Blue Review September 2021
Confirm member benefits using our Eligibility and Benefits Cost Share Estimator
Our Eligibility and Benefits Cost Share Estimator on NaviNet® gives you access to medical and behavioral health claim-level member eligibility, benefits and out-of-pocket costs. This tool provides you with information for your patients enrolled in our Commercial and Medicare Advantage (including Braven℠ Health) plans with a member ID number that includes “3HZN.”
With this tool and our other online resources, you no longer need to contact Provider Services or rely on printed member ID cards to confirm your patient’s eligibility and benefit information. 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.
Visit the Eligibility and Benefits Cost Share Estimator page for more in-depth details, including how to access and use the tool.
Prostate cancer clinical trials are available for your eligible patients
The health and wellness of our members and the communities we serve is important to us. That’s why we have partnered with the National Cancer Institute’s (NCI’s) Center for Cancer Research (CCR), part of the National Institutes of Health (NIH), to make it easier for you and your patients to find clinical trial opportunities that offer access to advanced cancer therapies.
Please review the information available about CCR’s prostate cancer clinical trials and share the resources with your patients who have been diagnosed with prostate cancer.
We are not affiliated, associated, endorsed by, or in any way officially connected to the National Cancer Institute’s (NCI’s) Center for Cancer Research, or any of its subsidiaries and affiliates.
Add or update your office email address(es) on our Provider Data Maintenance Tool
Our new Provider Data Maintenance Tool makes it easy to update important practice information that we display to our members. It also gives the ability to provide us with email addresses for key office contacts. NaviNet® Security Officers can also:
- Update phone and fax numbers
- Update location contact information, including email address
- Manage practice limitations
- Manage areas of expertise for behavioral health services
- Indicate if you offer telemedicine services
- Provide information about your race/ethnicity
Having the most current and accurate information in our Doctor & Hospital Finder helps our members find you, learn about your practice and get the care they need. Our new Data Maintenance Tool makes it easy for you to change the information we display to our members
NaviNet Security Officer can sign in to NaviNet to access the Data Maintenance Tool through the Horizon BCBSNJ Plan Central page. If you don’t have access to NaviNet, you can sign up for free with your Federal Tax ID.
Antibody testing: FDA and CDC do not recommend use to determine COVID-19 immunity
The FDA and CDC have issued guidance related to the appropriate use of COVID-19 antibody testing. Most recently, the FDA highlighted that antibody testing should not be used to determine immunity or protection against COVID-19 at any time, and especially after a person has received a COVID-19 vaccination.
Hospital and rehab facility discharge: What your patients need to know
Please be sure to tell your patients the following information when returning home after a hospital or rehabilitation inpatient stay:
A Case Manager will call them when they return home from a hospital or rehabilitation inpatient admission to make sure they have the correct medications and understand how to take them.
The Case Manager will also schedule a follow up appointment with their medical provider and answer questions. They should see their physician, in person or via telehealth, within seven days to help reduce risk of readmission.
If the stay was a result of an Emergency Room visit, they should call their medical provider and request a follow-up appointment within 30 days. This is for follow-up medical management and to prevent additional medical emergencies.
Horizon Health Guide: What to know
Members enrolled in certain National Accounts and the State Health Benefits Program (SHBP) and the School Employees’ Health Benefits Program (SEHBP) now have exclusive access to a? Horizon Health Guide, a customer service experience designed especially for those members. Over 600,000 of our members now speak to a Horizon Health Guide when they call for help.
Horizon Health Guides are single points of contact who:
- Advise members on how to get the most from their health plan benefits
- Help members manage a chronic or complex medical or behavioral health condition
- Schedule doctor’s appointments when requested
- Connect members to virtual doctor visits or on-the-spot nurse advice, 24/7/365
Horizon Health Guide is another way we collaborate with you to help our members, your patients, achieve their best health.
HEDIS: Initiation and engagement of Alcohol and Other Drug Abuse or Dependence Treatment (IET) measure
Early identification and treatment of alcohol or other drug (AOD) abuse or dependence is essential to avoid future substance-related illness and death, and can significantly improve patients’ quality of life.
