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- PHE Update: Prescription Limitation Change for Braven Health, HMO D-SNP and Medicare Part D membersPHE Update: Prescription Limitation Change for Braven Health, HMO D-SNP and Medicare Part D members
- Important Update: Additional Policy Changes as PHE EndsImportant Update: Additional Policy Changes as PHE Ends
- Some Benefits Changes as the PHE EndsSome Benefits Changes as the PHE Ends
- Referral Requirements for All ServicesReferral Requirements for All Services
- Referral Requirements for Services Not Related to COVID-19Referral Requirements for Services Not Related to COVID-19
- Pre-Certification/Prior Authorization requirements for Post-Acute Facility AdmissionsPre-Certification/Prior Authorization requirements for Post-Acute Facility Admissions
- Telemedicine Cost Share Waiver for Non-COVID-19-Related Services to EndTelemedicine Cost Share Waiver for Non-COVID-19-Related Services to End
- Telemedicine Cost Share Waiver for Non-COVID-19-Related Services to End for Self-Insured Health PlansTelemedicine Cost Share Waiver for Non-COVID-19-Related Services to End for Self-Insured Health Plans
- Submitting Pharmacy Claims for COVID-19 VaccinationsSubmitting Pharmacy Claims for COVID-19 Vaccinations
- Reminder: Select one method for COVID-19 and Influenza TestingReminder: Select one method for COVID-19 and Influenza Testing
- Antibody testing: FDA and CDC do not recommend use to determine immunityAntibody testing: FDA and CDC do not recommend use to determine immunity
- June 2021 Updates: COVID-19 treatment cost share waiverJune 2021 Updates: COVID-19 treatment cost share waiver
- Reminder: Use correct codes when evaluating for COVID-19Reminder: Use correct codes when evaluating for COVID-19
- Policy Update: Antibody Testing ClaimsPolicy Update: Antibody Testing Claims
- Submitting claims for COVID-19 vaccines delivered in non-traditional medical settingsSubmitting claims for COVID-19 vaccines delivered in non-traditional medical settings
- For Essential Workers, COVID-19 Treatment Covered Under Workers’ Compensation BenefitsFor Essential Workers, COVID-19 Treatment Covered Under Workers’ Compensation Benefits
- COVID-19 vaccine administration reimbursement at UCCsCOVID-19 vaccine administration reimbursement at UCCs
- COVID-19 vaccines will be covered at 100%COVID-19 vaccines will be covered at 100%
- Coverage for antibody infusion therapyCoverage for antibody infusion therapy
- Update: Antibody Testing ClaimsUpdate: Antibody Testing Claims
- COVID-19 Frequently Asked QuestionsCOVID-19 Frequently Asked Questions
- Reminder to use specific codes when evaluating for COVID-19Reminder to use specific codes when evaluating for COVID-19
- COVID-19 Update: Telemedicine Reimbursement Policy AddendaCOVID-19 Update: Telemedicine Reimbursement Policy Addenda
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Correct Coding Rules Bank for Radiology, Cardiology and Ultrasound ServicesCorrect Coding Rules Bank for Radiology, Cardiology and Ultrasound Services
- Correct Coding Rules Bank for Radiology, Cardiology and Ultrasound Services
- Correct Coding Rules BankCorrect Coding Rules Bank
- Code Pairs Added to this List Effective January 1, 2023Code Pairs Added to this List Effective January 1, 2023
- Code Pairs Removed from this List Effective December 31, 2022Code Pairs Removed from this List Effective December 31, 2022
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- Surgical and Implantable Device Management Program for Cardiac Surgeries Frequently Asked Questions Updated: March 25, 2021Surgical and Implantable Device Management Program for Cardiac Surgeries Frequently Asked Questions Updated: March 25, 2021
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- Credentialing and Recredentialing Policy for Participating Physicians and Healthcare ProfessionalsCredentialing and Recredentialing Policy for Participating Physicians and Healthcare Professionals
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- Outlier Audit Programs: Post Payment and Pre-PaymentOutlier Audit Programs: Post Payment and Pre-Payment
- Physician and Healthcare Professional Counseling and Termination Policy - Professional CompetencyPhysician and Healthcare Professional Counseling and Termination Policy - Professional Competency
- Participation Status in Products that Utilize Tiering and/or Subset of an Existing Horizon NetworkParticipation Status in Products that Utilize Tiering and/or Subset of an Existing Horizon Network
