Skip to main content
COVID-19

Blue Review

September 2022

  • Our collaboration with providers is leading the way for innovative care models and better outcomes. Read more on our new feature stories page.

  • To comply with the Consolidated Appropriations Act (CAA) that went into effect January 1, 2022, you must notify us of any changes to your practice information.

  • We use the following established guidelines and best practices to make coverage decisions:

    • The necessity and appropriateness of care and service within the member’s benefit coverage guidelines. or: Ensure the care and service with the member's benefit coverage guidelines Is necessary and appropriate.
    • Do not offer our employees, or delegates working on our behalf, incentives to encourage denials of coverage or service, or provide financial incentives to doctors to withhold covered health care services that are medically necessary and appropriate.
    • Look to emphasize access to the delivery of medically necessary and cost-effective health care services for members.
      • Make sure members have access to health care services that are medically necessary and cost-effective.
    • Encourage the reporting, investigation and elimination of underutilization or overutilization.
      • Underutilization is when a person does not receive the care or services that are necessary to properly meet his or her needs.
      • Overutilization is when a person receives treatments, tests and studies that are unnecessary.
      • Both underutilization and overutilization can result in costly and improper use of services and are not helpful to your patients.
  • Horizon is committed to respecting our members’ rights to confidentiality, quality of care and service. We encourage our members, whenever possible, to actively participate in making decisions about their health care and treatment options. You may review our Member Rights and Responsibilities by visiting HorizonBlue.com/rights.



    Please note this impacts all commercial and Medicare Advantage members, including Braven Health members.

  • Patient satisfaction is an important component of the overall patient experience. Satisfied patients are more likely to return to their doctor for care, adhere to screenings and have better clinical outcomes. Every single interaction at a doctor’s office can impact patient satisfaction.



    The Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey gives patients an opportunity to provide feedback on how satisfied they are with their provider and health plan. If we work together, we can ensure that patient has an overall positive experience.



    The CAHPS survey is sent receives a random sample of Medicare Advantage beneficiaries in March through June. Any patient interaction can impact CAHPS scores. Make patient satisfaction a top priority for your staff.



    Tips for creating a compassionate and patient-centric practice to boost your patient satisfaction:

    • Easy appointment booking – ensure patients can book appointments their preferred way (phone, email, online). Send a reminder a week before a patient’s appointment so they can reschedule if necessary or call the office with any questions.
    • Shorter wait times – patients should be notified of the estimated wait time when they check in. If a patient has to wait longer than their scheduled appointment time, be sure to inform them of the situation and provide them an updated wait time.
    • Positive interactions with doctors and staff – treat patients with compassion and be clear and direct while giving care. Explain to the patient what you are doing throughout the visit..
    • Be sure to listen actively to the patient’s needs and concerns and answer any questions they might have. Initiate positive interactions through staff with friendly greetings and helping patients that may be confused.

    We offer tools and resources for all physician's offices that you can immediately start to use toward your patient engagement goals. They cover topics such as coordination of care and ensuring patients are getting care quickly.

  • To further enhance your experience, we updated our Eligibility and Benefits Cost Share Estimator on NaviNet to return member cost share results for services requiring authorization. It will also tell you if a service requires an authorization and where to submit the request.

  • Horizon has contracted with Musculo to assist a small number of members enrolled in fully-insured plans that have rheumatoid arthritis (RA).



    Musculo addresses the mental and physical health of people living with RA by using specialized health coaches and technology to achieve improved health.



    If your patients ask about this vendor’s outreach, you can confirm they work with Horizon.



    For additional information you can call Musculo at 1-888-909-4485.

  • Horizon continually works to ensure that our code and claim-editing rules are up-to-date with standard business practices and that code- and claim-editing rules are fully and correctly implemented within our claim processing systems.



    We continue to see a high number of claim bill line denials with the message: THIS SERVICE IS NOT PAID. THE SUBMITTED DIAGNOSIS CODE IS NOT SPECIFIC ENOUGH FOR ACCURATE DETERMINATION OF BENEFIT ELIGIBILITY.



    • Based on our review, a large number of these claim bill line denials are the result of ICD-10 diagnosis coding that does not use the highest level of specificity.

      Such denials are based on ICD-10-CM Official Guidelines for Coding and Reporting pertaining to “Excludes1” notes which indicate that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 indicates that the two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. The billed service was denied because it was reported with one or more diagnosis code pairs that are subject to an Excludes1 note.

    • If you feel that denied claim bill lines should be reconsidered for reimbursement, please submit a corrected claim that includes the highest appropriate level of specificity.

    We encourage all health care professionals, facilities and ancillary providers and their billing offices and vendors to continue to work to ensure a high-level of accuracy and compliance with the most current and appropriate billing practices, rules and guidelines.



    When the most accurate and current codes are submitted, Horizon is able to quickly and efficiently process claims and generate accurate and appropriate reimbursement for the health care services you provide to our members.

  • Trinitas Regional Medical CenterTrinitas Regional Medical Center, an RWJBarnbas Health facility, is designated an OMNIA Tier 1 hospital for OMNIA health plan members, as of July 1, 2022. Trinitas Regional Medical center is a full-service health care facility serving those living and working in Union County. Read more.


Blue Review, written specifically for participating providers and other health care professionals, acute care facilities and ancillary facilities, is your convenient source for news and information from Horizon Blue Cross Blue Shield of New Jersey.