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Blue Review June 2022

June 2022

  • 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 the decision making about their health care and treatment options.

    To help ensure all parties are aware of our members' rights and responsibilities, they are always available online. We also publish this information in our member materials and in our office manuals.

  • What is CAHPS?

    The Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey asks patients to evaluate their health care experience, including their physicians, drug plans and access to care. The Centers for Medicare & Medicaid Services (CMS) sends this annual survey to our Medicare Advantage, Medicaid and Fully Integrated Dual Eligible Specials Needs Plan (FIDE-SNP) members.

    Why it's Important

    CAHPS surveys play an important role as a quality improvement (QI) tool and as a measure of patient experience used to identify both strengths and opportunities for improvement in clinical, quality and service performance.

    Research shows improving patient experience and engagement has many proven benefits. These include:

    • Better adherence to medical advice and treatment plans
    • Better knowledge of gaps in communication that can impact clinical quality safety and efficiency
    • Enhanced physician and employee satisfaction, and ability to retain patients and attract new ones

    How to Improve Scores

    Physicians and their staff can directly influence survey results by:

    • Offering your patients same-day appointments
    • Trying to minimize the wait time for appointments to no more than 15 minutes
    • Providing timely test results
    • Explaining things in easy-to-understand terms

    Let us Help

    We offer tools and resources for all physicians' offices that you can immediately start to use toward your patient engagement goals. Once registered for our resources, you can access the Playbook for Patient Engagement, which includes tactics, tips and a series of best practice videos.

    Further support is also provided through CAHPS Coaching, which is designed and dedicated for Primary Care Physicians who treat Medicare members. If you are eligible for this coaching program and want more information on how we can customize a plan to meet your interests and needs, and one that is convenient for your schedule, please call 1-888-652-2477 or email

  • We require that all participating practices are familiar with and comply with our Appointment Availability Access Standards for Primary Care-Type Providers, ObGyns, Specialists and Behavioral Health Providers. These important administrative policy guidelines help ensure that our members receive the care they need when they need it.

    Please review this content and keep our standards in mind when

    • Offering your patients a first-available appointment
    • Responding to after-hours calls for urgent or emergent care or
    • Monitoring office-waiting time

    Our goal is for all of our members to have timely appointments based on the clinical urgency of their physical and/or behavioral health needs.

    We also make our Access Standard information available to your patients.

    Access Standard Outcomes

    Below are our 2021 results for PCPs, OB/GYN, Specialists and Behavioral Health Practitioners:

    Sample ID Card

    Sample ID Card

    Sample ID Card

    Sample ID Card

    NOTE: Standards in red font indicate NCQA standards

  • What is the Health Outcomes Survey (HOS)?

    The HOS is a questionnaire sent to a random sample of Medicare Advantage (MA) plan members. It asks questions about their overall health and their perception of the care they receive.

    Why is it important?

    The HOS helps the Centers for Medicare and Medicaid Services review and track health plan performance. Results help determine Star ratings for MA plans.

    What does it cover?

    MA patients are asked questions about things like their risk of falling, urinary incontinence, monitoring of their physical activity, and other topics related to their physical and mental health.

    How can you help?

    • Talk to your patients about the importance of filling out the HOS if they receive it.
    • Educate yourself and your staff on the survey questions.
    • Encourage your patients to take an active role in their health.
    • Work with your patients to develop treatment plans and goals to get or stay healthy.
    • Provide an open, welcoming environment so your patients feel comfortable talking about their health concerns with you.

    Learn more about the HOS.

    HOS Measure Sample HOS Questions Recommendations/Best Practices

    Monitoring Physical Activity

    In the past 12 months, have you talked with a doctor or other health care professional about your level of exercise or physical activity?

    In the past 12 months, has a doctor or other health care professional advised you to start, increase or maintain your level of exercise or physical activity?

    • Talk about the importance of physical activity and the benefits of staying active.
    • Assess your patients' current level of physical ability and develop a plan with your patients to start or increase physical activity.
    • Refer patients with limited mobility to physical therapy to learn safe and effective exercises.
    • Provide educational materials, safe exercises and resources to improve physical activity.
    • Encourage patients to find community resources to engage in physical activity and social interaction.

    Improving Bladder Control

    In the past six months, have you experienced leaking of urine?

    Have you ever talked with a doctor, nurse, or other health care professional about leaking of urine?

    There are many ways to control or manage the leaking of urine, including bladder training exercises, medication and surgery. Have you ever talked with a doctor, nurse, or other health care professional about any of these approaches?

