Blue Review September 2023

News and Updates

• Self-service Coming November 1, 2023

  We know how important your time is. That's why we have a variety of self-service tools and resources that can help you save time without having to pick up the phone.

  As of November 1, 2023, Provider Services representatives will no longer be available for issues that can be resolved via Horizon's self-service tools. Instead, you can use one of several tools to find the information you need online including:

  • Member eligibility and enrollment
  • Claims status and payment status
  • Expected patient costs (preservice)
  • Updating your information in Horizon's systems
  • Online credentialing (coming soon)
    
    

  This applies for both Horizon BCBSNJ and Braven Health℠.

  You can find more information on our self-service tools, including how to access them on our resource guide.

  You can continue to speak to a representative if you have a question about the information provided by the self-service tool or if a self-service option is not available.

  Please let your billing agencies know about this change.

• Provider Services Call Center New Business Hours

  We recently announced that effective September 1, 2023 our Provider Services customer service hours on Fridays changed to 9 a.m. to 5 p.m., Eastern Time (ET). There is no change to our customer service hours on Monday through Thursday, which are 8 a.m. to 5 p.m., ET.

  To get your questions answered, we encourage you to use our automated phone system or our provider self-service tools for quick and convenient access.

• New Provider Portal: Availity Essentials Coming Soon

  We have chosen Availity Essentials as our new secure provider portal to replace NaviNet. Availity Essentials will be available to all Horizon and Braven Health℠ providers in spring 2024. The switch to Availity Essentials will happen in phases to ensure a smooth transition. You can continue to use NaviNet throughout the transition, into 2024. You will be able to use Availity Essentials for your Horizon and Braven Health℠ members.

• eviCore Reminders to Radiology Imaging Sites

  Horizon has partnered with eviCore healthcare to administer our Radiology and Imaging Services program. Below are reminders for Horizon and Braven Health&$8480; practices and providers that work with eviCore as part of this program.

  Notify eviCore of changes

  To minimize prior authorization denials and subsequent delays in patient care and claim payment, in-network Free Standing Radiology/Imaging Centers should email eviCore at credentialing@evicore.com to notify them of:

  • Changes in ownership and TINs
  • New site locations
  • Site closures
  • Additional equipment or modalities
  • Updated licenses and accreditations

  Upcoming site assessments

  It is imperative that sites respond to eviCore's appointment outreaches for scheduling their site assessments in a timely manner to ensure compliance with our standards.

  For more details, please review our Standards for All Types of Medical and Dental Diagnostic Radiology and Imaging Facilities administrative policy.

• Accureference Laboratory Out of Network

  Accureference Laboratory is out of network for all Horizon and Braven Health℠ members.

  We appreciate that you support our efforts to direct all laboratory services to a preferred our networks. These networks include national laboratories, and serve our members in the lines of business listed in the table below.

  Labcorp	Quest Diagnostics	BioReference Laboratories
  Commercial Managed Care Commercial Traditional/PPO Braven Health (Managed Care/ Medicare Advantage)	Commercial Managed Care Commercial Traditional/PPO Braven Health (Managed Care/ Medicare Advantage)	Commercial Traditional/PPO

  Please direct our members, or their lab samples, to our preferred laboratory network as shown in the chart above.

  You may contact your Network Specialist with any questions.

  Note: Pathology services provided in a hospital setting to members enrolled in Horizon managed care plans by a practice that participates in the Horizon Managed Care Network are allowed as an exception to the above-described LabCorp/Quest Diagnostics network use requirements.

  Labcorp is the commonly used name for Laboratory Corporation of America Holdings®. Laboratory Corporation of America® is a registered mark of Laboratory Corporation of America Holdings. Quest Diagnostics® is a registered mark of Quest Diagnostics. The laboratories referenced herein are independent from and not affiliated with Horizon Blue Cross Blue Shield of New Jersey or its companies.

