- HEDIS® Resources
- Claim Submission & BillingClaim Submission & Billing
- Claim Editing Policies
- Claim Submission Claim Submission
- Electronic Claim Adjustments
- Explanation of Payment
- PCP Billable Lists
- Demographic Updates
- Inquiries, Complaints & AppealsInquiries, Complaints & Appeals
- Inquiries
- Complaints
- Time Limits for Filing Inquiries/Complaints
- Resolving Inquiries/Complaints
- Appeals of Non-Utilization Management Determinations
- Appeals of Utilization Management/Medical Management Determinations
- Appeals of Post Service Medical Necessity Determinations
- PoliciesPolicies
- Medical Policies Medical Policies
- Administrative Policies Administrative Policies
- Allowable Practice Locations for Pathologists
- Appointment Availability Access Standards for Primary Care-Type Providers, ObGyns and Specialists
- Behavioral Health Providers Access Standards
- Credentialing and Recredentialing Policy for Ancillary and Managed Long Term Support Service (MLTSS) Providers
- Credentialing and Recredentialing Policy for Participating Physicians and Healthcare Professionals
- EDI and NaviNet Claims Submission Requirement
- Electronic Funds Transfer (EFT)
- Material Adverse Change (MAC) Notification Policy
- Medical Records Documentation Standards
- Medicare Advantage Readmission
- Never Events
- Out-of-Network Referral Policy
- Physician and Healthcare Professional Counseling and Termination Policy - Professional Competency
- Participation Status in Products that Utilize Tiering and/or Subset of an Existing Horizon Network
- Practitioner Office Site Quality and Medical Record Keeping Standards
- Provider Directory Management
- Retainer Based Medicine
- Tier Awareness Policy
- Use of Horizon Hospital Network Performance Data
- Use of Practitioner Performance Data
- BlueCard® Medical Policies
- Reimbursement Policies & Guidelines Reimbursement Policies & Guidelines
- After-hours and Weekend Care
- Anesthesia Reimbursement Guidelines
- ASC Multiple Procedure Methodology
- Assistant at Surgery
- Balloon Sinuplasty
- Bariatric Surgery Billed With Hiatal Hernia Repair
- Bilateral Procedures
- Billing Guidelines for Maternity Services
- Chemotherapy Administration
- Chronic Care Management Services
- Claim Editing Policies
- ClaimsXten Editing Rules
- Co-Surgeon Reimbursement
- Colonoscopy with Modifier 59
- Consultation Services Payment
- Consumable Medical Supplies
- Continuous Positive Airway Pressure or Bi-level Positive airway Pressure (CPAP/BiPAP) Supplies
- Daily Management of Epidural or Subarachnoid Continuous Drug Administration
- Determination of Refractive State
- Diabetic Supplies
- Distinct Procedural Service Modifiers
- Drug and Immunization Pricing
- Duplex Scanning
- Enhancement to CMS Always Bundled Edit
- Evaluation and Management Services with Chiropractic Manipulative Treatment
- Evaluation and Management Services with Osteopathic Manipulative Treatment
- Hip Arthroscopy
- Hot or Cold Pack Therapy
- Inpatient Consultations
- Knee Arthroscopy
- Lab Panel Rebundling
- Maternity Reimbursement
- Modifier 25
- Modifier 50 Bilateral Guidelines
- Modifier 52
- Modifier 53
- Modifier 54
- Modifier 55
- Modifier 56
- Modifier 78
- Modifier SU
- Multiple Procedure Reductions
- Noncovered Related Services
- Outpatient Consultations
- Outpatient Therapy Daily Maximum
- Physician Extenders Non-Surgical Services
- Pre-Admission Testing
