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Blue Review December 2022

  • Receive and Send Documents Electronically with HorizonDocs

    We encourage you to use HorizonDocs, one of several digital tools that help make your day-to-day interactions with us easier and more convenient.

    HorizonDocs is a web-based, centralized document repository that allows Horizon to securely request documentation from you and that allows you to securely respond with the requested documents all in one place.

    With HorizonDocs, the exchange of protected health information is safe and secure. Plus, HorizonDocs offers additional benefits and features, including the following:

    • HorizonDocs organizes documents by category and sub-category (e.g. Post-Service Medical Records: Commercial, MA, etc.).
    • Documents are requested from you based on your Tax ID Number.
    • You have the ability to control who has access to receive and send documentation via HorizonDocs based on the sensitivity level of the documents. Each user is assigned a permission level that allows them to view and respond to requests for their level.
    • Email are sent when documents are requested, sent and received.

    Examples of document requests you may receive via HorizonDocs include:

    • Lists of members who require screenings
    • Results and Recognition Performance and Incentive reports
    • HEDIS chart requests
    • Electronic Health Records (EHR) Data Submission Templates

    How to Access to HorizonDocs

    Your practice's NaviNet Security Officer is responsible for setting up permissions for HorizonDocs users based on document sensitivity level and for registering user email addresses to receive notifications when Horizon sends requests for documentation.

    Before you can use HorizonDocs, your office's Security Officer has to establish settings and grant access for users in your office. Your Security Officer is responsible for:

    • Setting up and managing user permissions in your office so that documents can be viewed by the appropriate staff per roles and "sensitivity level" settings.
    • Registering the email addresses of users so they will receive email notices when Horizon requests information through HorizonDocs.

    After your Security Officer grants you access, sign in to either the Horizon BCBSNJ or Horizon NJ Health plan central pages on NaviNet and click HorizonDocs within the Workflows for this Plan section.

    Visit our HorizonDocs webpage for more information.

  • Claim Payment Determination Appeals

    You have the right to appeal claim payment determinations you disagree with. Our appeals processes are documented within the Inquiries, Complaints and Appeals sections of our provider manuals.

    You must complete our internal claim payment appeal process BEFORE proceeding to submit a request to the state's external arbitrator, Maximus, in regard to a fully insured claim payment determination. This process is in compliance with the New Jersey Program for Independent Claims Payment Arbitration (PICPA) established by the Health Claims Authorization, Processing and Payment Act (HCAPPA), P.L. 2005, c. 352.

    Appealing a Claim Payment Determination

    As noted in the Inquiries, Complaints and Appeals section of our provider manuals, practices, providers and facilities may appeal a claim payment determination related to services provided to a patient enrolled in a fully insured plan, by completing and submitting a copy of the NJ Department of Banking and Insurance's (DOBI's) Health Care Provider Application to Appeal a Claims Determination form within 90 days of our determination.

    Please mail this form along with all pertinent information/ necessary to help us understand why you disputed our claim determination to:

    • Horizon BCBSNJ
      Appeals Department
      PO Box 10129
      Newark, NJ 07101-3129

    If it is determined that your request meets the eligibility criteria for a first-level HCAPPA appeal, we will advise you of our determination in writing within 30 calendar days of receiving your appeal.

    If that determination is unfavorable to you, we will provide instructions for your second-level appeal, a referral to external arbitration.

    Audit Findings

    You have the right to initiate a claim payment determination or first-level HCAPPA appeal following an audit performed by Horizon or by a vendor on our behalf, but please note that your interactions with the auditing entity (e.g., a final audit determination or any peer-to-peer discussions disagreeing with an audit determination) are not considered a claim payment determination appeal or first-level HCAPPA appeal.

    After Horizon has generated an official notice of claim denial or claim reimbursement recovery, as required by NJ State Law, you may submit a claim payment determination appeal or a first-level HCAPPA appeal to us for review as noted above.

  • Adherence to Antipsychotic Medications for Individuals with Schizophrenia (SAA)

    Schizophrenia is a chronic and disabling psychiatric disorder that requires ongoing treatment and monitoring. With proper symptom management and adherence to medications, hospitalization rates and readmissions for members with schizophrenia may decrease.