- Pass Through Billing (Modifier 90)Pass Through Billing (Modifier 90)
- Practice Location ReinstatementsPractice Location Reinstatements
- Practice Locations LimitPractice Locations Limit
- Practitioner Office Site Quality and Medical/Behavioral Health Record Keeping StandardsPractitioner Office Site Quality and Medical/Behavioral Health Record Keeping Standards
- Provider Directory ManagementProvider Directory Management
- Provider Outlier Program Frequently Asked QuestionsProvider Outlier Program Frequently Asked Questions
- Retainer Based MedicineRetainer Based Medicine
- SHBP/SEHBP Inpatient Readmission ReimbursementSHBP/SEHBP Inpatient Readmission Reimbursement
- Standards for All Types of Medical and Dental Diagnostic Radiology and Imaging FacilitiesStandards for All Types of Medical and Dental Diagnostic Radiology and Imaging Facilities
- Tier Awareness PolicyTier Awareness Policy
- Use of Horizon Hospital Network Performance DataUse of Horizon Hospital Network Performance Data
- Use of Practitioner Performance DataUse of Practitioner Performance Data
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Reimbursement Policies & GuidelinesReimbursement Policies & Guidelines
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- Add-on Payment for COVID-19 Diagnostic Testing Run on High Throughput Technology (U0005)Add-on Payment for COVID-19 Diagnostic Testing Run on High Throughput Technology (U0005)
- After-hours and Weekend CareAfter-hours and Weekend Care
- Ambulance ServicesAmbulance Services
- Ambulatory Electrocardiographic MonitoringAmbulatory Electrocardiographic Monitoring
- Anesthesia Reimbursement GuidelinesAnesthesia Reimbursement Guidelines
- ASC Multiple Procedure MethodologyASC Multiple Procedure Methodology
- Assistant at SurgeryAssistant at Surgery
- Balloon SinuplastyBalloon Sinuplasty
- Bariatric Surgery Billed With Hiatal Hernia RepairBariatric Surgery Billed With Hiatal Hernia Repair
- Behavioral Health Services Rendered by Supervised PractitionersBehavioral Health Services Rendered by Supervised Practitioners
- Bilateral ProceduresBilateral Procedures
- Billing Guidelines for Maternity ServicesBilling Guidelines for Maternity Services
- Biologics CodingBiologics Coding
- Cardiac Event DetectionCardiac Event Detection
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- Claim Editing PoliciesClaim Editing Policies
- Claims Requiring Additional DocumentationClaims Requiring Additional Documentation
- ClaimsXten Editing RulesClaimsXten Editing Rules
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- Co-Surgeon ReimbursementCo-Surgeon Reimbursement
- Collaborative Care Management ServicesCollaborative Care Management Services
- Colonoscopy with Modifier 59Colonoscopy with Modifier 59
- Conscious SedationConscious Sedation
- Consultation Services PaymentConsultation Services Payment
- Consumable Medical SuppliesConsumable Medical Supplies
- Continuous Positive Airway Pressure or Bi-level Positive airway Pressure (CPAP/BiPAP) SuppliesContinuous Positive Airway Pressure or Bi-level Positive airway Pressure (CPAP/BiPAP) Supplies
- COVID 19 Antibody TestingCOVID 19 Antibody Testing
- COVID-19 Testing and Testing Related ServicesCOVID-19 Testing and Testing Related Services
- Daily Management of Epidural or Subarachnoid Continuous Drug AdministrationDaily Management of Epidural or Subarachnoid Continuous Drug Administration
- Daily Maximum Units for Surgical Pathology and Microscopic ExaminationDaily Maximum Units for Surgical Pathology and Microscopic Examination
- Determination of Refractive StateDetermination of Refractive State
- Diabetic Screening ServicesDiabetic Screening Services
- Diabetic SuppliesDiabetic Supplies
- Distinct Procedural Service Modifiers (59, XE, XP, XS, XU)Distinct Procedural Service Modifiers (59, XE, XP, XS, XU)
- DME Rent to PurchaseDME Rent to Purchase
- Drug and Immunization PricingDrug and Immunization Pricing
- Duplex ScanningDuplex Scanning
- Drug Wastage – Modifier JWDrug Wastage – Modifier JW
- Duplicate Claim Logic for Independent Laboratory ServicesDuplicate Claim Logic for Independent Laboratory Services
- Evaluation and Management Services with Chiropractic Manipulative TreatmentEvaluation and Management Services with Chiropractic Manipulative Treatment
- Evaluation and Management Services with Osteopathic Manipulative TreatmentEvaluation and Management Services with Osteopathic Manipulative Treatment
