Horizon Medicare Blue (PPO)

Effective January 1, 2013, Horizon Blue Cross Blue Shield of New Jersey began offering a new Medicare Advantage (MA) plan–Horizon Medicare Blue (PPO), allowing New Jersey employers to offer an MA plan to their retirees who travel or live out of state. Unlike other MA plans, Horizon Medicare Blue (PPO) provides enrolled members with an in-network level of benefits when living or traveling outside of our local service area.

The Horizon Medicare Blue (PPO) plan takes advantage of an arrangement among Blue Plans–similar to the BlueCard Program–that covers MA PPO members at the in-network level of benefits when getting care from Blue Plan network physicians and hospitals in participating states.

Horizon Medicare Blue (PPO), like all other Horizon BCBSNJ Medicare Advantage plans, uses the Horizon Managed Care Network. Physicians, other health care professionals, facilities and ancillary providers that participate in our managed care network are considered in network for members enrolled in the Horizon Medicare Blue (PPO) plan.

Members enrolled in other Blue Plans’ MA PPO plans who live or travel in our local service area can also access their in-network benefits when they use physicians, other health care professionals, facilities and ancillary providers that participate in our Horizon Managed Care Network. From the perspective of other states’ MA PPO members, the Horizon Managed Care Network is our MA PPO Network.

Horizon Medicare Blue (PPO) covers all Medicare Part A and Part B benefits and additional supplemental benefits. Employers have the option of offering this plan to their retirees with or without Part D prescription drug coverage.

Horizon Medicare Blue (PPO) members:

• Do not need to choose a Primary Care Physician (PCP).
• Do not need referrals to see specialists.
• Have in-network and out-of-network benefits both in and outside of our local service area.
  • Members access their in-network benefits:
    • Within our local service area (New Jersey and the contiguous counties of Pennsylvania, Delaware and New York) by using physicians, other health care professionals, facilities and ancillary providers that participate in our Horizon Managed Care Network.
    • Outside our service area by using physicians, other health care professionals, facilities and ancillary providers that participate in another Blue Plan’s MA PPO Network.
  • Members access their out-of-network benefits:
    • Within our local service area (New Jersey and the contiguous counties of Pennsylvania, Delaware and New York) by using physicians, other health care professionals, facilities or ancillary providers that DO NOT participate in our Horizon Managed Care Network (including practitioners who participate only in our Horizon PPO Network).
    • Outside our service area by using physicians, other health care professionals, facilities or ancillary providers that DO NOT participate in another Blue Plan’s MA PPO Network.
    • Physicians or other health care professionals who have opted out of, or are excluded from, Medicare are not eligible to receive reimbursement for services rendered to a Medicare Advantage member.

• MA PPO National Network
• Horizon BCBSNJ participating network for MA PPO plans
• Reimbursement
• ID cards
• Benefits and eligibility
• Care management
• Medical Necessity Determinations
• Claims
• Service
• Appeals

MA PPO National Network

The Horizon Medicare Blue (PPO) product takes advantage of an arrangement among Blue Plans–similar to the BlueCard® Program–that enables MA PPO members to obtain in-network benefits when receiving care from Blue Plan network physicians and hospitals in participating states.

Members enrolled in other Blue Plans’ MA PPO products who reside or travel in our local service area will also access their in-network benefits when they use physicians, other health care professionals, facilities and ancillary providers that participate in our Horizon Managed Care Network.

From the perspective of other states’ MA PPO members, the Horizon Managed Care Network is our MA PPO Network.

• If you participate in our Horizon Managed Care Network and you see MA PPO members from other Blue Plans, these members will be extended the same contractual access to care and will be reimbursed in accordance with your Horizon BCBSNJ negotiated rate. These members will receive in-network benefits in accordance with their member contract.
• If you only participate in our Horizon PPO Network and you see MA PPO members from other Blue Plans, you will receive the Medicare-allowed amount for covered services.

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MA PPO Blue Plan Participating States/Territories*

*MA PPO members can obtain in-network benefit in states not participating in a MA PPO if they choose to receive services from participating Medicare providers.

Horizon BCBSNJ participating network for MA PPO plans

Like all other Horizon BCBSNJ Medicare Advantage plans, Horizon Medicare Blue (PPO) uses the Horizon Managed Care Network. Physicians, other health care professionals, facilities and ancillary providers that participate in our managed care network are considered in-network for members enrolled in the Horizon Medicare Blue (PPO) plan.