- Radiology, Preliminary and Double Reads
- Radiopharmaceuticals
- Reimbursement and Billing Guidelines for Anesthesia Claims
- Removal of Impacted Cerumen Requiring Instrumentation
- Screening and Diagnostic Mammography & 3D Tomosynthesis
- Services on Telemedicine Platforms
- Site of Service Differential
- Status N Codes
- Urinalysis with Evaluation and Management (E&M) Services
- Urine Drug Screening/Testing
- Utilization ManagementUtilization Management
- Clinical Practice Guidelines
- Physical and Occupational Therapy Authorizations
- Services Requiring Prior Authorization Services Requiring Prior Authorization
- Prior Authorization Procedure Search Tool
- Medicare Advantage
- NJ Direct
- OMNIA Health Plans
- SHBP
- Unite Here Health
- BlueCard® Members
- Utilization Management Request Tool
Alert
Toggle menu
- BACKback to www.horizonblue.com
- PROVIDERS
- Why JoinWhy Join
-
Products & ProgramsProducts & Programs
- Products & Programs
- AIM Specialty HealthAIM Specialty Health
- Case ManagementCase Management
- Chronic Care ProgramChronic Care Program
-
BlueCard® ProgramBlueCard® Program
- BlueCard® Program
- BlueCard AnnouncementsBlueCard Announcements
- BlueCard ClaimsBlueCard Claims
- BlueCard Medical Policy/Pre-Certification InfoBlueCard Medical Policy/Pre-Certification Info
- BlueCard Program FAQsBlueCard Program FAQs
- BlueCard Program OverviewBlueCard Program Overview
- BlueCard Program TutorialBlueCard Program Tutorial
- GeoBlue: International CoverageGeoBlue: International Coverage
- How to Identify BlueCard MembersHow to Identify BlueCard Members
- FIND A DOCTOR
- MEMBER SIGN IN
- SHOP FOR A PLAN
- Dental ServicesDental Services
- EDI & EFT TransactionsEDI & EFT Transactions
-
eviCore Health CareeviCore Health Care
- eviCore Health Care
- ArchiveArchive
- Cardiology Imaging ProgramCardiology Imaging Program
- Molecular and Genomic Testing ProgramMolecular and Genomic Testing Program
- Musculoskeletal ProgramMusculoskeletal Program
- Radiation Therapy ProgramRadiation Therapy Program
- Radiology/Imaging ServicesRadiology/Imaging Services
- Specialty ProgramsSpecialty Programs
- FIND A DOCTOR
- MEMBER SIGN IN
- SHOP FOR A PLAN
- Horizon Behavioral HealthHorizon Behavioral Health
-
Horizon Care@HomeHorizon Care@Home
- Horizon Care@Home
- About Horizon Care@HomeAbout Horizon Care@Home
- Find A ProviderFind A Provider
- Home Infusion TherapyHome Infusion Therapy
- Horizon Care@Home FAQsHorizon Care@Home FAQs
- Prior Authorization/Pre-Service RegistrationPrior Authorization/Pre-Service Registration
- FIND A DOCTOR
- MEMBER SIGN IN
- SHOP FOR A PLAN
- LabCorpLabCorp
- Medical Injectables ProgramMedical Injectables Program
- navihealthnavihealth
- Patient-Centered ProgramsPatient-Centered Programs
- Patient Health SupportPatient Health Support
- Pharmacy ProgramsPharmacy Programs
-
ProductsProducts
- Products
- Senior Market Product OverviewSenior Market Product Overview
- Managed Care ProductsManaged Care Products
- PPO and Indemnity ProductsPPO and Indemnity Products
- OMNIA Health PlansOMNIA Health Plans
- Horizon Patient-Centered Advantage EPO Silver and Bronze PlansHorizon Patient-Centered Advantage EPO Silver and Bronze Plans
- Horizon Medicare Blue (PPO)Horizon Medicare Blue (PPO)
- Horizon Medicare Blue Advantage (HMO)Horizon Medicare Blue Advantage (HMO)
- Horizon Medicare Advantage NJ DIRECT (PPO) PlansHorizon Medicare Advantage NJ DIRECT (PPO) Plans
