Participating Physicians and Other Health Care Professionals
The policies and procedures contained in this section of the website provide information concerning your responsibilities as a participating physician or other health care professional.
HCS network participants are selected based on their training, commitment and experience in workers’ compensation and personal injury protection (PIP) medical care treatment and management. If you have questions concerning any aspect of your participation in the HCS network, please call 1-800-985-7777.
HCS participating physicians and other health care professionals have agreed to follow HCS guidelines and policies. This manual does not modify the terms of your Participation Agreement with HCS. In the event of any conflict between your Agreement and the information contained in this manual, the terms of your Agreement will prevail.
It is expected that you establish the same type of positive relationship with the claimants served by HCS and its clients as you would with any other patients. In addition, it is expected that you provide claimants with insights and education regarding their diagnoses and treatment plans.
This will help them understand their role and accountability in the recovery process — an important element in achieving optimal treatment and return-to-work outcomes or return to optimal productivity under (PIP). Although workers’ compensation focuses on attaining maximum medical improvement and return to work, HCS wants to avoid any misunderstanding that you are the “company” physician or health care professional.
Should a medical condition exist that is not related to an applicable workers’ compensation- or PIP-covered injury, it is advisable that you refer the patient to his/her family physician. Payments for treatments arising from nonwork-related illnesses or injuries are the responsibility of the patient and/or his/her health insurance carrier.
HCS has a longstanding focus on medical care excellence. Its medical network is comprised of physicians who are focused on the treatment of injuries sustained on the job and in automobile accidents.
As medical costs continue to rise, HCS and its clients are focused more than ever on achieving optimal clinical outcomes at the lowest cost. As a market leader with significant market share in workers’ compensation and PIP, HCS is well positioned to create innovative approaches to reducing cost while improving medical outcomes.
HCS’ Outcomes-Focused Network (OFN) includes physicians focusing on the following specialties:
- Pain Management
- Physical Medicine & Rehabilitation
- Physical Therapy
The common goals of each participant in the OFN program include:
- Consistent outcomes
- Conservative treatment
- Prompt return to work
- Avoidance/Appropriate use of opioids
- Patient engagement
- Administrative efficiency
- Utilization of in-network resources
- Cost effectiveness
To learn more about the OFN program, please call HCS at 1-800-985-7777.
Appointment Scheduling is an administrative program designed to start injured workers on the path to successful recovery. The HCS Scheduler coordinates timely appointments with network providers for the injured worker. Appointments are scheduled based on the network provider’s specialty, availability and geographic proximity to the injured worker.
HCS’ appointment scheduling program promotes faster access to medical care, in-network utilization, and achieving optimal outcomes for the injured worker.
Evaluating Workers’ Compensation Claimants
The costs associated with lost work time incurred by workers’ compensation claimants are significant. We ask that you see injured workers the same day of injury, if possible, and without an appointment, if necessary. Modified duty may be available and appropriate.
For workers’ compensation claims, every workday lost is an expense to the employer. To avoid unnecessary cost to the employer or insurer, please see patients promptly.
Appointments for treatment by specialists or diagnostic testing should be made for the same day or next day, and gaps between appointments should be minimized. Every patient should have a follow-up appointment scheduled and/or a referral to a specialist with an appointment scheduled. No patient should be inactive at any time from his/her medical treatment program unless he/she is cleared for return to work and no further treatment is necessary. Please record scheduled appointments in the patient’s record.
To help physicians achieve a safe and rapid return to work for their patients, your assigned case manager will provide you with a return-to-work metric based on nationally accepted guidelines. HCS workers’ compensation clients are focused on this metric.
Modified duty may be available and appropriate. When return to regular job duties is not possible because the employee is unable to perform essential job functions, other options include temporary modified duty, or temporary or permanent assignment to new job duties.
The case manager will supply, when available, a Workers’ Compensation Physical Demands Analysis Form that has been completed by the employer. This form will outline the injured workers’ job duties. Many employers have modified or alternative job assignments of which you and the employee may not be aware.
Referring Patients for Care
Patients being treated under workers’ compensation benefits must be referred to HCS network hospitals, physicians and other health care professionals for work-related injuries and illnesses.
Patients being treated under personal injury protection (PIP) coverage are entitled to seek medical treatment from the physicians and health care professionals they choose. However, these patients should be encouraged to use HCS participating physicians and health care professionals. HCS network participants have expertise in the treatment of musculoskeletal injuries and focus on optimal outcomes at the lowest cost.