• Biosimilars for Humira® Now Covered for Patients With Horizon Pharmacy Coverage

  Effective July 1, 2023, Horizon covers the following biosimilar medicines for Humira — one of the highest-utilized specialty medicines — based on its formulary. Like Humira, the same utilization management rules apply to these biosimilars.

  The chart below shows which biosimilars are now covered for patients with Commercial pharmacy coverage:

  Commercial Formulary	Biosimilar on Formulary	Tier
  Net Results A	Amjevita™ and Cyltezo®	Tier 2
  Net Results F	Amjevita and Hadlima™	Tier 2
  Classic (Public and Labor)	Amjevita and Hadlima	Tier 2
  Classic	Amjevita and Hadlima	Tier 2
  HIM 2023	Amjevita and Hadlima	Tier 2

  For members with Braven Health℠ pharmacy coverage, Cyltezo is Tier 5.

  How This Impacts Covered Members Who Take Humira

  Humira will continue to be covered at the same coverage tier as the above-mentioned biosimilar products. If your Horizon or Braven Health patient already has a prior authorization for Humira on file and is looking to switch to a biosimilar, you will not need to submit a new clinical review.

  Savings cards or coupons and patient-assistant programs may be available to members who are prescribed one of the biosimilar medicines listed above. Members should visit the manufacturer websites for more information.

  For more information about your patients' pharmacy coverage, sign in to NaviNet.

  This page contains brand name medicines that are registered marks or trademarks of pharmaceutical manufacturers that are not affiliated with Horizon Blue Cross Blue Shield of New Jersey or the Blue Cross Blue Shield Association.

• Free Training: A Physician's Practical Guide to Culturally Competent Care

  A Physician's Practical Guide to Culturally Competent Care is a self-directed training course designed for physicians, physician assistants and nurse practitioners.

  With growing concerns about racial and ethnic disparities in health and about the need for health care systems to accommodate increasingly diverse patient populations, cultural competence has become a matter of national concern.

• Conflict Management and Verbal De-escalation – Helpful Hints

  As health care professionals, it's important to recognize the link between providing patients a high level of care and conflict management skills. How you respond to a patient when they are upset and angry is a critical element to the services that you have promised to offer. Providing a high level of care should be a continuous experience including when patients feel things are not going according to their perceived plan and are not medically appropriate for them.

  Conflict management at its core is about communication to lessen or de-escalate a tense situation. De-escalation is the way in which you bring the temperature of the conversation down. Once you're able to communicate more calmly, you can better support and allow members to communicate their needs so that you can appropriately respond. One helpful technique was developed by The Elections Group to assist election workers to de-escalate tense situations. An easy way to remember this technique is with the acronym, “T.V. RAIN”:

  Tone + Volume + Rate of speech + Inflection = Vocal De-Escalation

  Tone is the way we choose to speak where our voices reflect the meaning of our words. Monitoring our tone is a demonstration that we understand the member's frustration and that we want to help them fix the problem.

  • Speak calmly to demonstrate empathy.
    
    

  Volume is our ability to monitor the strength, intensity, pressure and power of the sound of our voices. It is not shouting over the member to be heard.

  • Monitor your volume and avoid raising your voice.
    
    

  Rate of Speech is simply choosing how fast we are speaking. Often when we are upset we speak more rapidly. Intentionally slowing our rate of speech can assist the member to regulate their emotions and help them understand what we are saying.

  • Speak slowly – though not too slowly – because it is soothing.
    
    

  Inflection is how we choose to adjust the tone in our voices. Much of our communication style is in inflection alone. A rising inflection at the end of a sentence makes it a question. However, in the same way that we can detect questions we can detect inflection changes that communicate indifference, frustration, or even anger.

  • Be aware of emphasizing words or syllables as that can negatively affect the situation.
    
    

  Verbal communication

  Remain respectful and courteous. Address the individual with civility and use phrases such as “please” and “thank you.”

  Instead of:	Try:
  “Calm down.”	“I can see that you are upset…”
  “I can't help you.”	“I want to help you. What can I do?”
  “I know how you feel.”	“I understand that you feel…”
  “Come with me.”	“May I speak with you?”