In fact, included in the HEDIS (Healthcare Effectiveness Data and Information Set) performance measures developed by the National Committee for Quality Assurance (NCQA) is Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment or IET. IET measures the percentage of adolescent and adult members with a NEW episode of AOD abuse or dependence who received the following:
- Initiation of AOD Treatment: The percentage of members who initiate treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization, telehealth or medication treatment within 14 days of the diagnosis.
- Engagement of AOD Treatment: The percentage of members who initiated treatment and who were engaged in ongoing AOD treatment within 34 days of the initiation visit.
How you can improve patient engagement:
- Screen regularly for alcohol and drug misuse (e.g. DAST, CAGE, AUDIT)
- Discuss the importance of timely follow-up visits, schedule follow-up appointments before the patient leaves the office and/or outreach to those who cancel appointments to reschedule
- Coordinate care with all treating providers
- Refer patients to culturally appropriate treatment, which focuses on co-occurring issues such as mental health, trauma, eating disorders, etc.
- Consider referring your patients to Horizon’s Behavioral Health Case Management Program
- Discuss barriers to follow-up care
- Use motivational interviewing to help patient resistance to treatment
- Consider evidence-based treatment. For example, the Substance Abuse and Mental Health Service Administration (SAMHSA) has implemented SBIRT (Screening, Brief Intervention and Referral to Treatment). SBIRT is a reimbursable, evidence-based prevention and early intervention initiative.
Our Behavioral Health HEDIS Team is available to assist providers with meeting performance goals. Contact our Clinical Quality Improvement Liaisons (CQILs) for help by emailing BH_Hedisteam@Horizonblue.com.
Returning Outstanding Credit Balances
The Credit Balance Adjustment Request Form allows your facility to return any improper or additional claim reimbursements from patient billing or claims processing to us. All credit balances outstanding for 30 days or more should be reported using the Credit Balance Adjustment Request Form.
Ensure you are using the most current version of the form.
You must submit copies of payment vouchers, hospital bills and any other pertinent information with your completed Credit Balance Adjustment Request Form either by fax to 1-973-274-2336 or mail to:
PO Box 420
Newark, NJ 07101-0420
Managing medical record requests
You are often required to fulfill medical record requests throughout the year.
We are committed to supporting you, especially with HEDIS® medical record requests. You will be receiving a short survey from Survey Monkey about HEDIS medical record requests. Completing this survey can help prepare you for the next HEDIS season.
Cognitive assessment: resources for providers
Do you have a patient with a cognitive impairment? Medicare covers a separate visit for a cognitive assessment so you can more thoroughly evaluate cognitive function and help with care planning.
The Cognitive Assessment & Care Plan Services (CPT® code 99483) typically start with a 50-minute face-to-face visit that includes a detailed history and patient exam, resulting in a written care plan.
As of January 1, 2021, Medicare increased the payment for these services to $282 (may be geographically adjusted) when provided in an office setting, added these services to the definition of primary care services in the Medicare Shared Savings Program, and permanently covers these services via telehealth.
- Visit the Cognitive Assessment & Care Plan Services page on the CMS website.
- Visit the Aging’s Alzheimer’s and Dementia Resources for Professionals page on the NIH website.
Change Healthcare Medical record review reminder
Horizon will collaborate with Change Healthcare LLC (CHC) to review medical charts and claims for services that use selected drugs and modifier JW for drug usage. This helps Horizon evaluate and validate the integrity of medical claims that have been submitted for billing and reimbursement.
CHC will request medical documentation for your patients selected for review by mail. All documentation requested must be sent directly to CHC and must include the drug Medication Administration report to be considered a complete medical record.
Documentation can be sent to CHC secure email at CHC_MR@changehealthcare.com or fax it to 1-952-236-1332.
You may also mail the documentation to:
1849 West Drake Drive, Suite 101
Tempe, AZ 85283
Improving your patients access to care
Our appointment availability access standards for Primary Care Physicians (PCPs), obstetricians and gynecologists (Ob/Gyns), specialists and behavioral health care professionals help ensure that our members receive care when they need it.