- NJ SHBP/SEHBP Benefit PlansNJ SHBP/SEHBP Benefit Plans
- FEPFEP
- Horizon Medicare Blue Advantage (HMO) Frequently Asked QuestionsHorizon Medicare Blue Advantage (HMO) Frequently Asked Questions
- FIND A DOCTOR
- MEMBER SIGN IN
- SHOP FOR A PLAN
- Recognition Programs and PartnershipsRecognition Programs and Partnerships
- Risk Adjustment OverviewRisk Adjustment Overview
-
Self ServiceSelf Service
- Self Service
-
Interactive Voice Response System (IVR)Interactive Voice Response System (IVR)
- Interactive Voice Response System (IVR)
- Referral Process Using the Interactive Voice Response SystemReferral Process Using the Interactive Voice Response System
- Effective use of the Interactive Voice Response SystemEffective use of the Interactive Voice Response System
- FIND A DOCTOR
- MEMBER SIGN IN
- SHOP FOR A PLAN
- Provider Online ServicesProvider Online Services
- FIND A DOCTOR
- MEMBER SIGN IN
- SHOP FOR A PLAN
- FIND A DOCTOR
- MEMBER SIGN IN
- SHOP FOR A PLAN
-
Policies & ProceduresPolicies & Procedures
- Policies & Procedures
- HEDIS® ResourcesHEDIS® Resources
-
Claim Submission & BillingClaim Submission & Billing
- Claim Submission & Billing
- Claim Editing PoliciesClaim Editing Policies
- Claim SubmissionClaim Submission
- Electronic Claim AdjustmentsElectronic Claim Adjustments
- Explanation of PaymentExplanation of Payment
- PCP Billable ListsPCP Billable Lists
- FIND A DOCTOR
- MEMBER SIGN IN
- SHOP FOR A PLAN
- Demographic UpdatesDemographic Updates
-
Inquiries, Complaints & AppealsInquiries, Complaints & Appeals
- Inquiries, Complaints & Appeals
- InquiriesInquiries
- ComplaintsComplaints
- Time Limits for Filing Inquiries/ComplaintsTime Limits for Filing Inquiries/Complaints
- Resolving Inquiries/ComplaintsResolving Inquiries/Complaints
- Appeals of Non-Utilization Management DeterminationsAppeals of Non-Utilization Management Determinations
- Appeals of Utilization Management/Medical Management DeterminationsAppeals of Utilization Management/Medical Management Determinations
- Appeals of Post Service Medical Necessity DeterminationsAppeals of Post Service Medical Necessity Determinations
- FIND A DOCTOR
- MEMBER SIGN IN
- SHOP FOR A PLAN
-
PoliciesPolicies
- Policies
- Medical PoliciesMedical Policies
-
Administrative PoliciesAdministrative Policies
- Administrative Policies
- Allowable Practice Locations for PathologistsAllowable Practice Locations for Pathologists
- Appointment Availability Access Standards for Primary Care-Type Providers, ObGyns and SpecialistsAppointment Availability Access Standards for Primary Care-Type Providers, ObGyns and Specialists
- Behavioral Health Providers Access StandardsBehavioral Health Providers Access Standards
- Credentialing and Recredentialing Policy for Ancillary and Managed Long Term Support Service (MLTSS) ProvidersCredentialing and Recredentialing Policy for Ancillary and Managed Long Term Support Service (MLTSS) Providers
- Credentialing and Recredentialing Policy for Participating Physicians and Healthcare ProfessionalsCredentialing and Recredentialing Policy for Participating Physicians and Healthcare Professionals
- EDI and NaviNet Claims Submission RequirementEDI and NaviNet Claims Submission Requirement
- Electronic Funds Transfer (EFT)Electronic Funds Transfer (EFT)
- Material Adverse Change (MAC) Notification PolicyMaterial Adverse Change (MAC) Notification Policy