Behavioral Health Information

• Horizon No Longer Using Quartet Health Services for Members

  We recently announced that as of September 1, 2023, we stopped using Quartet Health Services to assist us with bridging the gap between physical health practices and behavioral health resources.

  We are committed to expanding the resources that medical providers can access to help meet their patients' behavioral health needs.

  If you have any questions or have a patient who needs behavioral health resources, please call:

  • Horizon members - 1-800-626-2212
  • Braven Health℠ members - 1-888-444-0422

• Improve Outcomes for Patients with Substance Use Disorder

  More than 20 million Americans over 12 years old have Substance Use Disorder (SUD), according to the National Committee for Quality Assurance (NCQA). To treat SUD successfully, it's important to identify it early and include counseling or other behavioral therapies shown to reduce morbidity and mortality, improve health, productivity, social outcomes and reduce health care spending.

  The HEDIS measure: Initiation and Engagement of Substance Use Disorder Treatment (IET) measures the percentage of new SUD episodes for members age 13 years and older that result in treatment initiation and engagement. In order to meet compliance the following rates must be reported:

  • Initiation of SUD Treatment: The percentage of new SUD episodes that result in treatment initiation through an inpatient SUD admission, outpatient visit, intensive outpatient encounter, partial hospitalization, telehealth visit or medication treatment within 14 days.
  • Engagement of SUD Treatment: The percentage of new SUD episodes that have evidence of treatment engagement within 34 days of the initiation visit.
    
    

  Strategies to improve patient engagement:

  • Discuss the importance of timely follow-up visits, schedule follow-up appointments before the member leaves the office and/or reach out to members who cancel appointments to reschedule.
  • Consider telemedicine visits when in-person visits are not available.
  • Screen members regularly for alcohol and drug abuse (e.g., Drug Abuse Screen Test (DAST); Cutting down, Annoyance by criticism, Guilty feeling and Eye-openers (CAGE) Questionnaire, Alcohol Use Disorders Identification Test (AUDIT)).
  • Coordinate care with the patient's treatment team.
  • Use the same diagnosis for substance use at each follow-up visit to ensure member is engaged in prescribed treatment.
  • Refer members to culturally appropriate treatment and consider social determinants of health (SDOH) factors as possible barriers to health equity.
  • Consider referring members to Horizon's Behavioral Health Case Management Program.
  • Discuss safety planning and crisis/relapse intervention for the patient.
  • If applicable, notify our Concurrent Review team of the patient's aftercare information on the day of discharge.
    
    

  Horizon's Behavioral Health HEDIS Team is available to assist providers and may be emailed at BH_Hedisteam@HorizonBlue.com

  Braven Health providers can call 1-888-444-0501.

Risk Adjustment Information

• Helping Members Get Care: In-Home Assessments to Close Care Gaps

  Getting patients the care they need is our top priority. At Horizon, our Risk Adjustment team uses a proactive approach to identify, document and revalidate patients' chronic conditions annually. Two examples are In-Home Assessments (IHAs) and In-Office Assessments for Horizon and Braven Health℠ members.

  In-home assessments

  • We use the vendors Inovalon and Signify to perform the IHAs for eligible members. These visits help capture their full health condition and close clinical and quality gaps, at no cost to them.
  • We share medical information gathered during the IHA with our members' Primary Care Provider (PCP). Additionally, the IHA provider will assist with transitioning the care to the member's PCP and scheduling any in-office visits.
  • The 2023 project for eligible members kicked off in April 2023 and continues through December 31, 2023.
  • In an effort to promote this IHA opportunity to members, we encourage you to increase member participation.
  • As an incentive for completion, each member is eligible for a gift card once the assessment is completed.

