Case Management
Providers - Case Management
- Policy Update: Antibody Testing Claims
- Update: Members’ cost sharing waived for treatment of COVID-19 through June 2021
- Submitting claims for COVID-19 vaccines delivered in non-traditional medical settings
- Every shot counts – keeping your patients informed about the COVID-19 vaccines
- For Essential Workers, COVID-19 Treatment Covered Under Workers’ Compensation Benefits
- Submitting Pharmacy Claims for COVID-19 Vaccinations
- Update: Prior Authorization Requirements for Inpatient Admissions and Post-Acute Facility Admissions to be Reinstated
- COVID-19 vaccine administration reimbursement at UCCs
- COVID-19 vaccines available in Essex County – Information for your staff and patients
- Reimbursement Policy effective January 1, 2021: Add-on Payment for COVID-19 Diagnostic Testing Run on High Throughput Technology (U0005)
- COVID-19 vaccines will be covered at 100%
- Coverage for antibody infusion therapy
- Waiving Prior Authorization Requirements for Emergent In-Network Inpatient Admissions and Post-Acute Facility Admissions
- Update: Antibody Testing Claims
- Update: Cost-share waiver for telemedicine and COVID-19 testing extended
- Cost Sharing on Claims with Multiple Diagnoses
- Dates for Certain Prior Authorization Waivers Further Extended
- Dates for Prior Authorization Waivers Extended
- New Laboratory COVID-19 Antibody Testing Codes: 86328 and 86769
- Help for health care professionals
- COVID-19 Update: Medical Policy Revisions & Implementations
- 72 Doctors, Nurses, Pharmacists and Health Clinicians from Horizon BCBSNJ Answer Governor Murphy’s “HealthCare Professionals Call to Serve”
- New Jersey Pandemic Relief Fund Efforts Get $2 Million Boost from Horizon
- A special message from Howard A. Cutler, Vice President, Healthcare Delivery
- Behavioral Health Continuity During the COVID-19 Public Health Emergency
- COVID-19 Frequently Asked Questions
- Waiving Pre-Certification/Prior Authorization requirements for Physical Health Post-Acute Facility Admissions
- Horizon BCBSNJ Commits $2.5 Million for Masks, Face Shields, Food and Social Services to Protect Our Communities and Our Health Professionals
- COVID-19 Update: Authorizations Waived for Oxygen Following ER Discharge
- Reminder to use specific codes when evaluating for COVID-19
- COVID-19 Update: Telemedicine Reimbursement Policy Addenda
- Provisionally Join Horizon BCBSNJ Network(s) to Assist with the COVID-19 Pandemic
- Waiving Pre-Certification/Prior Authorization requirements for acute inpatient facility admissions
- Providing Telephonic care with no costs to members
- COVID-19 Response: Eliminating Cost-Sharing for Qualified In-Network Telemedicine Services
- COVID-19 CPT testing codes
- Eliminating Cost Sharing Related to COVID-19 Testing and Evaluation
- Staying Informed: COVID-19 Coronavirus
- Our Commitment
- Join Our NetworksJoin Our Networks
- Join a Horizon BCBSNJ or Horizon NJ Health Network (Physicians and Other Healthcare Professionals )
- Join the Horizon BCBSNJ Network (Ancillary Providers)
- Join the Horizon NJ Health Network (Ancillary Providers)
- Join the Horizon Dental Network
- Our Healthcare Facilities
- AIM Specialty HealthAIM Specialty Health
- Diagnostic Imaging Program
- Frequently Asked Questions
- Groups Enrolled With AIM
- Muskoskeletal Program
- Procedure Codes Reviewed by AIM
- Sleep Disorder Management Program
- Braven Health
- Case ManagementCase Management
- Chronic Care ProgramChronic Care Program
- Clinical Laboratory Services
- BlueCard ProgramBlueCard Program
- BlueCard Announcements
- BlueCard Claims
- BlueCard Medical Policy/Pre-Certification Info