    • Ask patients if they have had any bladder control issues or urinary leakage.
    • Discuss ways to decrease the risk of bladder control issues, including pelvic floor exercises, avoiding bladder irritants and maintaining a healthy weight.
    • Discuss treatments for bladder control issues that may arise with age, such as behavioral therapy, exercises, medications, medical devices and surgery.
    • Provide educational brochures and materials as conversation starters for this sensitive subject.

    Reducing Fall Risk

    Have you fallen in the past 12 months?

    In the past 12 months, have you had a problem with balance or walking?

    In the past 12 months, have you talked with your doctor or other health care professional about falling or problems with balance or walking?

    Has your doctor or other health care professional done anything to help prevent falls or treat problems with balance or walking?

    • Assess patients for balance problems, recent falls, difficulty walking and other fall risks.
    • Recommend routine eye exams and hearing tests.
    • Review medications for any issues that increase fall risk.
    • Suggest exercises to improve muscle strength and balance.
    • Perform bone density screening, especially for high-risk patients.
    • Discuss home safety tips, such as removing trip hazards, installing handrails, and using non-slip mats and night lights.

  • Good health — and health care — shouldn't depend on what you look like or where you live. Unfortunately, for people of color, that's not always the case.

    Through Our Pledge, we continue to address health care disparities related to race and other social barriers our members face in accessing care. As part of this commitment, we're helping our network physicians understand how implicit bias, or how having attitudes towards people or associating stereotypes with them without our conscious knowledge, can adversely impact patient outcomes.

    We encourage you to take advantage of free virtual training that's available to you and your staff. The U.S. Department of Health and Human Services' Office of Minority Health has free, continuing education e-learning programs to help health care professionals provide culturally competent care.

    Thank you for your continued dedication to working together to improve access to care in New Jersey.

  • In simple terms, Risk Adjustment is a process for health plans in which a member's demographics and diagnoses are used to determine their projected cost for future care. Risk Adjustment ensures that the health conditions, health status and demographics of the beneficiaries in a health plan are accurately documented — and that the health plans managing those beneficiaries are appropriately compensated for the associated costs of that management.

    One of the most important components of Risk Adjustment is ensuring members receive high-quality care. You are encouraged to accurately document your patient's conditions to the highest level of specificity. This helps create a better overall picture of your patient's health, resulting in the improvement of health outcomes and linkage to appropriate care management or disease intervention programs that the health plan offers.

    ABCs of HCCs

    Hierarchical Condition Categories (HCCs) are sets of medical codes that are linked to specific clinical diagnoses. Each HCC represents multiple diagnoses with similar clinical complexity and expected annual care costs.

    HCC models rely on a member's reported ICD-10-CM diagnosis codes to establish the member's health status annually. Therefore, thorough clinical documentation and complete diagnosis coding at every visit, or at least annually, are critical to accurate HCC reporting.

    So what can you do? You should:

    • Perform an annual visit with your patients as early in the year as possible.
    • Fully engage in Horizon Risk Adjustment projects, including meeting with the Risk Adjustment team to review performance.
    • Participate in coding and document education and training.
    • Participate in other trainings offered through Horizon.

    Key takeaways for physicians

    You should:

    • Fully assess and document all chronic conditions annually.
    • Thoroughly document in the patient's chart all HCC conditions evaluated for each visit.
    • Code to the highest level of specificity.
    • Remove inaccurate codes or codes that no longer pertain to the patient's health care status.
    • Monitor and decrease the use of unspecified ICD-10 diagnosis codes.

    Why Medical Record Retrieval Requests?

    Medical record retrieval allows us to verify that the diagnoses submitted on claims are supported and substantiated in the medical record. This process also:

    • Provides us the opportunity to confirm if suspected chronic conditions that haven't been submitted on a claim in the current year still exist.
    • Provides a thorough and accurate health picture of the member.
    • Closes gaps in medical record documentation.
    • Supports government audits.
    • Supports Medicare Advantage Star rating measures.

    This process helps you better understand your patients' full spectrum of health conditions so you can better manage their care. Additionally, review of medical records can help reveal undocumented, inaccurate or missing diagnoses, which can interfere with your patients receiving appropriate care.

    You may receive letters from vendors that contract with Horizon such as Inovalon or Episource requesting access to medical records for chart review. These vendors are independent companies that provide secure, clinical documentation services and contact physicians on our behalf.