- Evaluation and Management Services billed with Global Radiology, Stress Test, Stress Echo, Myocardial Profusion ImagingEvaluation and Management Services billed with Global Radiology, Stress Test, Stress Echo, Myocardial Profusion Imaging
- False ClaimsFalse Claims
- Free Flap Breast ReconstructionFree Flap Breast Reconstruction
- Frequency of Care Coordination Services and ESRD ProceduresFrequency of Care Coordination Services and ESRD Procedures
- Frequency of G0179Frequency of G0179
- Hip ArthroscopyHip Arthroscopy
- Horizon Fee Schedule Updates based on Third Party SourcesHorizon Fee Schedule Updates based on Third Party Sources
- Hospital Non-Patient Laboratory ServicesHospital Non-Patient Laboratory Services
- Hot or Cold Pack TherapyHot or Cold Pack Therapy
- Inpatient ConsultationsInpatient Consultations
- Knee ArthroscopyKnee Arthroscopy
- Lab Panel RebundlingLab Panel Rebundling
- Laboratory Services Billed by PhysiciansLaboratory Services Billed by Physicians
- Laser Treatment of Psoriasis or ParapsoriasisLaser Treatment of Psoriasis or Parapsoriasis
- Maternity ReimbursementMaternity Reimbursement
- Maximum Units for AnesthesiaMaximum Units for Anesthesia
- Medical Nutrition Therapy (MNT)Medical Nutrition Therapy (MNT)
- Medicare Advantage Hospital Sequestration ReimbursementMedicare Advantage Hospital Sequestration Reimbursement
- Microsurgery and Robotic SurgeryMicrosurgery and Robotic Surgery
- Modifier 25Modifier 25
- Modifier 50 Bilateral GuidelinesModifier 50 Bilateral Guidelines
- Modifier 52Modifier 52
- Modifier 53Modifier 53
- Modifier 54Modifier 54
- Modifier 55Modifier 55
- Modifier 56Modifier 56
- Modifier 57Modifier 57
- Modifier 76Modifier 76
- Modifier 77Modifier 77
- Modifier 78Modifier 78
- Modifier SUModifier SU
- Modifiers CQ/COModifiers CQ/CO
- Multiple Procedure ReductionsMultiple Procedure Reductions
- Mutually and Non-Mutually Exclusive NCCI Supplemental EditsMutually and Non-Mutually Exclusive NCCI Supplemental Edits
- Non-ESRD ESA Level ReportingNon-ESRD ESA Level Reporting
- Noncovered Related ServicesNoncovered Related Services
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Outpatient Facility Code Edits: Bundling and Revenue CodesOutpatient Facility Code Edits: Bundling and Revenue Codes
- Outpatient Facility Code Edits: Bundling and Revenue Codes
- Bundled ServicesBundled Services
- Lab codes when billed with other servicesLab codes when billed with other services
- Revenue Codes Requiring HCPCS CodesRevenue Codes Requiring HCPCS Codes
- Typically packaged codesTypically packaged codes
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- Outpatient Laboratory Claims: Referring Practitioner RequiredOutpatient Laboratory Claims: Referring Practitioner Required
- Outpatient Services Prior to Admission or Same-Day SurgeryOutpatient Services Prior to Admission or Same-Day Surgery
- Outpatient Therapy Daily MaximumOutpatient Therapy Daily Maximum
- Physician Extenders Non-Surgical ServicesPhysician Extenders Non-Surgical Services
- Pre-Payment Coding Reviews Documentation RequestsPre-Payment Coding Reviews Documentation Requests
- Pre-Payment Documentation Requests: Facility ClaimsPre-Payment Documentation Requests: Facility Claims
- Post Payment Documentation Requests: Facility ClaimsPost Payment Documentation Requests: Facility Claims
- Pulmonary Diagnostic Procedures when billed with E&M CodesPulmonary Diagnostic Procedures when billed with E&M Codes
- Radiology, Preliminary and Double ReadsRadiology, Preliminary and Double Reads
- RadiopharmaceuticalsRadiopharmaceuticals
- Reimbursement and Billing Guidelines for Anesthesia ClaimsReimbursement and Billing Guidelines for Anesthesia Claims
- Removal of Impacted Cerumen Requiring InstrumentationRemoval of Impacted Cerumen Requiring Instrumentation
- Screening and Diagnostic Mammography & 3D TomosynthesisScreening and Diagnostic Mammography & 3D Tomosynthesis
- Site of Service DifferentialSite of Service Differential
- Smoking CessationSmoking Cessation
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Telemedicine ServicesTelemedicine Services
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- Telemedicine Services Reimbursement Policy: Temporary Addendum for Horizon BCBSNJ Commercial/ASO plans and productsTelemedicine Services Reimbursement Policy: Temporary Addendum for Horizon BCBSNJ Commercial/ASO plans and products
