Staying In Network

As a Horizon BCBSNJ member, you have access to the largest network of qualified doctors, specialists and other health care professionals1 in New Jersey and a broad network of participating hospitals throughout New Jersey and nearby in Delaware and Pennsylvania.

How we define “in network”

“In network” means that doctors, other health care professionals, hospitals and facilities participate in our Horizon Managed Care Network and/or our Horizon PPO Network and Horizon Hospital Network. Use our Doctor & Hospital Finder to find qualified doctors, other health care professionals, hospitals and other facilities that participate with your Horizon BCBSNJ plan. Remember to select your Horizon BCBSNJ plan from the drop down menu when searching for a participating doctor or hospital.

All doctors and other health care professionals who participate in our networks must pass our credentialing and review process. This process checks the credentials of doctors and other health care professionals including, but not limited to, licenses and certificates, malpractice insurance, educational background and hospital affiliations.

How we define “out of network”

An “out-of-network” provider is a doctor, other health care professional, hospital or facility that does not participate with a particular Horizon BCBSNJ health insurance plan. Some members such as those who are enrolled in an OMNIASM Health Plan or Horizon HMO do not have out-of-network benefits, except in an emergency. (Members should check their benefits information for details.) Both OMNIA Tier 1- and Tier 2-designated doctors and hospitals are “in network” for OMNIA Health Plan members.

How much will I pay for out-of-network care?

If your plan does not offer out-of-network benefits (such as Horizon HMO or OMNIA Health Plans), you will be responsible to pay for the entire billed amount of care or services received from an out-of-network provider.

If you’re enrolled in a plan that offers out-of-network benefits (such as Horizon PPO), your costs may include a higher deductible, coinsurance and/or copayment. Also, you will generally be responsible for the difference between the amount Horizon BCBSNJ has agreed to pay for a service (called our “allowance”) and the amount the doctor or other health care professional actually charges for the service.

Out-of-network doctors and other health care professionals are not required to accept Horizon BCBSNJ’s payment2 for their services. This means an out-of-network doctor or other health care professional can bill you for the balance of the charges after Horizon BCBSNJ has paid your claim.

Example

Jane will have surgery at an ambulatory surgical center (ASC). There are two ASC's in her area. One participates with Horizon BCBSNJ and the other does not. This chart shows how much more a member might pay at an out-of-network facility, compared to an in-network facility:

Provider

Provider’s charge

Horizon BCBSNJ’s allowance

Jane’s coinsurance or copayment

Horizon BCBSNJ’s payment

Amount Jane pays

Out of Network (For members with out-of-network benefits)

$5,000

$1,500

$300

Jane pays 20% of the allowance.

$1,200

Horizon BCBSNJ covers 80% of the allowance.

$3,800

Jane pays her coinsurance and the difference between the allowance and the provider’s charge.

Out of Network (For members without out-of-network benefits)

$5,000

$0

Horizon BCBSNJ will not pay for any services provided by an out-of-network provider.

Not applicable.

$0

$5,000

Jane will have to pay the full amount charged because she does not have out-of-network benefits.

In Network

$5,000

$1,500

$35

This is Jane’s copayment for in-network services.

$1,465

Horizon BCBSNJ pays the balance up to the allowance.

$35

Jane only pays her copayment. The provider cannot bill her for more than $35.

1 Based on physician data as of 1/21/17 and is subject to change.
2 Horizon BCBSNJ uses a variety of sources to calculate its reimbursement rate for out-of-network services. Industry resources provided by entities such as FAIR Health, the Centers for Medicare & Medicaid Services (CMS) and other databases supply fee schedules that correspond to the variety of service codes billed by medical service providers. The resource applicable to your plan depends on the fee schedule selected for your health plan. Please read your benefit booklet or other member materials for the fee schedule applicable to your plan or contact your group administrator. Horizon BCBSNJ uses these fee schedules to calculate a reimbursement allowance that corresponds to your out-of-network benefits, taking into account your coinsurance liability (usually expressed as a percentage) and out-of-network deductible.