Blue Review March 2023
Keep your Demographic Data Updated with New Process
The information we maintain about you must be accurate, current and complete. You need to keep your information up-to-date with us.
Use our New Horizon Data Submission Template to Update Your Data
Effective March 1, 2023, begin using our new Horizon Data Submission Template. The template allows you to send us your updates and to meet the requirement to validate your data in our systems quarterly. As of April 1, 2023, we will no longer accept updates sent to the Enterprise PDM mailbox. This new process is a faster and timelier way to update your information.
- Practitioners and Group Practices
Submit all your changes using this new process, including network terminations, TIN changes and practice name changes.
You can continue to use the Provider Data Maintenance Tool on NaviNet for all changes except network terminations, TIN changes and practice name changes.
- Ancillary Providers
Use this new process to make updates to your phone, fax, email address(es) and billing information. All other changes can be made by contacting your Horizon Ancillary Contract Specialist by phone or emailing Ancillary_ProviderNetwork@HorizonBlue.com.
How to get started using the Horizon Data Submission Template
You will need to request a blank template to start the process of making changes to your data.
- Email a request for a blank template to autosubmission_@HorizonBlue.com
- The subject line should state Requesting Practitioner Template or Requesting Ancillary Template
You will receive a complete instruction guide on how to fill out and send us your completed template.
Review important details on Demographic Updates.
Call Provider Services at 1-800-624-1110, weekdays, 8 a.m. to 5 p.m., Eastern Time (ET). Behavioral health providers can also email BHNetworkRelations@HorizonBlue.com. Please include your name, NPI and county.
View our Provider Directory Management administrative policy to learn more about how we ensure our provider files are accurate.
Thank you for your help in providing our members with accurate information about our networks.
- Practitioners and Group Practices
Share Race and Ethnicity Information to Help Patients Find the Right Care
Health disparities throughout our health care system disproportionately impact the marginalized communities we serve. We are taking a multifaceted approach to reduce these disparities. One step includes collecting provider race and ethnicity data.
Did you know when a member chooses a health provider that shares the same race and ethnicity, it can help build a strong doctor-patient relationship? This helps the patient feel comfortable speaking up during visits and fosters mutual trust and patient engagement.
That's why we are asking you to update your demographic information in your provider profile to show your race and ethnicity. This information appears in our Doctor and Hospital Finder to help members find a health care professional who's right for them. It also helps us ensure our network meets the diverse cultural needs of our members and helps us address any access issues.
We encourage you to update your demographic information as soon as possible using our Provider Data Maintenance Tool or new Horizon Data Submission Template.
The ultimate goal is to achieve the best outcomes for everyone, regardless of race or ethnicity. However, until the gaps are narrowed, collecting this information is just one of the many steps needed to address health inequities our members face.
Improve Patient Care and Outcomes with Correct Coding and Documentation
You play a vital role in your patients' health when you code and document accurately. Entering correct codes and thorough notes helps us identify high-risk patients and better manage the care of patients with chronic conditions. Once we identify these patients, we can get them into disease and case management programs and preventive health initiatives. But we need your help to do that.
Plus, there's a bonus — proper coding and documentation also saves your office from unnecessary administrative tasks and claim payment delays.
Know What Should Be Coded and Documented
You must code for any condition that is MEAT: Monitored, Evaluated, Assessed and/or Treated during a patient's visit. Don't just document a condition in a problem list, or in the history or physical exam. Conditions must be listed on the assessment/plan and reported on the claim to accurately capture and code.
Here are important tips on documenting conditions:
- A condition only exists when it's documented.
- Diagnoses do not carry over from visit to visit or year to year.
- A condition can be coded and reported as many times as a patient receives care and treatment for the condition.
- Do not code for conditions that were previously treated and no longer exist.
- Conditions can be coded when documentation states condition is being monitored and treated by a specialist.
- For example: “Patient on Coumadin for atrial fibrillation; followed by Dr. Hill, cardiologist.”
- Co-existing conditions can be coded when documentation states that the conditions affect the care, treatment or management of the patient.
- Document and code status conditions at least once a year.
- Examples: Transplant status, amputation status, dialysis status, chemotherapy status or artificial opening status/maintenance.
- Do not code unconfirmed diagnoses.
- Examples: probable, possible, suspected, working diagnosis.
- Do not use arrows or symbols alone to indicate a diagnosis.
- Be sure the diagnoses codes billed are consistent with medical record documentation.
All medical records should have the following:
- Support a face-to-face or telemedicine encounter with the patient.
- Be complete and precise and reflect the diagnoses, scope of care and services provided.
- Include encounters completed by an acceptable physician or other health care professional (e.g., physicians, certified physician assistants, nurse practitioners).
- Be clear and legible, with the patient's name and date of the encounter appearing on all pages.