    RADV (Risk Adjustment Data Validation)

    RADV allows the Centers for Medicare & Medicaid Services (CMS) to audit members' medical records to verify diagnosis codes that are tied to hierarchical condition categories (HCCs). RADV allows the health plan to get a better understanding of all members' health, as well as how the physicians are billing. All RADV requests are mandated by CMS with a goal of 100 percent compliance for all targeted physician groups.

    For more information or to set up a meeting with the Risk Adjustment team, please email us at

  • Beginning May 1, 2022, CareCentrix began managing the Horizon Supportive Care Program℠ and the Braven Health Supportive Care Program℠ on our behalf. These programs manage utilization of post-acute care services and include a community-based palliative care program for our members enrolled in Commercial fully insured, Horizon Medicare Advantage and Braven Health plans. Members can get more support after an acute hospital stay to help avoid unnecessary hospital readmissions and get the right care when and where they need it.

    Please become familiar with the process for submitting authorization requests for post-acute care and the support services available through these programs.

  • See how you can save time and resources with our online tool. With this tool you can get 24/7 access to medical and behavioral health claim‐level member eligibility, benefits and estimated out‐of‐pocket costs.

  • You can now use our Provider Data Maintenance Tool on NaviNet to add your practice's contact information for Quality Chart medical record requests. The new Quality Chart detail allows you to add and update the office contact who manages your Quality Chart medical record requests and the address where your Quality Chart information can be accessed.

    Providing and maintaining the appropriate office contact for Quality Chart medical record requests will help to improve our interactions with you during our annual Healthcare Effectiveness Data and Information Set (HEDIS®) audit. As you are aware, HEDIS reporting is a requirement of health plans by NCQA and the Centers for Medicare and Medicaid Services (CMS) for use in health plan accreditation, Star Ratings, and regulatory compliance. HEDIS reporting is an important part of keeping our members healthy.

    We will only use this Quality Chart contact information for these specific requests and not for all medical record information requests from Horizon or our business partners working on our behalf.

    How to Access our Provider Data Maintenance Tool

    To submit/update this information and any other important demographic information about your practice:

    • Log in to and select Horizon BCBSNJ within the My Health Plans menu
    • Select Provider Data Maintenance from the Workflows for This Plan menu
    • Select one of the editing tiles, such as Edit Physician Details
    • Under the Action column, click on the pencil icon for the health care professional to be updated
    • Access the View/Add Quality Chart Location Details link on the bottom right of the page

    Learn More About the Provider Data Maintenance Tool.

  • Mental illness can emerge in childhood or adolescence and can be especially distressing at this time of life. Symptoms can include behavior disruptions, hallucinations, illogical thinking and severe depression.

    The National Committee for Quality Assurance (NCQA) states that while antipsychotic medications serve as effective treatment for a closely defined set of psychiatric disorders in children and adolescents, they are commonly prescribed for nonpsychotic conditions where psychosocial interventions are considered first-line treatment. Psychosocial interventions may be underused, and children and adolescents may needlessly experience the risks associated with antipsychotic medications.

    Healthcare Effectiveness Data and Information Set (HEDIS) measures are curated by the NCQA. This article focuses on Use of First-Line Psychosocial Interventions for Children and Adolescents on Antipsychotics (APP). APP measures the percentage of children and adolescents (age 1 to 17 years) who received new antipsychotic medication prescription who had documentation of psychosocial care as first-line treatment.

    APP applies to Commercial and Medicaid providers. To meet this measure, documentation of psychosocial care needs to occur within 90 days prior through 30 days after the earliest prescription dispensing date.

    Best Practices:

    • Educate patients and caregivers on the importance of medication compliance and side-effects.
    • Coordinate care with the child's treatment team, when appropriate.
    • Maintain appointment availability in your practice and schedule follow-up appointments before your patient and their caregiver leave your office.
    • Reach out to patients and caregivers that do not keep follow-up appointments and develop tracking methods for patients due or past due for follow-up visits, and have staff follow up with them.
    • Instruct your patient and their caregiver on safety planning and crisis intervention options, including specific contact information and facilities

    Horizon's Behavioral Health HEDIS Team is available to assist you with meeting performance goals. Please email them at

  • The need for mental health care is growing, especially in response to the COVID-19 pandemic, and it's more important than ever to integrate behavioral health care with physical health care. Primary Care Providers are usually the first to identify patients facing depression, stress, anxiety or a Substance Use Disorder (SUD).

    As a primary care medical provider, you may not always have the resources needed to support your patients' mental health needs. Trying to manage these concerns in addition to caring for all of the patients you see on a daily basis can be overwhelming for both you and your staff.