Members enrolled in our Horizon Medicare Blue (PPO) plan have in-network and out-of-network benefits.

Treating members enrolled in Horizon Medicare Blue (PPO)

In-network services

Members enrolled in our Horizon Medicare Blue (PPO) access their in-network benefits when they use physicians, other health care professionals, facilities and ancillary providers that participate in our managed care network.

Out-of-network services

Members enrolled in our Horizon Medicare Blue (PPO) and members enrolled in other Blue Plans’ MA PPO products who reside or travel in our local service area access their out-of-network benefits within our local service area by using physicians, other health care professionals, facilities or ancillary providers that DO NOT participate in our Horizon Managed Care Network (including practitioners who participate only in our Horizon PPO Network).

Please note that PPO physicians or other health care professionals who have opted out of, or are excluded from, Medicare are not eligible to receive reimbursement for services rendered to a Medicare Advantage member.

Treating members enrolled in other Blue Plans’ MA PPO products

In addition to seeing Horizon Medicare Blue (PPO) members, you may also see members enrolled through other Blue Cross and/or Blue Shield MA PPO Plans who reside or travel in our service area.

Members enrolled in other Blue Plans’ MA PPO products who reside or travel in our local service area will access their in-network benefits when they use physicians, other health care professionals, facilities and ancillary providers that participate in our managed care network.

These members will be extended the same contractual access to care. Services provided to these members will be reimbursed at our negotiated rates.

Urgent and Emergent Care

Urgent and emergent care will be reimbursed at the in-network level of benefits.

Locating a network physician or pharmacy

To locate participating physicians and other health care professionals, please access our Doctor & Hospital Finder. Within the Advanced Search feature, select Horizon Medicare Advantage PPO within the Plan dropdown menu to review only those physicians or other health care professionals who will be considered in-network for members enrolled in a MA PPO plan.

Participating pharmacies.

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Reimbursement

Reimbursement for in-network services

Reimbursement for eligible services provided to Horizon Medicare Blue (PPO) members and to members enrolled through other Blue Plans’ MA PPO plans by physicians and other health care professionals that participate in our Horizon Managed Care Network will be calculated at our managed care rates.

Reimbursement for out-of-network services

Reimbursement for eligible services provided to Horizon Medicare Blue (PPO) members and to members enrolled through other Blue Plans’ MA PPO plans by physicians and other health care professionals that participate only in our Horizon PPO Network will be calculated at Medicare’s allowance.

Physicians or other health care professionals who have opted out of, or are excluded from, Medicare are not eligible to receive reimbursement for services rendered to a Medicare Advantage member.

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ID cards

You’ll recognize MA PPO members by the MA-in-the-suitcase logo on the members’ ID card.

Also take note of the three-letter prefix. The prefix will identify the plan in which the patient is enrolled and is critical for verifying benefits and eligibility and for submitting claims.

Horizon Medicare Blue (PPO) member ID numbers will include either a YKK or YKM prefix.

The member ID card will also include any precertification/prior authorization contact information.

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Benefits and eligibility

There are two ways to verify benefits and eligibility for a patient enrolled in a Horizon Medicare Blue (PPO) plan or in another Blue Cross and/or Blue Shield MA PPO plan.

You can either:

1. Log in to NaviNet.net, access the Horizon BCBSNJ Plan Central page and mouse over Eligibility & Benefits and click Eligibility & Benefits Inquiry.
2. Call the BlueCard® Eligibility Line at 1-800-676-BLUE (2583). Be sure to provide the member’s alpha prefix located on the ID card

Please note: Information obtained regarding member eligibility is not a guarantee or a promise of reimbursement. Reimbursement determination only occurs after a claim is processed according to the member’s benefits.

Horizon Medicare Blue (PPO) enrolled member benefits

• No Primary Care Physician (PCP) selection is required.
• No referrals are required.
• In-network and out-of-network benefits.
• Covers all Medicare Part A and Part B benefits, as well as additional supplemental benefits.
• Offered with and without Part D prescription drug coverage. Employer groups may choose to convert the Medicare Advantage coverage they offer their employees to Medicare Advantage with Prescription Drug (MAPD) coverage–Horizon Medicare Blue Group w/Rx (PPO).

Review the 2016 Horizon Medicare Blue (PPO) Summary of Benefits.

Please note: The Summary of Benefits outlines the standard Horizon Medicare Blue (PPO) benefits offered to consumers. Group employers that offer Horizon Medicare Blue (PPO) to their employees have the ability to select certain benefit variations to best suit the needs of their employees. Please verify all Horizon Medicare Blue (PPO) members online through NaviNet.net or via the BlueCard® Eligibility Line at 1-800-676-BLUE (2583).

