Participation Status in Products that Utilize Tiering and/or a Subset of an Existing Horizon Network

Administrative Policy:
Physician and Health Care Professional Participation Status in Products that Utilize Tiering and/or a Subset of an Existing Horizon Network

Effective Date:
January 1, 2014

Last Revised Date:
February 1, 2016

Subject:
Selection of physicians and other health care professionals eligible for reimbursement when treating members enrolled in products that utilize tiering and/or a subset of an existing Horizon network.

Scope:
This policy applies to all physicians and health care professionals participating in the Horizon Network for care rendered to members enrolled in one of the products that utilize tiering and/or a subset of an existing Horizon Network.

Purpose:
The purpose of this policy is to define the process for selecting physicians and other health care professionals who will be included for participation in one or more of the products that utilize tiering and/or a subset of an existing Horizon network.

Definitions:

  • ACO: Accountable Care Organization (ACO) is a group of hospitals, doctors and other health care providers who all agree to share accountability for a set of patients' complete range of care so that the quality of care for all patients improves while unnecessary expenses are reduced. Providers' earnings are tied to meeting specific health care quality goals — especially keeping patients healthier — as well as to care that results in cost savings.
  • EPO: Exclusive Provider Organization is a managed care plan where services are covered only when members have their care rendered by hospitals, physicians and other health care professionals in the product’s network (except in the case of an emergency).
  • PCMH: Patient Centered Medical Home (PCMH) coordinates patients’ health care needs and helps ensure that they receive the highest quality of care, at the right setting and at the right time. This patient-centered approach provides a personalized and comprehensive health care program that enables patients to become engaged in their health care.
  • ETG: Episode Treatment Group – used to classify an entire episode of care regardless of where the patient has received treatment (ER & hospital costs are excluded).
  • Mixed Specialty Practice: A group practice that includes one or more evaluated specialties. A practitioner’s status is based on efficiency (among other criteria) at the group practice tax ID or group practice level.
  • OMNIA Tier 1: OMNIA members have lower copayments and out-of-pocket costs when using these doctors, hospitals and other healthcare professionals.
  • Tier 2: OMNIA members can access a Tier 2 doctor, hospital or other healthcare professional via their in-network benefits at a higher out-of-pocket cost.

Policy and Procedures:
There are no out-of-network benefits for products that utilize tiering and/or a subset of an existing Horizon BCBSNJ Network. Therefore, members enrolled in a product that utilizes tiering and/or a subset of an existing Horizon BCBSNJ Network will not have the option of using physicians and other health care professionals that are not participating in this product.

Participation Status:
Participation in a tier and/or subset of a Horizon network will be done at the group practice level. All participating physicians and other health care professionals affiliated with a Group Tax ID number(s) included in a product that utilizes tiering and/or a subset of an existing Horizon network will be considered participating as it pertains to the services rendered to members in the products that utilize tiering and/or a subset of an existing Horizon network. Services rendered by a participating group to members in a product that utilizes tiering and/or a subset of an existing Horizon network will be considered in-network. Note: In-network benefits for products that utilize a tiered Horizon network may include different member cost share obligations depending on the tier status of the participating provider. (See the OMNIA section below for further details regarding tiered network issues).

All participating physicians and other health care professionals affiliated with a Group Tax ID number(s) that have been excluded from products that utilize tiering and/or a subset of an existing Horizon Network will be considered nonparticipating, only as it pertains to the services rendered to members enrolled in a product that utilizes tiering and/or a subset of an existing Horizon network. Therefore, services rendered by a group that does not participate in a subset of an existing Horizon network to members enrolled in a product that utilizes tiering and/or a subset of an existing Horizon Network will be considered out of network. In the aforementioned scenario, members enrolled in a product that utilize tiering and/or a subset of an existing Horizon Network who received services by a physician or other health care professional in a group practice that is excluded will have no out-of-network benefits. Consequently, these claims will be denied.

If a participating physician submits claims under a Group Tax ID that is included for participation in a product that utilizes tiering and/or a subset of an existing Horizon Network, Horizon BCBSNJ shall pay those claims based on the participating allowance under the current Managed Care Network rates. If the same physician submits claims under a Group Tax ID that is excluded for participation in a product that utilizes tiering and/or a subset of an existing Horizon Network, Horizon BCBSNJ will deny those claims, except for those services rendered in the Emergency Room.

Notification of Inclusion and Exclusion Status and Practitioner Responsibilities:

Horizon BCBSNJ will evaluate the group practices that are included for participation in products that utilizes tiering and/or a subset of an existing Horizon Network every year or as needed to ensure sufficient access to members in products that utilize tiering and/or a subset of an existing Horizon Network. Horizon BCBSNJ will provide written notification of participation status at the Group Tax ID level directly to the group practice. However, each participating physician and other health care professional is responsible for verifying their participation status with all of their group affiliations prior to rendering services and submitting claims for members enrolled in a product that utilizes tiering and/or a subset of an existing Horizon Network. For confirmation, physicians may also reference Horizon BCBSNJ’s online Provider Directory. Failure to verify participation status of your group affiliations may result in denial of claims.