- Telemedicine Services Reimbursement Policy: Temporary Addendum for Horizon Medicare AdvantageTelemedicine Services Reimbursement Policy: Temporary Addendum for Horizon Medicare Advantage
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- Ulcer Debridement and Ulcer StagesUlcer Debridement and Ulcer Stages
- Urgent Care Center Billing RequirementsUrgent Care Center Billing Requirements
- Urinalysis with Evaluation and Management (E&M) ServicesUrinalysis with Evaluation and Management (E&M) Services
- Urine Drug Screening/TestingUrine Drug Screening/Testing
- Vascular CodingVascular Coding
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Utilization ManagementUtilization Management
- Utilization Management
- Utilization Management Request ToolUtilization Management Request Tool
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- UNITE HERE HEALTHUNITE HERE HEALTH
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ResourcesResources
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Consumer Assessment of Healthcare Providers and Systems (CAHPS)Consumer Assessment of Healthcare Providers and Systems (CAHPS)
- Consumer Assessment of Healthcare Providers and Systems (CAHPS)
- Focusing on Your Horizon and Braven Health Patients’ Experience: Tools to Help YouFocusing on Your Horizon and Braven Health Patients’ Experience: Tools to Help You
- Discussion Checklist for CAHPS and HOS SurveysDiscussion Checklist for CAHPS and HOS Surveys
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- Cultural CompetencyCultural Competency
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HEDIS ResourcesHEDIS Resources
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HEDIS Measure Guidelines for Behavioral Health ProvidersHEDIS Measure Guidelines for Behavioral Health Providers
- HEDIS Measure Guidelines for Behavioral Health Providers
- Follow-Up Care for Children Prescribed ADHD Medication (ADD)Follow-Up Care for Children Prescribed ADHD Medication (ADD)
- Antidepressant Medication Management (AMM)Antidepressant Medication Management (AMM)
- Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM)Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM)
- Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP)Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP)
- Follow-Up After Emergency Department Visit for Substance Use (FUA)Follow-Up After Emergency Department Visit for Substance Use (FUA)
- Follow-Up After Hospitalization for Mental Illness (FUH)Follow-Up After Hospitalization for Mental Illness (FUH)
- Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)
- Follow-Up After Emergency Department Visit for Mental Illness (FUM)Follow-Up After Emergency Department Visit for Mental Illness (FUM)
- Initiation and Engagement of Substance Use Disorder Dependence Treatment (IET)Initiation and Engagement of Substance Use Disorder Dependence Treatment (IET)
- Adherence to Antipsychotic Medications for Individuals with Schizophrenia (SAA)Adherence to Antipsychotic Medications for Individuals with Schizophrenia (SAA)
- Diabetes Screening for People with Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications (SSD)Diabetes Screening for People with Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications (SSD)
- Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia (SMC)Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia (SMC)
- Diabetes Monitoring for People with Diabetes and Schizophrenia (SMD)Diabetes Monitoring for People with Diabetes and Schizophrenia (SMD)
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HEDIS Measurement Year (MY) 2023 Provider Tips for Optimizing HEDIS ResultsHEDIS Measurement Year (MY) 2023 Provider Tips for Optimizing HEDIS Results
- HEDIS Measurement Year (MY) 2023 Provider Tips for Optimizing HEDIS Results
- Best Practices Overall for CodingBest Practices Overall for Coding
- Adherence to Antipsychotic Medications for Individuals With Schizophrenia (SAA)Adherence to Antipsychotic Medications for Individuals With Schizophrenia (SAA)
- Adult Immunization Status (AIS-E)Adult Immunization Status (AIS-E)
- Adults’ Access to Preventive/Ambulatory Health Services (AAP)Adults’ Access to Preventive/Ambulatory Health Services (AAP)
- Advanced Care Planning (ACP)Advanced Care Planning (ACP)
- Antibiotic Utilization for Respiratory Conditions (AXR)Antibiotic Utilization for Respiratory Conditions (AXR)
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