- Resemble the SOAP format: Subjective, Objective, Assessment, and Plan.
- Include the physician or other health care professional's credentials, with all appropriate signatures.
- Include the professional's signature date, which cannot be over 30 days from the patient encounter.
- Contain a signed discharge summary report that includes both an admission and discharge date (for hospital inpatient medical records).
- A condition only exists when it's documented.
Important Reminders about Medical Record Requests and Retention
We review medical records to determine whether a member's condition has been monitored, evaluated, assessed, and/or treated at any time during the year. Some quality programs, like Medicare Stars and HEDIS®, require medical records to evaluate a provider's performance in quality as well as service.
You must adhere to our standards and obligations regarding medical record retention. Failure to comply with a request for medical records and or additional documentation can result in termination from our network(s).
In support of these activities, your office may have received or will receive medical records requests from our contracted vendor, Inovalon. We thank you for your cooperation with Inovalon by sending records or allowing us to retrieve them from your office.
Your response is required for medical documentation requests
According to your Provider Agreement(s), you agree:
- That Horizon and its affiliates and designees have the right to review any and all documents, books and records, including but not limited to medical records, maintained by you in connection with services you provided.
- To provide copies of these materials, in the manner and within the time frame requested.
We do not provide reimbursement for medical record copies, postage and/or for any other miscellaneous costs associated with the retrieval of medical records.
Please keep the following information in mind as you manage and maintain patient medical records:
Patient Population Medical Record Retention Requirement Braven Health
Medicare Advantage (MA) Members
Physicians and other health care professionals
- Maintain medical records for a minimum of 10 years.
All Other (non-MA) Members Physicians and other health care professionals
- Retain records for seven years from the date of the most recent entry.
- Discharge summary sheets: retain for 20 years after discharge.
- For adult patients: retain records for 10 years following the most recent discharge.
- For minor patients: retain records for 10 years following the most recent discharge, or until the patient is age 23 years, whichever is longer.
Receive and Send Documents Electronically with HorizonDocs
If you're a professional provider, we encourage you to use HorizonDocs. This web-based, centralized document repository allows Horizon to securely request documentation from you and 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:
- 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 can 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.
- Emails 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 HorizonDocs
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 NaviNet and select Horizon BCBSNJ or Horizon NJ Health from the My Health Plans menu. Then, click HorizonDocs within the Workflows for this Plan section.
Visit our HorizonDocs webpage for more information.
Returning Outstanding Credit Balances
You can return any improper or excess claim reimbursement amounts from patient billing or claims processing with our Credit Balance Adjustment Request Form. Use the form to report all credit balances outstanding for 30 days or more.
Submit completed forms and relevant documentation (i.e., previous adjustment requests, payment vouchers, correspondence, etc.) to Schaheda Fisher:
Schaheda Fischer, PP-12P
3 Penn Plaza East
Newark, NJ 07105-0420
Recredentialing Required for Most Hospital-Based Practitioners
All participating Horizon and Horizon NJ Health hospital-based physicians and other health care professionals — except Radiologists, Anesthesiologists, Pathologists, and Emergency Room Physicians — must be recredentialed every three years.
Please review our Credentialing and Recredentialing Policy for Participating Physicians and Health Care Professionals administrative policy. If you fail to meet any of the standards, you will be subject to loss or restriction of network participation and termination of your agreement.
How to get recredentialed with Horizon:
- CAQH ProView
We encourage you to use CAQH ProView, a valuable credentialing and recredentialing resource.
- If you're already registered with CAQH, please review and/or update your information and then re-attest that your information is true, accurate and complete.
- If you're not registered with CAQH, please register. After registration, complete an online application and then attest that the information provided is true, accurate and complete.
- New Jersey Universal Recredentialing Application Form
If you are unable to use CAQH ProView, complete a copy of the NJ Physician Recredentialing Application Form available at New Jersey Department of Banking and Insurance.
Thank you for your cooperation with Andros, the business partner who works with us to help manage our recredentialing responsibilities, when they reach out to you.
- CAQH ProView
Doula Services Practitioners are Invited to Join Our Managed Care Network
We encourage Doula Services Practitioners to submit an application to be considered for participation in our Horizon Managed Care Network. Participation in our Horizon Managed Care Network allows doulas to treat eligible patients enrolled in certain Horizon managed care plans at an in-network level of benefits.
Doulas may participate in our Horizon Managed Care Network if their primary office address is in New Jersey or one of the following counties in New York, Pennsylvania or Delaware:
- NY: Bronx, Kings, Nassau, New York, Orange, Putnam, Queens, Richmond, Rockland, Suffolk or Westchester counties
- PA: Bucks, Chester, Delaware, Lehigh, Monroe, Montgomery, Northampton, Philadelphia or Pike counties
- DE: Kent, New Castle or Sussex counties
Visit our Doula Services Practitioners webpage for more information and instructions.