- Medical Records Documentation StandardsMedical Records Documentation Standards
- Medicare Advantage ReadmissionMedicare Advantage Readmission
- Never EventsNever Events
- Out-of-Network Referral PolicyOut-of-Network Referral Policy
- 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
- Practitioner Office Site Quality and Medical Record Keeping StandardsPractitioner Office Site Quality and Medical Record Keeping Standards
- Provider Directory ManagementProvider Directory Management
- Retainer Based MedicineRetainer Based Medicine
- 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
- FIND A DOCTOR
- MEMBER SIGN IN
- SHOP FOR A PLAN
- BlueCard® Medical PoliciesBlueCard® Medical Policies
-
Reimbursement Policies & GuidelinesReimbursement Policies & Guidelines
- Reimbursement Policies & Guidelines
- After-hours and Weekend CareAfter-hours and Weekend Care
- 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
- Bilateral ProceduresBilateral Procedures
- Billing Guidelines for Maternity ServicesBilling Guidelines for Maternity Services
- Chemotherapy AdministrationChemotherapy Administration
- Chronic Care Management ServicesChronic Care Management Services
- Claim Editing PoliciesClaim Editing Policies
- ClaimsXten Editing RulesClaimsXten Editing Rules
- Co-Surgeon ReimbursementCo-Surgeon Reimbursement
- Colonoscopy with Modifier 59Colonoscopy with Modifier 59
- 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
- Daily Management of Epidural or Subarachnoid Continuous Drug AdministrationDaily Management of Epidural or Subarachnoid Continuous Drug Administration
- Determination of Refractive StateDetermination of Refractive State
- Diabetic SuppliesDiabetic Supplies
- Distinct Procedural Service ModifiersDistinct Procedural Service Modifiers
- Drug and Immunization PricingDrug and Immunization Pricing
- Duplex ScanningDuplex Scanning
- Enhancement to CMS Always Bundled EditEnhancement to CMS Always Bundled Edit
- 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
- Hip ArthroscopyHip Arthroscopy
- Hot or Cold Pack TherapyHot or Cold Pack Therapy
- Inpatient ConsultationsInpatient Consultations
- Knee ArthroscopyKnee Arthroscopy
- Lab Panel RebundlingLab Panel Rebundling
- Maternity ReimbursementMaternity Reimbursement
- 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 78Modifier 78
- Modifier SUModifier SU
- Multiple Procedure ReductionsMultiple Procedure Reductions
- Noncovered Related ServicesNoncovered Related Services
- Outpatient ConsultationsOutpatient Consultations
- Outpatient Therapy Daily MaximumOutpatient Therapy Daily Maximum
- Physician Extenders Non-Surgical ServicesPhysician Extenders Non-Surgical Services
- Pre-Admission TestingPre-Admission Testing
- 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
- Services on Telemedicine PlatformsServices on Telemedicine Platforms
- Site of Service DifferentialSite of Service Differential
- Status N CodesStatus N Codes
- Urinalysis with Evaluation and Management (E&M) ServicesUrinalysis with Evaluation and Management (E&M) Services
- Urine Drug Screening/TestingUrine Drug Screening/Testing
- FIND A DOCTOR
- MEMBER SIGN IN
- SHOP FOR A PLAN
- FIND A DOCTOR
- MEMBER SIGN IN
- SHOP FOR A PLAN
-
Utilization ManagementUtilization Management
- Utilization Management
- Clinical Practice GuidelinesClinical Practice Guidelines