- BlueCard Program FAQs
- BlueCard Program Overview
- BlueCard Program Tutorial
- GeoBlue: International Coverage
- How to Identify BlueCard Members
- Dental Services
- EDI & EFT TransactionsEDI & EFT Transactions
- eviCore Health CareeviCore Health Care
- Cardiology Imaging Program
- Molecular and Genomic Testing Program
- Musculoskeletal Program
- Radiation Therapy Program
- Radiology/Imaging Services Radiology/Imaging Services
- Horizon Behavioral Health℠
- Horizon Care@HomeHorizon Care@Home
- About Horizon Care@Home
- Find A Provider
- Home Infusion Therapy
- Prior Authorization/Pre-Service Registration
- Medical Injectables Program
- Patient Health Support
- Pharmacy ProgramsPharmacy Programs
- E-Prescribing & Incentives
- Medicare Part D
- Pharmacy Guidelines
- Specialty Pharmaceuticals for Office Administration
- ProductsProducts
- Medicare Advantage Network Plans Overview
- Managed Care Plans
- PPO and Indemnity Products
- OMNIA Health Plans
- Horizon Medicare Blue Advantage (HMO)
- NJ SHBP/SEHBP Benefit Plans
- FEP
- Braven Health℠ Plans(Medicare Advantage)
- Recognition Programs and PartnershipsRecognition Programs and Partnerships
- Remote Patient Monitoring for COPD Provided by HGE Health
- Risk Adjustment OverviewRisk Adjustment Overview
- Self ServiceSelf Service
- Interactive Voice Response System (IVR) Interactive Voice Response System (IVR)
- Referral Process Using the Interactive Voice Response System
- Effective use of the Interactive Voice Response System
- Provider Online Services
- Surgical and Implantable Device Management ProgramSurgical and Implantable Device Management Program
- About the Surgical and Implantable Device Management Program
- Cardiac Services Cardiac Services
- Orthopedic Services Orthopedic Services
- Safety and Quality Award Program Q&A
- Surgical and Implantable Device Management Program Orthopedic Services Frequently Asked Questions Updated: March 25, 2021
- Medical Policy Criteria and Guidelines
- PA/MND Process
- Using Out-of-Network Providers in Surgical Services
- Value-Based ProgramsValue-Based Programs
- HEDIS® Resources
- Claim Submission & BillingClaim Submission & Billing
- Claim Editing Policies
- Claim Reimbursement
- Claim Submission Claim Submission
- Electronic Claim Adjustments
- Explanation of Payment
- PCP Billable Lists
- Pre-payment Correct Coding Reviews
- Prompt Pay Guidelines
- Demographic UpdatesDemographic Updates
- The Importance of Demographic Updates
- Provider Directory Management Policy
- CMS Audits to Validate Directory Information
- Initiating Demographic Updates
- Inquiries, Complaints & AppealsInquiries, Complaints & Appeals
- Inquiries
- Complaints
- Time Limits for Filing Inquiries/Complaints
- Resolving Inquiries/Complaints
- Appeals of Non-Utilization Management Determinations
- Appeals of Utilization Management/Medical Management Determinations
- Appeals of Post Service Medical Necessity Determinations
- PoliciesPolicies
- Medical Policies Medical Policies
- Allied Health
- DME
- Drugs
- Introduction
- Medicine
- Obstetrics
- Pathology
- Radiology
- Surgery
- Treatment
- MCG Care Guidelines
- Documentation Submission Guidelines
- Administrative Policies Administrative Policies
- Allowable Practice Locations for Pathologists
- Appointment Availability Access Standards for Primary Care-Type Providers, ObGyns, Specialists and Behavioral Health Providers
- Credentialing and Recredentialing Policy for Ancillary and Managed Long Term Support Service (MLTSS) Providers
- Credentialing and Recredentialing Policy for Participating Physicians and Healthcare Professionals
- EDI and NaviNet Claims Submission Requirement
- Electronic Funds Transfer (EFT)