Products that utilize tiering and/or a subset of an existing Horizon BCBSNJ network:

Horizon Medicare Blue Patient Centered w/Rx (HMO)

Sixteen (16) specialties, which are identified below, have been evaluated to determine inclusion in the Horizon Medicare Blue Patient Centered w/Rx (HMO) product.

Inclusion in Horizon Medicare Blue Patient Centered w/Rx (HMO) product will be at the group tax ID number and not the individual physician or other health care professional. Therefore, practitioners that are affiliated with multiple tax ID numbers may be included for participation in Horizon Medicare Blue Patient Centered w/Rx HMO when rendering services to a member in the Horizon Medicare Blue Patient Centered w/Rx (HMO) product at one group, but excluded from participation in the product when rendering services to a member of the Horizon Medicare Blue Patient Centered w/Rx (HMO) product at the other group. As a result, the physicians and other health care professionals who are included for participation in the Horizon Medicare Blue Patient Centered w/Rx (HMO product based upon their particular group practice or group tax ID number(s) will be reimbursed based on the current fee schedule for the Managed Care Network for services rendered to Horizon Medicare Blue Patient Centered w/Rx HMO members at the participating group.

Specialties:
The following specialties have been selected to be included in the Horizon Medicare Blue Patient Centered w/Rx (HMO) product:

  • Allergy & Immunology
  • Cardiology
  • Cardiothoracic Surgery
  • Cardiovascular Surgery
  • Chiropractic Medicine
  • Dermatology
  • Endocrinology
  • Gastroenterology
  • Neurology
  • Ophthalmology
  • Orthopedic Surgery
  • Otolaryngology
  • Podiatry
  • Pulmonology
  • Rheumatology
  • Urology

All other specialties will automatically be included in the Horizon Medicare Blue Patient Centered w/Rx HMO product provided that the specialty is not affiliated with a Mixed Specialty Practice, which includes one or more specialties identified above.

Criteria for Inclusion:
Group practices from the Horizon BCBSNJ’s current Managed Care Network will be evaluated for inclusion in Horizon Medicare Blue Patient Centered w/Rx (HMO) product, based upon one or more of the following criteria:

  • Risk-adjusted cost efficiency at the group practice level using Episode Treatment Group (ETG) data;
  • Geographic access and coverage requirements and standards.

OMNIA

Twenty-seven (27) specialties, which are identified below, have been evaluated to determine tier status in the OMNIA product.

Tier status for OMNIA will be deemed at the group tax ID number and not the individual physician or other health care professional. Therefore, practitioners that are affiliated with multiple tax ID numbers may be deemed OMNIA Tier 1 for participation in OMNIA when rendering services to a member in the OMNIA product at one group, but deemed Tier 2 in the product when rendering services to a member of the OMNIA product at the other group.

Specialties:
The following specialties have been selected to be included in the OMNIA product:

  • Allergy & Immunology
  • Cardiology
  • Cardiothoracic Surgery
  • Cardiovascular Surgery
  • Chiropractic Medicine
  • Dermatology
  • Family Practice
  • Endocrinology
  • Gastroenterology
  • General Surgery
  • Hematology
  • Hematology Oncology
  • Internal Medicine
  • Neurological Surgery
  • Neurology
  • Oncology
  • Ophthalmology
  • Orthopedic Surgery
  • Otolaryngology
  • Pediatric
  • Plastic Surgery
  • Podiatry
  • Pulmonology
  • Reproductive Endocrinology
  • Rheumatology
  • Urology
  • Vascular Surgery

All other specialties will automatically be deemed OMNIA Tier 1 in the OMNIA product provided that the specialty is not affiliated with a Mixed Specialty Practice, which includes one or more specialties identified above.

Criteria for OMNIA Tier 1:
Primary Care Physicians: PCPs from the existing Horizon Managed Care Network were evaluated as OMNIA Tier 1 based on participation with Horizon BCBSNJ patient-centered programs, which include our Patient-Centered Medical Home and/or Accountable Care Organization programs. Some exceptions may apply.

Specialties:
Group practices from Horizon BCBSNJ’s current Managed Care Network will be evaluated for tier status in the OMNIA product, based upon one or more of the following criteria:

  • Risk-adjusted cost efficiency at the group practice level using Episode Treatment Group (ETG) data;
  • Hospital admitting privileges to OMNIA Tier 1 hospitals (where applicable);
  • Referral patterns to OMNIA Tier 1 hospitals where applicable; and
  • Geographic access and coverage requirements and standards.

Some exceptions may apply.

REFERENCES:

Horizon Healthcare of New Jersey, Inc. Agreement with Physicians and Other Health Care Professionals, Section 8.3
N.J.A.C. 11:24-6.2; 11:24A-4.10.
Patient Protection and Affordable Care Act of 2010

HCM-PP-HCS-024-0915