- Physical and Occupational Therapy AuthorizationsPhysical and Occupational Therapy Authorizations
-
Services Requiring Prior AuthorizationServices Requiring Prior Authorization
- Services Requiring Prior Authorization
- Prior Authorization Procedure Search ToolPrior Authorization Procedure Search Tool
- Medicare AdvantageMedicare Advantage
- NJ DirectNJ Direct
- OMNIA Health PlansOMNIA Health Plans
- SHBPSHBP
- Unite Here HealthUnite Here Health
- BlueCard® MembersBlueCard® Members
- FIND A DOCTOR
- MEMBER SIGN IN
- SHOP FOR A PLAN
- Utilization Management Request ToolUtilization Management Request Tool
- FIND A DOCTOR
- MEMBER SIGN IN
- SHOP FOR A PLAN
- FIND A DOCTOR
- MEMBER SIGN IN
- SHOP FOR A PLAN
-
ResourcesResources
- Resources
- Cultural CompetencyCultural Competency
-
Manuals & User GuidesManuals & User Guides
- Manuals & User Guides
- AgreementsAgreements
- Ancillary ManualAncillary Manual
- Benefits-at-a-GlanceBenefits-at-a-Glance
- Hospital ManualHospital Manual
- Participating Physician and Other Health Care Professional Office ManualParticipating Physician and Other Health Care Professional Office Manual
- Point of ContactPoint of Contact
- Prior Authorization GuidePrior Authorization Guide
- FIND A DOCTOR
- MEMBER SIGN IN
- SHOP FOR A PLAN
- Network MailingsNetwork Mailings
- Network SpecialistsNetwork Specialists
- NewslettersNewsletters
- Office Manager SeminarsOffice Manager Seminars
- Provider FAQsProvider FAQs
-
TrainingTraining
- Training
- CMS Training RequirementsCMS Training Requirements
-
EducationEducation
- Education
- ProductsProducts
- NavinetNavinet
-
Online ToolsOnline Tools
- Online Tools
- Physical and Occupational Therapy Authorization ToolPhysical and Occupational Therapy Authorization Tool
- Utilization Management Request ToolUtilization Management Request Tool
- Radiation Therapy Medical Necessity DeterminationRadiation Therapy Medical Necessity Determination
- Electronic Funds TransferElectronic Funds Transfer
- Health Risk AdjustmentHealth Risk Adjustment
- FIND A DOCTOR
- MEMBER SIGN IN
- SHOP FOR A PLAN
- FIND A DOCTOR
- MEMBER SIGN IN
- SHOP FOR A PLAN
- WebinarsWebinars
- FIND A DOCTOR
- MEMBER SIGN IN
- SHOP FOR A PLAN
- FIND A DOCTOR
- MEMBER SIGN IN
- SHOP FOR A PLAN
-
FormsForms
- Forms
- Forms by Plan TypeForms by Plan Type
- Forms by Specialty TypeForms by Specialty Type
-
Forms by TypeForms by Type
- Forms by Type
- Appeal / DisputeAppeal / Dispute
- Assess / Evaluate / ExamineAssess / Evaluate / Examine
- AuthorizationsAuthorizations
- ClaimClaim
- ConsentConsent
- CredentialingCredentialing
- Electronic Transaction FormsElectronic Transaction Forms
- Enroll / Elect / ApplyEnroll / Elect / Apply
- Horizon NJ TotalCare (HMO SNP) FormsHorizon NJ TotalCare (HMO SNP) Forms
- Inquiry / RequestInquiry / Request
- Prescription Drug Mail OrderPrescription Drug Mail Order
- FIND A DOCTOR
- MEMBER SIGN IN
- SHOP FOR A PLAN
- Frequently Used FormsFrequently Used Forms
- MiscellaneousMiscellaneous
- W9 Form-DentalW9 Form-Dental
- W9 Form-MedicalW9 Form-Medical
- FIND A DOCTOR
- MEMBER SIGN IN
- SHOP FOR A PLAN
- NewsNews
- FIND A DOCTOR
- MEMBER SIGN IN
- SHOP FOR A PLAN
Are you sure you want to leave this website?
You are leaving the Horizon Blue Cross Blue Shield of New Jersey website. Please click Continue to leave this website. Or, if you would like to remain in the current site, click Cancel.