    We are Here to Help

    Our dedicated Horizon Behavioral Health℠ team is available 24/7/365. We're here to assist your practice with support and programs to help you care for your Horizon patients' mental health so their physical health can improve.

    Integrating Care for Your Patients

    Our Horizon Behavioral Health program can collaborate with you to:

    • Help your patients find the right level of care. We will provide your patients with care navigation to find the right health care professionals and resources — either digitally, virtually or in person — to address their unique behavioral health needs, even in a crisis. Horizon Behavioral Health has a network of more than 8,400 providers who offer a full range of mental health and SUD services (data as of March 2022).

    • Access specialized clinical expertise. Our experienced team of psychiatric medical directors, psychologists and behavioral health clinicians will provide oversight of Care Management programs that can help your patients manage their end-to-end care.

    • Connect behavioral health care with primary health care and social needs. Our Integrated System of Care (ISC) Program is a specialized program for Horizon members with serious mental illness (SMI) and/or SUD. Your patients with SMI and SUD can participate in a program that emphasizes the integration of medical, behavioral and social services to improve clinical outcomes. For more information, contact the ISC team at 1-844-281-8924 or

    To find out more on how our Behavioral Health program can assist your practice with providing behavioral health care to your patients, call our dedicated care team at 1-800-626-2212.

  • Horizon recommends that claim adjustment requests be sent electronically via standard HIPAA 837 transaction sets. We accept electronic claim adjustment requests for professional (837P), institutional (837I) claims, and dental (837D).

    Submitting claim adjustment requests electronically allows us to address your electronic adjustment requests more quickly, speeding our adjudication and payment to you.

    You may electronically submit any adjustments that do NOT require the submission of additional supporting documentation, such as medical records, for:

    • Local professional, institutional, and dental claims, including State Health Benefits Program.
    • Federal Employee Program® (FEP®) professional, institutional, and dental claims.
    • BlueCard® professional and institutional claims.
      (Claims for your patients enrolled in other Blue Cross Blue Shield Plans that you submit to us for processing and reimbursement).

    Contact your vendor or clearinghouse for information about 837 transactions. Most clearinghouses already send us 837 transactions and can work with you to submit adjustment requests in the appropriate format.

    If you have questions, please contact the Horizon eService Desk at 1-888-334-9242 or email: Representatives are available weekdays, 7 a.m. to 6 p.m., Eastern Time.

  • To indicate the electronic transaction you're submitting is an adjustment request, include the following required information within your electronic 837 transaction:

    1. Frequency Code

    The appropriate Frequency Code must be present on your 837 transaction to indicate the information being submitted is for a claim adjustment. The Frequency Code is reported in Loop 2300, Data Element CLM05:3 (“Claim Frequency Type Code”).

    • Institutional claim adjustment submissions may use values 5, 7, 8, F, G, H, I, J, K, M, or N to indicate that the transaction is an adjustment.
    • Professional and dental claim adjustment submissions may use values 7 or 8 to indicate that the transaction is an adjustment.

    2. Explanation for Adjustment

    • Electronic Institutional claim adjustment requests must include in Loop 2300, Data Segment NTE (“Billing Note”) the Adjustment Reason and Narrative explaining why the claim is being adjusted. (Example: Adjustment Reason: Subscriber ID corrections; Narrative: Transposed subscriber ID, correct Sub ID is 12345678 for John Smith, DOB 11-22-1970.)
    • Electronic Professional and Dental claim adjustment requests must include in Loop 2300, Data Segment NTE (“Claim Note”) the Adjustment Reason and Narrative explaining why the claim is being adjusted. (Example: Adjustment Reason: Number of units; Narrative: Units billed incorrectly, changed units from 010 to 001.)

    3. Original Reference Number

    All 837 electronic adjustment transactions must include the claim number of the originally processed claim found on your remittance advice (i.e., the ICN/DCN of the claim you want adjusted). This number should be listed in Loop 2300, Data Segment REF (“Payer Claim Control Number”) for all types of claims (Institutional, Professional, and Dental).

    The Original Reference Number (ORN) submitted on the electronic adjustment can be found on the 835-remittance advice referenced by Claim Payment Information qualifier – CLP07 or the original claim number on your Explanation of Payment (EOP). The ORN is the only number that should be sent as the original adjudicated claim.

    Original Claim Remittance Advice Resubmitted Claim Secondary Claim
    2003 REF (F8) Not Used 2100 | CLP07 2300 | REF (F8) Not Used

Please share this information with your vendor or clearinghouse to ensure your electronic transactions are being submitted correctly.