Horizon Introduces Local Support to Close Member Care Gaps
To encourage eligible members to take advantage of certain preventive measures necessary to maintain their best health, beginning on March 13, 2023 Horizon will collaborate with Walgreens to provide convenient, local support for a select group of 4,000 qualified Horizon NJ TotalCare (HMO D-SNP) members and 13,000 Individual plan members who are experiencing gaps in care.
Your patients who are part of the targeted pilot population will have access to certain health services at a local Walgreens Health Corner. These services will be completed by a Health Advisor who is a Registered Nurse or Clinical Pharmacist.
Services available to these members include:
- At-home colorectal cancer and diabetes screening kits
- HbA1c control
- Annual flu vaccine
- Blood pressure measured
These services are also available to eligible DSNP members only:
- Functional assessment survey: Monitoring physical activity
- Fall risk assessment survey: Reducing risk of falling
- Older adult care: medication review
- Older adult care: pain assessment
The Walgreens Health Advisor will advise your patients to call you to schedule their annual visits, screenings and follow ups and may contact your office to help set up those appointments. In addition, Walgreens Health will provide you with an after-visit summary and test results for participating members seen in one of their Health Corners.
Member of Walgreens Boots Alliance ©2021 Walgreen Co. All rights reserved.
Walgreens is independent from and not affiliated with Horizon Blue Cross Blue Shield of New Jersey.
Get Ready for the CAHPS Survey
The CAHPS Survey is coming, and here are some fast facts on how it impacts members, patients, physicians and care staff.
Fast Facts on the Consumer Assessment of Healthcare Providers and Systems Survey:
- CAHPS is a mandated survey administered by Centers of Medicare and Medicaid Services (CMS) and is an integral part of CMS' efforts to improve health care in the U.S.
- The surveys contain 68 questions and measures a member's perception of the care they received from primary care providers and specialists.
- CMS sends the CAHPS survey to a random sample of health plan members annually from March to June.
- The survey will be sent to members who have Braven Medicare PPO (Freedom and Choice) and Horizon NJ TotalCare (HMO D-SNP) plans.
- Medicare uses this information to give an overall performance Star Rating to Medicare health and prescription drug plans. CAHPS accounts for nine measures within the overall Stars ratings and over half of the survey questions ask about the member's interactions with providers.
- Star Ratings are released annually and reflect the experiences and health outcomes of people enrolled in Medicare Advantage and Part D prescription drug plans.
Fast facts on measuring patient experience:
- Patient experience includes the range of interactions that patients have with the health care system. This includes care from physicians, nurses, support staff, their health care plan and other health care facilities.
- Patient experience is an important component of health care quality. It includes several aspects of health care delivery that patients value highly when they seek and receive care, such as getting timely appointments, easy access to information, and good communication with health care providers.
- The more patient-centric a practice becomes, the better the quality of the patient experience will be realized. In addition, this will help primary care providers attract/retain and create loyal patients.
- Research shows that better patient experiences with their healthcare translates into better adherence to medical advice and treatment plans. Moreover, it can help reveal problems and gaps in communication that can have broad impact on clinical quality, safety and efficiency.
For key tips and best practices on how to improve the patient experience for Medicare members with Braven and Horizon NJ TotalCare (HMO D-SNP) plans, review our Playbook for Patient Engagement, for Braven and Horizon NJ TotalCare (HMO D-SNP) plans. .
NCQA HEDIS Behavioral Health Follow-Up Measures:
Mental illness and/or substance use may emerge at any time of life with symptoms including behavior disruptions, interpersonal struggles, suicidal-ideation, self-harm, overdose and severe depression. The National Committee for Quality Assurance (NCQA) emphasizes providing follow-up care to patients after emergency department visits or inpatient/high-intensity admissions for mental health or substance improves patient outcomes, decreases the likelihood of re-hospitalization, decreases relapse risk and reduces overall cost of care.
- Follow-up after hospitalization for Mental Illness (FUH): percentage of inpatient discharges with a diagnosis of mental illness or intentional self-harm among patients age 6 + that resulted in follow-up care with a mental health provider within 7 days or within 30 days.
- Follow-up after ER visit for Mental Illness (FUM): percentage of ER discharges with a diagnosis of mental illness or intentional self-harm among patients age 6 + that resulted in follow-up care with a mental health provider within 7 days or within 30 days.
- Follow-up after hospitalization for Substance Use (FUA): percentage of inpatient discharges with a diagnosis of substance use among patients age 13 + that resulted in follow-up care with a provider within 7 days or within 30 days.
- Follow-up after high-intensity treatment for Substance Use (FUI): percentage of high intensity discharges with a diagnosis of substance use among patients age 13 + that resulted in follow-up care with a provider within 7 days or within 30 days.