    Healthcare Effectiveness Data and Information Set (HEDIS) measures are designed by the National Committee for Quality Assurance (NCQA). The SAA HEDIS measure examines the percentage of members with schizophrenia or schizoaffective disorder who had at least two prescriptions filled for any antipsychotic medication and who had a Proportion of Days Covered (PDC) of at least 80 percent for antipsychotic medications during the measurement period.

    It is important for members to follow up with aftercare providers. Especially if a member has been hospitalized for symptoms relating to schizophrenia. Aftercare providers may include outpatient, intensive outpatient, partial hospitalization or non-acute inpatient settings.

    NCQA recommends the following best practices for providers:

    • Educate members and their caregivers on the importance of medication compliance
    • Discuss potential medication side-effects and when to call their provider
    • Schedule follow-up appointments before patient leaves appointment
    • Reach out to members that do not keep follow-up appointments
    • Instruct on crisis intervention options including specific contact information and facility

    Horizon's Behavioral Health HEDIS Team is available to assist providers with meeting performance goals and may be contacted by emailing

  • Doula Services for Individual Health Coverage (IHC) Members — Helping to Improve Outcomes

    New Jersey's maternal health outcomes and disparities are among the worst in the United States. The state is currently 47th in the nation in maternal mortality.

    We are committed to working with you to prevent pregnancy-related deaths, which happen to non-white women in disproportionate numbers. To help improve health outcomes for mothers and babies, we're launching a pilot program that will cover in-network birthing doula services for your patients enrolled in IHC plans, effective January 1, 2023.

    A birthing doula is a trained professional who provides continuous physical, emotional and informational support throughout pregnancy. Doula providers also connect families with community resources to help them address social challenges that contribute to overall health.

    When caring for your pregnant patients enrolled in IHC plans, consider doulas as part of their overall care team and patient support for best outcomes.


    • State of New Jersey. Nurture NJ - Combating New Jersey's Maternal and Infant Mortality Crisis. Retrieved on November 8, 2022 from
    • New Jersey Health Care Quality Institute. Maternity Action Plan. Retrieved on November 8, 2022 from
  • Hospital Forum Webinar Sessions Held

    Thank you to those who attended one of our 2022 Hospital Forum sessions.

    This year's forum sessions were shorter and more focused online webinars, but still conveyed important updates and information to staff members of network hospitals while answering questions and receiving feedback.

    Many thanks to the Horizon staff for sharing their time and expertise to present the following topics at the sessions:

    • Inpatient Case Management
    • Post-acute Facility Pre-admission Intake Process
    • Integrated Care Management
    • UM Appeals
    • Horizon Community Health Overview
    • Managed Long Term Support Services (MLTSS)
    • Braven Health Plan Changes for 2023
    • Risk Adjustment Data Validation
    • Horizon Eligibility and Cost Share Estimator Tool

    Contact your Network Hospital Specialist if you would like to receive a copy of the presentation slides.

  • Horizon Value Access Plans Will Be Discontinued In 2023

    Horizon Value Access Plans will be discontinued in 2023. These Managed Care Network plans were offered only to residents who resided in Hunterdon, Morris, Sussex or Warren counties.

    All Regional Network Product Rate Agreements signed in 2021 will be terminated on December 31, 2022. This change does not impact any other Agreements with us. Members enrolled in Horizon Value Access Plans will have the option to enroll in one of our other plans during the 2023 open enrollment period.

    If you have questions, please call your Network Specialist or your Ancillary Contract Specialist

    Thank you for your continued participation with Horizon and for the quality care you provide to your patients, our members.

  • Amazon Pharmacy Will Be the Only Participating Home Delivery Option for Commercial Members With Horizon Pharmacy Benefits

    Starting January 1, 2023, Amazon Pharmacy prescription home delivery will be the only home delivery option for your patients who are enrolled in commercial Horizon health plans that include Horizon Pharmacy. AllianceRx Walgreens Pharmacy home delivery will no longer be available to these patients.

    Amazon Pharmacy can fill prescriptions for 90-day supplies of maintenance medicines, with the exception of Schedule II controlled substances. Those prescriptions should be sent to a local in-network pharmacy of your patients' choice.

    Horizon members (excluding those enrolled in Medicare Advantage, Medicare Prescription Drug and Braven Health℠ plans) also get drug discount card pricing called MedsYourWay™¹ built in to the Amazon Pharmacy experience. All covered and eligible purchases count toward the member's deductible or out-of-pocket costs whether they use their insurance or MedsYourWay.