- Material Adverse Change (MAC) Notification Policy
- Medical Records Documentation Standards
- Medicare Advantage Readmission
- Never Events
- Out-of-Network Referral Policy
- Outlier Audit Programs: Post Payment and Pre-Payment
- Physician and Healthcare Professional Counseling and Termination Policy - Professional Competency
- Participation Status in Products that Utilize Tiering and/or Subset of an Existing Horizon Network
- Practice Location Reinstatements
- Practice Locations Limit
- Practitioner Office Site Quality and Medical Record Keeping Standards
- Provider Directory Management
- Provider Outlier Program Frequently Asked Questions
- Retainer Based Medicine
- Standards for All Types of Medical and Dental Diagnostic Radiology and Imaging Facilities
- Tier Awareness Policy
- Use of Horizon Hospital Network Performance Data
- Use of Practitioner Performance Data
- BlueCard Medical Policies
- Reimbursement Policies & Guidelines Reimbursement Policies & Guidelines
- Add-on Payment for COVID-19 Diagnostic Testing Run on High Throughput Technology (U0005)
- After-hours and Weekend Care
- Ambulance Services
- Ambulatory Electrocardiographic Monitoring
- Anesthesia Reimbursement Guidelines
- ASC Multiple Procedure Methodology
- Assistant at Surgery
- Balloon Sinuplasty
- Bariatric Surgery Billed With Hiatal Hernia Repair
- Bilateral Procedures
- Billing Guidelines for Maternity Services
- Cardiac Event Detection
- Cardiovascular Implant Device Monitoring Services
- Casting, Strapping and Splints
- Chemotherapy Administration
- Chronic Care Management Services
- Claim Editing Policies
- Claims Requiring Additional Documentation
- ClaimsXten Editing Rules
- Clinical Trials Support Program
- Co-Surgeon Reimbursement
- Colonoscopy with Modifier 59
- Conscious Sedation
- Consultation Services Payment
- Consumable Medical Supplies
- Continuous Positive Airway Pressure or Bi-level Positive airway Pressure (CPAP/BiPAP) Supplies
- COVID 19 Antibody Testing
- Daily Management of Epidural or Subarachnoid Continuous Drug Administration
- Daily Maximum Units for Surgical Pathology and Microscopic Examination
- Determination of Refractive State
- Diabetic Screening Services
- Diabetic Supplies
- Distinct Procedural Service Modifiers (59, XE, XP, XS, XU)
- DME Rent to Purchase
- Drug and Immunization Pricing
- Duplex Scanning
- Drug Wastage – Modifier JW
- Duplicate Claim Logic for Independent Laboratory Services
- Enhancement to CMS Always Bundled Edit
- Evaluation and Management Services with Chiropractic Manipulative Treatment
- Evaluation and Management Services with Osteopathic Manipulative Treatment
- Evaluation and Management Services billed with Global Radiology, Stress Test, Stress Echo, Myocardial Profusion Imaging
- Frequency of Care Coordination Services and ESRD Procedures
- Frequency of G0179
- Hip Arthroscopy
- Hospital Non-Patient Laboratory Services Hospital Non-Patient Laboratory Services
- Hot or Cold Pack Therapy
- Inpatient Consultations
- Knee Arthroscopy
- Lab Panel Rebundling
- Laboratory Services Billed by Physicians
- Laser Treatment of Psoriasis or Parapsoriasis
- Maternity Reimbursement
- Maximum Units for Anesthesia
- Medical Nutrition Therapy (MNT)
- Microsurgery and Robotic Surgery
- Modifier 25
- Modifier 50 Bilateral Guidelines
- Modifier 52
- Modifier 53
- Modifier 54
- Modifier 55
- Modifier 56
- Modifier 57
- Modifier 76
- Modifier 77
- Modifier 78
- Modifier SU
- Multiple Procedure Reductions
- Mutually and Non-Mutually Exclusive NCCI Supplemental Edits
- Non-ESRD ESA Level Reporting
- Noncovered Related Services
- Outpatient Consultations
- Outpatient Laboratory Claims: Referring Practitioner Required