Our goal is for 90% of members to have access to timely appointments based on the clinical urgency of their physical and/or behavioral health needs. The results of our 2020 appointment availability survey for commercial plans identified opportunities for improvement in a number of areas, including the following standards that fell below the targeted goal:
|2020 Appointment Availability Survey: PCP|
|Type of Care||Access Standard||Results|
|Urgent Care||An appointment within 24 hours||83% of PCPs met the standard|
|After-Hours Care||Respond to urgent or emergent calls within 30 minutes||85% of PCPs met the standard|
|2020 Appointment Availability Survey Ob/Gyns|
|Type of Care||Access Standard||Results|
|Routine Care||An appointment within two weeks||80% of Ob/Gyn met standard|
|Urgent Care||An appointment within 24 hours||70% of Ob/Gyn met standard|
|After-Hours Care||Respond to urgent or emergent calls within 30 minutes||83% of Ob/Gyn met standard|
|Office Waiting Time||Shall not exceed 30 minutes from appointment time||89% of Ob/Gyn met standard|
|2020 Appointment Availability Survey: Specialist|
|Type of Care||Specialist Access Standard||Results|
|Routine Care||An appointment within three weeks||82% of specialists met standard|
|Urgent Care||An appointment within 24 hours||72% of specialists met standard|
|Emergency Care||Response within one hour or direct member to the ER||88% of specialists met standard|
|After-Hours Care||Respond to urgent or emergent calls within 30 minutes||68% of specialists met standard|
|Office Waiting Time||Shall not exceed 30 minutes from appointment time||88% of specialists met standard|
|2020 Appointment Availability Survey: Behavioral Health Practitioners|
|Type of Care||Standard||Prescriber Results||Non Prescriber Results||2020 Overall Survey Result||2020 Goal Met 90%|
|Routine Care||Appointment not to exceed 10 business days||62%||79%||78%||No|
|Urgent Care||Appointment within 48 hours||71%||73%||73%||No|
|Non-Life Threatening Emergent Care||Appointment within six hours of the request or refer patient to another participating practitioner, clinic or hospital emergency room||71%||63%||64%||No|
Please 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.
Further details on these standards are available on our Administrative Policies page, and may also be reviewed within our Participating Physician and Other Health Care Professional Office Manual. Access Standard information is also made available online to our members.
eviCore Prior Authorizations
Horizon works with eviCore healthcare to manage Prior Authorizations/Medical Necessity Determinations (PA/MND) services for our members. Please review the suggestions below to help ensure that the PA/MND process goes smoothly.
When submitting PA/MND requests to eviCore:
- Request the procedure no later than 48 hours from the patient’s exam. Waiting may cause delays in care and patient dissatisfaction.
- Prepare for the PA request. Have all patient records readily available when you initiate the case. If required medical information is missing, the case will go to medical review delaying the determination.
- Review our Medical Information Requirements for Programs Administered by eviCore documentation for more details.
- If you are forwarding the PA requests to a radiology vendor, please be sure to provide the required medical information as soon as possible following the patient’s office visit to avoid delays or possible denials for lack of clinical information.
Read more about eviCore healthcare for more information and details about these programs.
If you have questions about the programs managed by eviCore healthcare, please contact your Network Specialist.
Attend a Horizon educational webinar
There are a variety of educational webinars available to participating physicians, health care professionals and their office staff. These sessions feature information about our products, policies and procedures, initiatives and online tools.
Our goal is to provide sessions that reflect the current educational needs of our network and to address your questions. Each session will include an opportunity for an interactive Q&A with the presenter, time permitting.
Behavioral Health webinars
If you are a Behavioral Health practitioner or work for a behavioral health practice, you are also encouraged to take advantage of our behavioral health-specific educational webinars. Visit our Horizon Behavioral Health℠ webpage and click the Training Schedule link under “Upcoming Trainings”.
New resources to help you promote preventive care and screenings