Physicians as defined in New Jersey workers’ compensation managed care organization regulations. Initial treaters have a key role in the HCS program because they coordinate the medical care that patients receive. In most cases, initial treaters specialize in family practice, internal medicine or occupational medicine.
Managed Workers’ Compensation Program
Workers’ compensation covers employees with work-related injuries or illnesses. When an employer or insurer offers a managed care workers’ compensation program administered by HCS, employees are required to notify their supervisors of any work-related injury or illness. The employer or insurer refers the employee to a participating physician for diagnosis and treatment. The physician may refer the employee for radiology, therapeutic services, specialty care or hospital care, if needed.
In non-emergent situations, HCS or the claimant’s insurer precertifies hospital admissions and notifies the hospital admissions or case management department of any impending admissions.
In an emergency, HCS or the claimant’s insurer contacts the hospital to confirm that the employee is eligible for benefits as promptly as possible.
HCS or the claimant’s insurer also conducts daily medical necessity reviews until the claimant is discharged.
This is how the claim management process works:
- The employer notifies HCS or the insurance company of a worker’s injury.
- The insurance company assigns a case manager to the claim. Note: State of New Jersey employees’ workers compensation program claims are assigned to HCS case managers.
- The case manager contacts the provider’s office to schedule an office visit for the diagnosis and treatment of the injured worker.
- Within one day of the office visit, HCS requires that the treating physician sends the patient treatment plan to injured worker’s case manager. The treatment plan must include the patient’s work status.
- The case manager reviews the injured worker’s treatment plan and initiates authorization for services that are medically necessary to address the compensable injury or illness. Compensable injuries/illnesses must be causally related to an event or accident that occurred while fulfilling the worker’s job responsibilities.
- Within three days of the office visit, HCS requires the physician to submit a dictated note/report of the injured worker’s office visit to the case manager.
- The physician may refer the employee for specialty care or hospital care, if needed.
Precertification with the assigned case manager is required for certain services including hospital admissions and all surgical procedures. Physicians are required to precertify such procedures with the case manager.
Under New Jersey Workers’ Compensation law, covered services are not subject to deductibles or copayments. Employees are not responsible for any out-of-pocket costs for medical services authorized by HCS, and balance billing by physicians and health care professionals is prohibited.
For workers’ compensation-related claims, HCS will process medical bills according to the terms of applicable network participation agreements.
Personal Injury Protection (PIP) Program
“PIP” is the popularly used acronym for personal injury protection benefits, a package of benefits required by statute to be provided with every insurance policy for a private passenger automobile registered or garaged in New Jersey. It is the medical benefit component of automobile insurance policies that covers persons injured in auto accidents. HCS provides administrative services under PIP for covered medical services.
Automobile insurers that provide PIP coverage in New Jersey may use HCS to administer PIP automobile accident-related benefits using network services and precertification processes. The goal is to coordinate appropriate medical care services to achieve optimal medical outcomes, while containing automobile accident-related costs.
New Jersey PIP laws and regulations require precertification of certain procedures, treatments, diagnostic tests and other services, including the purchase of durable medical goods, as approved by the state, provided that the requirement for precertification is not unreasonable. No precertification requirement will apply within 10 days of the insured event.
Precertification with the assigned case manager is required for certain services, including hospital admissions and all surgical procedures.
For PIP-related claims, HCS will process medical bills according to the terms of applicable network participation agreements. Reimbursement amounts will be reduced by any applicable copayments or deductibles as defined by a claimant’s automobile insurance policy.
Under current New Jersey PIP regulations, providers may seek reimbursement from the claimant for any copayments or deductibles that were applied to the payment.
Payment is issued by the PIP.