- Outpatient Therapy Daily Maximum
- Physician Extenders Non-Surgical Services
- Pre-Admission Testing
- Pre-Payment Documentation Requests: Facility Claims
- Post Payment Documentation Requests: Facility Claims
- Pulmonary Diagnostic Procedures when billed with E&M Codes
- Radiology, Preliminary and Double Reads
- Radiopharmaceuticals
- Reimbursement and Billing Guidelines for Anesthesia Claims
- Removal of Impacted Cerumen Requiring Instrumentation
- Screening and Diagnostic Mammography & 3D Tomosynthesis
- Site of Service Differential
- Smoking Cessation
- Status N Codes
- Telemedicine Services Telemedicine Services
- Telemedicine Services Reimbursement Policy: Temporary Addendum for Horizon BCBSNJ Commercial/ASO plans and products
- Telemedicine Services Reimbursement Policy: Temporary Addendum for Horizon Medicare Advantage
- Ulcer Debridement and Ulcer Stages
- Urinalysis with Evaluation and Management (E&M) Services
- Urine Drug Screening/Testing
- Vitamin D Testing
- Utilization ManagementUtilization Management
- Clinical Practice Guidelines
- PT/OT Outpatient Prior Authorization for Horizon Medicare Advantage Plans
- Services Requiring Prior Authorization Services Requiring Prior Authorization
- Prior Authorization Procedure Search Tool
- BlueCard Members
- Medicare Advantage
- OMNIA Health Plans
- SHBP/SEHBP
- UNITE HERE HEALTH
- Utilization Management Request Tool
- Cultural Competency
- Educational WebinarsEducational Webinars
- Electronic ID CardsElectronic ID Cards
- HealthSphereHealthSphere
- Manuals & User GuidesManuals & User Guides
- Agreements
- Ancillary Manual
- Hospital Manual Hospital Manual
- Claims Submissions and Reimbursement
- Coordination of Benefits
- HIPAA
- Horizon Behavioral Health
- Identification
- Inquiries, Complaints and Appeals
- Patient Health Support
- Patient-Centered Programs
- Policies, Procedures and General Guidelines
- Products
- Programs Administered by eviCore healthcare
- Quality Management
- Quality Recognition Programs
- Service
- The BlueCard Program
- Utilization Management
- Participating Physician and Other Health Care Professional Office Manual Participating Physician and Other Health Care Professional Office Manual
- At Your Service
- The BlueCard Program
- Claims Submissions and Reimbursement
- Coordination of Benefits
- HIPAA
- Horizon Behavioral Health
- Horizon Hospital Network
- Identification
- Inquiries, Complaints and Appeals
- Member Rights and Responsibilities
- Patient-Centered Programs
- Patient Health Support
- Payment Summaries and Vouchers
- Policies, Procedures and General Guidelines
- Products
- Provider Responsibilities
- Quality Management
- Quality Recognition Programs
- Referrals
- Service
- Special Programs
- Utilization Management
- Welcome Kit Handbook
- Network Specialists
- Newsletters
- Provider Self-Service ToolsProvider Self-Service Tools
- Quality Resource CenterQuality Resource Center
- TrainingTraining
- CMS Training Requirements CMS Training Requirements
- Education Education
- Forms by Plan TypeForms by Plan Type
- Forms by Specialty TypeForms by Specialty Type
- Horizon Behavioral Health
- Radiology Center Assessment Tool (RCAT)
- Radiology Professional Group Assessment Tool
- Reimbursement / Payment
- Forms by TypeForms by Type
- Appeal / Dispute
- Assess / Evaluate / Examine
- Authorizations
- Claim
- Consent
- Credentialing
- Electronic Transaction Forms
- Enroll / Elect / Apply
- Horizon NJ TotalCare (HMO D-SNP) Forms
- Inquiry / Request
- Prescription Drug Mail Order
- Frequently Used Forms
- Miscellaneous
- W9 Form-Dental
- W9 Form-Medical
- News & Legal Notices
- Provider Alerts
- BlueCard Announcements