  In-office assessments

  • Horizon contracts with Inovalon to use their Converged Patient Assessment Platform (previously called ePass) to complete these assessments. This online tool helps capture all health information and potential preventive care gaps.
  • We greatly encourage our providers to use the online platform to engage and conduct an in-office assessment on eligible members.
  • These assessments are referred to as SOAP notes — Subjective, Objective, Assessment and Plan.
  • The 2023 project for eligible members kicked off in April 2023 and concludes December 31, 2023.
  • As an incentive for completion, each provider is eligible for $150 for each electronically submitted assessment through the Converged Patient Assessment Platform.
  • The Provider Engagement team will reach out to providers with reminders for outstanding open assessments.

  Want more information?

  Our Provider Engagement team is available for education regarding this intervention and all other Risk Adjustment projects and activities, which strive to provide the best quality of care for our members, your patients.

  If you have any questions or educational needs, please email RiskAdjustment@HorizonBlue.com.

  Inovalon and Signify have contracted with Horizon to perform in-home assessments for our eligible members with chronic health conditions. Inovalon and Signify are independent from and not affiliated with Horizon or the Blue Cross Blue Shield Association.

• Send Requested Medical Records and Post Service Appeals Quicker with HorizonDocs

  All Horizon and Braven Health℠ professional providers are encouraged 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 and appeals, all in one place.

  With HorizonDocs, the exchange of Protected Health Information (PHI) is safe, secure and HIPAA compliant. Plus, HorizonDocs allows you to:

  • Organize documents by category and sub-category (e.g., Post-Service Medical Records and Post-Service Appeals: Commercial, Braven Health, etc.).
  • View documents sent and received based on your Tax ID Number.
  • 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.
  • Receive confirmation emails when documents are requested, sent and received.
    
    

  You can access the below through HorizonDocs:

  • 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 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.

Quality Information and Tips

• Ensure Timely Access to Primary Care

  Primary Care Physicians (PCPs) play a pivotal role in the health care system, acting as the first point of contact for patients. Ensuring your Horizon and Braven Health members have quick access to routine and sick appointments is paramount for delivering quality, patient-centered care. Research shows that easy access not only improves the patient experience and satisfaction, but also contributes to better health outcomes.

  Here are some industry standard best practices:

  Improved communication

  • Enhance communication channels to facilitate appointment bookings.
  • Provide clear instructions on how to request appointments and ensure that staff promptly responds to requests.
  • Use automated systems to send appointment reminders and allow patients to easily reschedule or cancel appointments if necessary.

  Efficient scheduling and appointment management

  • Offer a sufficient number of same-day appointments to accommodate urgent health care needs.
  • Consider offering extended hours, including early mornings, evenings or weekends, to accommodate patients with busy schedules.
  • Implement an online appointment system that allows patients to book appointments conveniently, reducing administrative burden and improving access.

  Advanced triage and telemedicine

  • Train staff members to triage phone calls, assessing the urgency and severity of patients' concerns.
  • Incorporate telemedicine into your practice to provide virtual consultations for routine follow-ups, minor illnesses, and medication management.

  Collaborative care models

  • Foster a collaborative environment by involving nurse practitioners, physician assistants and other health care professionals. This approach optimizes resource utilization and allows for prompt evaluation and management of patients.
  • Establish effective communication channels with specialists, laboratories and other health care providers to streamline referrals, obtain timely test results and facilitate efficient care coordination.

  Continuous quality improvement

  • Regularly review access metrics, such as wait times for appointments, patient feedback and appointment availability. Identify areas for improvement and make necessary adjustments to enhance access to your practice.
  • Actively seek patient feedback to gauge their satisfaction with appointment availability and wait times. Surveys can provide valuable insights into areas that require improvement.
    
    

  Here's more information on improving member access to care and providing telemedicine to your patients.

• Working to Improve Member Access to Care

  We require all participating practices to comply with the guidelines of our Appointment Availability Access Standards for Primary Care-Type Providers, Ob/Gyns, Specialists and Behavioral Health Providers administrative policy. These guidelines help ensure that Horizon and Braven Health℠ members are offered timely appointments and responses based on the clinical urgency of their physical and/or behavioral health needs.

