Horizon Casualty Services, Inc. (HCS), a subsidiary of Horizon Blue Cross Blue Shield of New Jersey, is an approved New Jersey Workers’ Compensation Organization and provides Personal Injury Protection Services (PIP) for automobile insurers.
HCS is a subsidiary of Horizon Blue Cross Blue Shield of New Jersey. It is an approved New Jersey Workers’ Compensation Managed Care Organization and provides a full range of Personal Injury Protection Services (PIP) for automobile insurers.
Workers’ compensation benefits cover work-related injuries and illnesses. Personal injury protection (PIP) benefits cover injuries sustained in automobile accidents.
Workers’ compensation insurers, self-insured employers and automobile insurers and their claimants can benefit significantly by using HCS. HCS provides an array of administrative, medical network and medical management services to achieve optimal medical and return-to-work outcomes. HCS helps claimants to return to work, and helps contain workers’ compensation and PIP costs.
The HCS network includes:
- Initial treating physicians (initial treaters)
- Physical therapy centers
- Ambulatory surgical centers (ASCs)
- 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. Employees are required to notify their supervisors of any work-related injury or illness. The employer or its insurance company will refer the employee to a HCS participating physician for diagnosis and treatment.
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. State of New Jersey employees’ workers compensation program claims are assigned to HCS case managers.
- The case manager contacts your 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 you fax a patient treatment plan to the injured worker’s case manager. The treatment plan must include the patient’s work status. HCS treatment plan forms are available at HorizonCasualty.com/resources.
- 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 that you submit a dictated note/report of the injured worker’s office visit to the case manager.
- You 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.
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.
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.
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, physicians and health care professionals are able to seek reimbursement from the claimant for any applicable copayments or deductibles that were applied to the reimbursement.