    You can submit prescriptions to Amazon Pharmacy by:

    • EPRESCRIBING: Amazon Pharmacy 001
    • FAX: 1-512-884-5981
    • MAIL: 4500 S Pleasant Valley Rd, Suite 201 Austin, TX 78744
    • PHONE: 1-855-206-3605, then press 1

    If you or your patients have questions about Amazon Pharmacy, please visit or call Amazon Pharmacy Customer Care at 1-855-549-1760. Representatives are available 24/7. If your patient has questions about their Pharmacy benefits, they should call the phone number listed on their member ID card.

    ¹ MedsYourWay drug discount card pricing, administered by Inside Rx LLC, is not insurance. Members are responsible for the cost of prescription(s) when using the card. Limitations apply.

    Amazon Pharmacy is contracted by Horizon Blue Cross Blue Shield of New Jersey to provide pharmacy home delivery services. Amazon Pharmacy and Inside Rx LLC are independent from and not affiliated with Horizon Blue Cross Blue Shield of New Jersey

  • Are you prepared for the CAHPS survey?

    The Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey and the Health Outcomes Survey (HOS) play a crucial role in creating positive patient experiences. These surveys allow plans and providers to gather information about the quality of care patients receive and improve health outcomes and patient retention.

    View this helpful guide for best tips and practices.

    We also encourage you to view our Quality Resource Center for other helpful resources.

  • Braven Health℠ Plans Use the Horizon Managed Care and Horizon Hospital Networks

    Medicare-eligible beneficiaries who reside in all 21 New Jersey counties can enroll in a Braven Health Medicare Advantage plan for coverage beginning January 1, 2023.

    What You Need to Know

    • You already participate with Braven Health Medicare Advantage (MA) plans if you participate in our Horizon Managed Care Network or Horizon Hospital Network.
    • Members enrolled in the following Braven Health plans have in-network benefits with providers in our broad Horizon Managed Care Network or Horizon Hospital Network.
      • Braven Medicare Freedom (PPO)
      • Braven Medicare Choice (PPO)
      • Braven Medicare Access Group w/Rx (HMO-POS)
      • Braven Medicare Group w/Rx (PPO)
    • Members enrolled in our Braven Medicare Plus (HMO) consumer plan – which is only offered to Medicare beneficiaries who live in Bergen, Essex, Hudson, Middlesex, Monmouth, Ocean or Union counties – have no out-of-network benefits.
      • Members enrolled in this plan must receive care from providers that participate in the subset of our Horizon Managed Care Network or the subset of our Horizon Hospital Network.
    • You can confirm your participation status in all our Braven Health plans on our Doctor & Hospital Finder.
    • Braven Health has its own Payer ID 84367, different from Horizon.

    Are You Ready to Provide Care in 2023?

    • Register for Braven Health EDI prior to January 1, 2023. All trading partners and direct submitters (who are not already registered) must register for Braven Health EDI prior to January 1, 2023 to submit and receive electronic transactions related to Braven Health members.
    • Register to attend one of our webinars.
      • Professional medical practices can register to attend a Braven Health webinar.
      • Behavioral health practitioners can register for one of our Important Updates & Reminders or Orientation sessions, which will include information about Braven Health. Behavioral health ancillary providers can request a Braven Health training session by emailing
      • Hospital staff, please contact your Hospital Network Specialist for information about Braven Health.
    • Review our dedicated Braven Health provider web page at for plan details, participation and more.
  • Improving Access: Braven Health℠ Does Not Require Referrals

    To help your patients access care, Braven Health products do not require referrals.

    Referrals are NOT required for members enrolled in any Braven plans for 2022 and 2023, including:

    • Braven Medicare Choice (PPO)
    • Braven Medicare Freedom (PPO)
    • Braven Medicare Plus (HMO).

    Sending Patients for Care

    Members rely on their Primary Care Provider to help them stay healthy and to manage their care, which includes recommending specialists. To help your patients avoid extra costs, refer them to in-network specialists and tell them to use the doctor/hospital finder tool to confirm whether the specialist you recommend is within their plan's network. If the specialist isn't in network, ask them to call your office for another specialist referral.

    Also, encourage your patients to send or bring any test or lab results, prescribed medicines or consultation findings from the specialist to your office during their next visit.

    More Information About Braven Health

    Braven Health products will be expanded to all 21 counties in New Jersey beginning January 1, 2023.