  Please ensure that all staff members are familiar with these guidelines and follow them when:

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

  We also make the Access Standards available to our members, your patients.

  2022 Access Standard Survey Results

  Each year, we conduct a survey to see how well our participating PCP, Ob/Gyn, Specialist and Behavioral Health practices comply with these standards. Below are 2022 survey results for Horizon providers.

  Behavioral Health: Summary of Commercial Standard Performance (2022)

  • Follow up routine care continues to exceed goal.
  • Follow-up after psychiatric hospitalization results met our 80% goal but there is room to continue improving these results.
  • Routine appointments continue to fall below the standard and overall target goal of 90%.
  • Urgent and non-life threatening emergent appointments continue to fall below our target goal of 80%.

  BH: % MEETING COMMERCIAL STANDARD

  Standard	Total (n=334)	Solo (n=248)	Group (n=86)	Prescribing (n=47)	Non-Prescribing (n=287)
  Routine care: Within 10 days	68%	69%	64%	51%	¹70%
  Urgent care: Within 2 days	54%	56%	50%	43%	56%
  SHBP urgent care (base, n=301): Within 1 day	39%	40%	36%	29%	40%
  Emergent care: Within six hours, or referred	62%	63%	58%	57%	62%
  Psychiatric follow-up: Within 7 days of discharge	80%	78%	¹87%	72%	82%

  ¹ A significant difference between Solo and Group (95%).

  BH: % MEETING COMMERCIAL STANDARD

  Standard	Total (base varies)	Solo (base varies)	Group (base varies)
  Follow-up routine care [PRESCRIBERS]: up to 30 days	94% n=47	95% n=20	93% n=47
  Follow-up routine care [NON-PRESCRIBER]: up to 20 days	97% n=287	98% n=228	95% n=59

  BH: % MEETING COMMERCIAL STANDARD

  Standard	Total (base varies)	Solo (base varies)	Group (base varies)	Prescribing (base varies)	Non-Prescribing (base varies)
  Wait time for MGCN/TRAD: Up to 30 minutes	95% n=334	¹97% n=248	90% n=86	89% n=47	96% n=287
  Rescheduling opportunity: % Yes (reduced base)	100% n=8²	100% n=5²	100% n=3²	100% n=1²	100% n=7²
  Wait time for MA: Up to 15 minutes	71% n=289	72% n=210	70% n=79	77% n=43	70% n=246
  Rescheduling opportunity: % Yes (reduced base)d	100% n=8²	100% n=3²	100% n=5²	100% n=3²	100% n=5²

  ¹ A significant difference between Solo and Group (95%).
  ² Low number of respondents.

  PCP: Summary of Commercial Standard Performance (2022)

  PCPs, Ob/Gyns and Specialists

  • Routine Care results for PCPs and Ob/Gyns are strong and meet or exceed our goals.
  • Urgent Care, Emergency Care and After Hours care for PCPs, Ob/Gyns and Specialists continue to fall below our goals and need improvement.

  PCP: % MEETING COMMERCIAL STANDARD

  Standard	Total (n=278)	Solo (n=136)	Group (n=142)
  Routine preventive care: Within four months (0-124 days)	97%	96%	97%
  Symptomatic routine care: Within two weeks (0-14 days)	92%	93%	91%
  Urgent care: Within 24 hours (0-1 day)	79%	80%	78%
  Emergency care: Send to ER, immediately, within one hour	80%	83%	78%
  After hours care: Within 30 minutes	74%	¹82%	67%

  ¹ A significant difference between Solo and Group (95%).