Best practice suggestions
- Provide education on importance of follow-up within seven or 30 days from discharge, medication compliance and side-effects
- Coordinate care with patient's treatment team
- Maintain appointment availability, outreach patients who missed appointments
- Discuss safety planning and crisis/relapse intervention for the patient
Horizon's Behavioral Health HEDIS Team is available to assist providers and may be contacted by email at BH_Hedisteam@horizonblue.com.
Register for Risk Adjustment Webinars
Horizon, in collaboration with Pulse 8, offers a variety of free monthly webinars for our participating Horizon provider groups. Each webinar includes a high-level overview of Risk Adjustment (RA), Hierarchical Condition Categories (HCCs), and the role of the Provider and Support Personnel.
For more information, please email RiskAdjustment@HorizonBlue.com.
Review Appointment Availability Access Standards
Providing the right care at the right time is important to your patients. We maintain appointment availability access standards for Primary Care Physicians (PCPs), obstetricians and gynecologists (Ob/Gyns), specialists and behavioral health care professionals to help ensure that our members receive care when they need it.
These standards should be kept 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.
This information, in addition to being available on our Administrative Policies page, may also be reviewed within our Participating Physician and Other Health Care Professional Office Manual.Access standard information is also made available to our members.
Behavioral Health Programs to Support your Patients' Needs
Millions of Americans are dealing with behavioral health issues and the challenge of finding the appropriate care to address their needs. If you have identified a patient that needs support, our dedicated Horizon Behavioral Health℠ team is here to help. We are available 24/7 to help your eligible patients with questions about behavioral health benefits, provider access, program support and services.
Helping your patient access care
In addition to access to our behavioral health provider network, members' benefits may also include access to additional support programs and treatment options for mental health and Substance Use Disorder (SUD) treatment, including:
- Integrated System of Care (ISC) program
The first of its kind in New Jersey, ourISC program uses a virtually integrated care delivery system to provide timely, coordinated and outcome-driven care to your eligible patients with serious mental illness (SMI) and SUD. A behavioral health provider who participates in the ISC program will assign eligible Horizon members a care coordinator.
- Peer Support program
Peer Support is non-clinical help provided by trained professionals who use their personal recovery experiences to connect your eligible patients to treatment and other resources. Peers in the program are supervised by licensed clinicians and can aid members in their recovery from a wide range of conditions, including mental health conditions and SUD.
You can inform your patients that they can self-refer by contacting a Peer Support provider directly or you can refer your patient directly. View a listing of available programs on HorizonBlue.com/peer-support.
Contacting our Behavioral Health team
If you or your eligible patients have questions about behavioral health member benefits and/or program support and services, call 1-800-626-2212, 24 hours a day, seven days a week.
Claim Information for Braven Health℠ Audiology/Hearing Aid Benefits
HearUSA manages the audiology and hearing aid services provided to your patients enrolled in Braven Health Medicare Advantage plans.
For Braven Health Medicare Advantage plans, HearUSA:
- Is the exclusive in-network provider for annual routine hearing exams, fittings/evaluations for hearing aids and hearing aids.
- Will administer the benefits for audiology services and hearing aids.
- Will process claims on our behalf for Braven Health Medicare Advantage plans.
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.
Check Member Out-of-Pocket Cost Share and Prior Authorization Requirements Online
You no longer need to call us to get eligibility, cost-share estimates and to see if the service requires prior authorization for your patients with a member ID number that includes 3HZN. You can easily access this information with our Eligibility and Benefits Cost Share Estimator.
This self-service solution gives you the information you need at the diagnosis and CPT/Revenue code level, plus a reference number.
To get started using the tool, log on to NaviNet and click the Cost Share Estimator icon on the Horizon BCBSNJ Plan Central page or highlight Eligibility and Benefits under the workflow menu and click on the Cost Share Estimator drop down.
Join one of our educational webinars to learn how easy it is to use our online Eligibility and Benefits Cost Share Estimator.
If you can't make one of our scheduled webinars, contact your Network Specialist or your Hospital Relations Representative to schedule a training session for your staff.
Get Free CME Credits — Register for Webinar on Implicit Bias and Learn How It May Impact Your Patients
Register Today: Horizon and Rutgers Biomedical and Health Sciences present: Understanding and Addressing Implicit Bias
Join an interactive discussion about recognizing implicit bias and how it may impact patient care and safety. This free webinar will use real-life examples to show where there is bias and empowers you to improve patient relationships and outcomes. You'll hear how most people don't realize bias occurs and how you can have certain attitudes toward people or stereotypes without realizing it.
- Date: Wednesday, April 5, 2023
- Time: Noon to 2 p.m.
- Via Zoom: Registration is required. Please register by April 3, 2023.
We are committed to working with you to end health care disparities and make sure patients get the care they need. Through Our Pledge, we continue to address health care disparities related to race and other social barriers our members face in accessing care.