    For more information about this expansion, please join us at one of the webinars listed below:

    Wednesday, December 7, 2022, 10 a.m. to 11 a.m.

    Tuesday, December 13, 2022, noon to 1 p.m.

    Tuesday, December 20, 2022, 10 a.m. to 11 a.m.

  • Cut Prescription Costs and Reduce Calls for Prior Authorization with Real Time Benefit Check Tool

    When it comes to filling prescriptions, you and your Braven Health℠ patients can benefit when you use our Real Time Benefit Check tool. Easy and convenient to use, the tool uses the ePrescribe function of your Electronic Health Record (EHR) system and offers these benefits:

    • Shows you lower-cost alternative medications under the patient's prescription drug plan
    • Reduces calls to the pharmacy regarding prior authorizations
    • Helps lower patients' out-of-pocket prescription costs
    • Improves medication adherence due to lower costs
    • Increases patient experience and satisfaction
    • Can be used with most Medicare health plans

    How to Get Started

    To add this tool to your EHR, contact your IT liaison. It may be as simple as turning on the feature, depending on your EHR system.

    Older versions of Allscripts with TouchWorks, NextGen, and Greenway systems may need an upgrade to the newest version. Contact your Account Representatives for more details.

    If you use Epic, setup information can be found on Galaxy, the portal where Epic houses documentation.

    Contact Information

    If you have questions, please reach out to your Network Relations Representative or call the Physician Services line at 1-800-624-1110.

    Braven Health and Horizon are committed to supporting you in providing the best quality of care and experience for your patients.

    Allscripts with TouchWorks, Epic, Greenway and NextGen are independent from, and not affiliated with, Horizon BCBSNJ or the Blue Cross and Blue Shield Association.

  • Get Quick and Easy Access to What Your Patients Will Owe and if the Service Needs Authorization

    You no longer need to call Provider Services or rely on the printed member's ID card for member eligibility and cost share information. With just a single sign in to NaviNet, you can use the Eligibility and Benefits Cost Share Tool to check information for your patients enrolled in our Commercial and Medicare Advantage (including Braven Health℠) plans with a member ID number that includes "3HZN".

    Start using the tool today!

    Simply log on to NaviNet and from the Horizon Plan Central page highlight Eligibility and Benefits and click on Cost Share Estimator.

    The self-service tool will give you access to member medical and behavioral health claim-level:

    • Eligibility
    • Benefit coverage
    • Estimated out-of-pocket costs
    • Prior authorization requirements and where to submit the requests

    If the member ID number does not include "3HZN", please continue to call the Provider Services number on the member's ID card for information.

  • 2023 Audiology/Hearing Aid Benefits for Braven Health℠ Members

    HearUSA is expanding their role in the management of audiology and hearing aid services provided to patients enrolled in Braven Health℠ Medicare Advantage plans. Effective January 1, 2023, HearUSA will also manage these services for members enrolled in our Braven Health PPO plans.

    For all beneficiaries enrolled in Braven Health Medicare Advantage plans, HearUSA will:

    • Be the exclusive in-network provider for an annual routine hearing exam, fitting/evaluation for a hearing aid, and hearing aids.
    • Administer the benefits for audiology services and hearing aids.
    • Process claims on our behalf for Braven Health Medicare Advantage plans. See below for details.

    Members and providers may call HearUSA at 1-800-442-8231 to verify benefits, find a convenient HearUSA network provider location, and/or schedule services to be provided at a HearUSA network location.

    Review coverage and claim submission details.

    The benefit information provided here is not a guarantee of reimbursement. Claim reimbursement is subject to member eligibility and all member and group benefit limitations, conditions and exclusions. You can use our Eligibility and Benefits Cost Share Estimator on NaviNet® to confirm member-audiology benefits and hearing aid benefit amounts before providing services.

    The information provided here is not intended to replace or modify the terms, conditions, limitations, and exclusions contained within health, dental or vision benefit plans issued or administered by Horizon. In the event of a conflict between the information contained in this document and your plan documents, your plan documents shall control.

    Audiology Distribution, LLC, doing business as HearUSA and HearUSA centers are independent from and not affiliated with Braven Health or Horizon Blue Cross Blue Shield of New Jersey. HearUSA administers hearing benefits and provides related products and services through their network of independently practicing audiologists, hearing care professionals and company-owned hearing centers for eligible Braven Health members.