Precertification is required for certain services, including all surgical procedures and hospital admissions. 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.
Patient Treatment Forms
HCS uses the following forms for communications and medical bill payment:
- Workers’ Compensation Patient Treatment Plan Form
- Workers’ Compensation Physical Demands Analysis Form
- Weekly Physical/Occupational Therapy Plan Form
- Procedure/Surgery And After Care Precertification Form
- Progress & Treatment Status Psychologist/Psychiatrist Report Form
Patient medical records must be made available to HCS upon reasonable request.
Legal Requests for Medical Records
If your office is contacted for original or copies of medical records for a patient being treated under workers’ compensation benefits, please direct the call to the assigned case manager. The assigned case manager will notify the claim professional who is coordinating the claim. The claim professional will provide the necessary documentation. Please do not complete a separate medical report at the request of an attorney.
You must notify HCS in writing if:
- Your license, certification or registration to practice is suspended actively or stayed, or revoked for any reason.
- Your certification(s) to prescribe medication is suspended actively or stayed, or revoked for any reason.
- Your medical staff privileges at any hospital are voluntarily or involuntarily withdrawn, restricted temporarily or permanently, suspended actively or stayed, or revoked for any reason.
- You change your name or the name of your group practice.
- Your tax identification number or address changes or you join or leave a group practice.
- You fail to maintain required medical malpractice insurance.
- You take a leave of absence or resign from the medical staff of any hospital.
- You are indicted, convicted of, or plead guilty to a criminal offense, regardless of the nature of the offense.
- You are subject to any disciplinary action by any government program, licensing, professional registration or certification authority, or hospital privileging authority.
Please mail all pertinent information to:Horizon Casualty Services Inc.
Attn: Network Services
PO Box 10175
Newark, NJ 07101-3175
Clinical Quality Improvement (CQI) Committee
The HCS CQI Committee is an interdisciplinary committee that reviews, analyzes, recommends and approves clinical quality improvement and management activities. The CQI Committee assures that HCS assesses, maintains and improves quality standards in accordance with applicable laws and regulations, HCS and Horizon BCBSNJ policies and procedures, accreditation organizations and client contracts. The mission of the committee is to promote optimal medical and return-to-work outcomes for the patients/claimants covered under client insurance programs by monitoring, assessing and improving the quality of care provided by HCS’ network of physicians and other healthcare professionals. The Committee meets on a quarterly basis, or more often if necessary.
- Maintain a structured, ongoing oversight committee for clinical quality management and improvement functions performed by the HCS network of physicians and other healthcare professionals.
- Review credentialing/re-credentialing clinical network candidates to determine appropriateness for network participation.
- Evaluate the effectiveness of the CQMP annually and revise the program, as appropriate.
- Review and approve clinical quality programs.
- Review Quality of Care Reviews to offer medical opinions, include commentary and provide recommendations on complaint disposition.
- Review all HCS clinical policies and procedures, treatment guidelines and protocols for effectiveness annually and provide updates as needed.
- Monitor progress of quality improvement goals by reviewing quality outcomes reporting data to determine improvement strategies.
- Establish organizational standards of care/guidelines for identified services.
Physicians or other health care professionals may terminate their Agreement with HCS according to the terms contained within the Agreement.
Please mail the termination letter to the addresses set forth in your Agreement with HCS. Written notices of termination must be sent by a nationally recognized overnight courier or certified mail with return receipt requested.
If HCS wishes to terminate the Agreement, you will be notified in accordance with the terms of your contract with HCS.
Credentialing and Recredentialing
HCS credentialing and recredentialing standards apply to all physicians and other health care professionals, and are available for review upon request. Please call HCS at 1-800-985-7777 to obtain a copy of the credentialing or recredentialing standards.
After the initial credentialing, all participating physicians and other health care professionals undergo recredentialing every three years. The recredentialing process includes, but is not limited to, credentials verification, review of clinical quality, utilization management and customer satisfaction.
The recredentialing process is delegated to Horizon Blue Cross Blue Shield of New Jersey and requires the prompt return of forms and documents required for recredentialing.
To help ensure uninterrupted network participation, HCS recommends that you join the Council for Affordable Quality Healthcare (CAQH) to facilitate the credentialing/recredentialing process. You may complete an online application at caqh.org.
License, Certification or Registration
To maintain your participating status with HCS, all physicians and health care professionals are required to maintain a current, unrestricted, valid license, certification or registration to practice medicine in New Jersey, or in a contiguous state if the physician and health care professional’s practice is outside New Jersey.