  PCP: % MEETING COMMERCIAL STANDARD (Managed Care and Traditional Medicare only)

  Standard	Total (n=278)	Solo (n=136)	Group (n=142)
  Length of wait past appointment time: No more than 30 minutes	89%	91%	86%
  Rescheduling Opportunity Offered: % Yes (reduced base)	95%	100%	92%

  PCP: % MEETING COMMERCIAL STANDARD (Medicare Advantage only)

  Standard	Total (n=262)	Solo (n=129)	Group (n=133)
  Length of wait past appointment time: No more than 15 minutes	55%	58%	53%
  Rescheduling Opportunity Offered: % Yes (reduced base)	90%	94%	87%

  Ob/Gyn: Summary of Commercial Standard Performance (2022)

  OB/GYN: % MEETING COMMERCIAL STANDARD

  Standard	Total (n=140)	Solo (n=60)	Group (n=80)
  Routine preventive care: Within four months (0-124 days)	96%	98%	95%
  Symptomatic routine care: Within two weeks (0-14 days)	76%	¹88%	66%
  Urgent care: Within 24 hours (0-1 day)	56%	65%	50%
  Emergency care: Send to ER, immediately, within one hour	69%	¹80%	61%
  After hours care: Within 30 minutes	68%	72%	65%

  ¹ A significant difference between Solo and Group.

  OB/GYN: % MEETING COMMERCIAL STANDARD (Managed Care and Traditional Medicare only)

  Standard	Total (n=140)	Solo (n=60)	Group (n=80)
  Length of wait past appointment time: No more than 30 minutes	88%	87%	89%
  Rescheduling Opportunity Offered: % Yes (reduced base)	90% n=10¹	80% n=5¹	100% n=5¹

  ¹ Low number of respondents.

  OB/GYN: % MEETING COMMERCIAL STANDARD (Medicare Advantage only)

  Standard	Total (n=127)	Solo (n=129)	Group (n=133)
  Length of wait past appointment time: No more than 15 minutes	54%	54%	53%
  Rescheduling Opportunity Offered: % Yes (reduced base)	90% n=52¹	88% n=24¹	93% n=28¹

  ¹ Low number of respondents.

  Specialists: Summary of Commercial Standard Performance (2022)

  SPECIALISTS: % MEETING COMMERCIAL STANDARD

  Standard	Total (n=245)	Solo (n=117)	Group (n=128)
  Routine care: Within three weeks (0-21 days)	75%	75%	74%
  Urgent care: Within 24 hours (0-1 day)	51%	51%	52%
  Emergency care: Send to ER or within one hour	68%	69%	67%
  After hours care: Within 30 minutes	57%	56%	58%

  SPECIALISTS: % MEETING COMMERCIAL STANDARD (Managed Care and Traditional Medicare only)

  Standard	Total (n=245)	Solo (n=117)	Group (n=128)
  Length of wait past appointment time: No more than 30 minutes	87%	88%	85%
  Rescheduling Opportunity Offered: % Yes (reduced base)	100%	100%	100%

  SPECIALISTS: % MEETING COMMERCIAL STANDARD (Medicare Advantage only)

  Standard	Total (n=220)	Solo (n=104)	Group (n=116)
  Length of wait past appointment time: No more than 15 minutes	61%	58%	63%
  Rescheduling Opportunity Offered: % Yes (reduced base)	88%	90%	85%

• It's a Great Time to Promote the Flu Shot!

  Promoting the flu vaccine to your patients typically requires careful timing to maximize its effectiveness. While September may seem a bit early, it's actually an appropriate time to start promoting the flu vaccine. Here's why:

  • You can raise awareness among patients and ensure they have ample time to schedule appointments or go to their local pharmacy or other select locations to receive the shot.

  • It takes approximately two weeks after receiving the flu vaccine for the body to develop optimal protection. By offering the vaccine in early fall, patients can build immunity before the flu season typically begins (which can vary, but often starts in the fall or winter). Encouraging early vaccination increases the chances of individuals being protected when flu activity starts to rise.

  • It provides an opportunity to address any patient concerns or misconceptions and emphasize the safety and efficacy of the vaccine before flu season begins. This can enable a smoother vaccination process when demand increases.

  • Promoting the flu vaccine early allows health care providers to efficiently plan their vaccination campaigns, ensure sufficient vaccine supply and organize clinics or outreach programs.

  Here's more information about flu vaccines from the Centers for Disease Control and Prevention.