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Care management

Prior authorization

Certain services require prior authorization (PA) for members enrolled in Horizon Medicare Blue (PPO) plans. A list of services that require prior authorization is available online.

Prescription drug prior authorization

Certain prescription drugs require prior authorization. This process requires the prescribing physician to provide the following information to help determine medical necessity:

• The member’s diagnosis.
• The duration of the proposed treatment.
• The member’s treatment plan.
• A description of failed treatment, if any exists.

Upon receipt of this information we will consider your request and provide you with our answer. Physicians are encouraged to prescribe appropriate first line agents before using alternative drugs.

Precertification/prior authorization requirements for members enrolled in other Blue plans

Precertification/preauthorization may be required by the Blue Cross and/or Blue Shield Plan through which the MA PPO member is enrolled. Guidelines and requirements may be obtained during the verification of benefits and eligibility.

MA PPO members enrolled in other Blue Cross and/or Blue Shield Plans who obtain services in New Jersey are ultimately responsible for obtaining precertification/preauthorization, when required. However, we strongly encourage Horizon BCBSNJ participating physicians, other health care professionals and facilities to obtain precertification/preauthorization on behalf of an MA PPO member enrolled in another Blue Cross and/or Blue Shield Plan to help expedite the claim adjudication process.

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Medical Necessity Determinations

The medical necessity review and determination process for Horizon Medicare Advantage products is different than that of other managed care products. If you or the member disagrees with a coverage determination we have made, the decision may be appealed.

Medical determinations

We have up to 14 days to determine whether an initial request for a service is medically appropriate and covered. If additional clinical information is required, we may have up to an additional 14 days to make a determination.

In some cases, the standard pre-service review process could endanger the life or health of the member. As a participating physician or other health care professional, you may request an expedited 72-hour pre-service determination for a Medicare Advantage patient if, in your opinion, the health or the ability of your patient to function could be harmed by waiting for a medical necessity determination.

Expedited determinations may be requested by calling 1-800-664-BLUE (2583).

Non-expedited determinations may be requested in writing to:

Horizon Blue Cross Blue Shield of New Jersey
Utilization Management Appeals Department
210 Silvia Street, TT-02T
West Trenton, NJ 08628

Fax: 1-877-798-5903

Medicare Part D prescription drug determinations

Requests for a coverage determination will be responded to within 24 hours for an expedited request (or sooner if the member’s health requires us to) or within 72 hours for a non-expedited coverage determination.

Part D drug coverage determinations include:

• Prior authorization determinations for those drugs that require prior authorization.
• Requests that we cover a Part D drug that is not on the plan’s List of Covered Drugs (formulary).
• Requests that we waive a restriction on the plan’s coverage for a drug, including:
• Being required to use the generic version of a drug instead of the brand name drug.
• Being required to try a different drug first before we will agree to cover the drug you are asking for. (This is sometimes called "step therapy.")
• Quantity limits. For some drugs, there are restrictions on the amount of the drug you can have.
• Requesting that we reimburse for a prescription drug the member already purchased (a coverage decision about payment).

Expedited Medicare Part D drug determinations may be requested by calling 1-800-693-6651.

Non-expedited Medicare Part D drug determinations may be requested in writing to:
 

Prime Therapeutics LLC
Attn: Medicare Appeals Department
1305 Corporate Center Drive, Bldg N10
Eagan, MN 55121

Fax: 1-800-693-6703

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Claims

Claims for services provided to members enrolled in Horizon Medicare Blue (PPO) plans may be submitted to us electronically.

Claims for MA PPO members enrolled in other Blue Cross and/or Blue Shield Plans should be submitted to Horizon BCBSNJ, just as you would any other BlueCard® claim. We will work with the other Blue Plan to adjudicate and finalize the claim according to the member’s benefits and eligibility and issue reimbursement to you.

Claims may also be submitted in hard copy to the following addresses:

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Service

Horizon BCBSNJ has a number of service areas that provide more specific information and help with prior authorizations and precertification. For these specialized service areas to perform their functions efficiently and effectively, it’s important that basic benefits, enrollment and eligibility inquiries are resolved or verified prior to making an authorization request.

Please seek basic benefits, enrollment and eligibility information prior to contacting our Precertification Call Center for an authorization request. If you require documentation that a service does not require precertification, a Physician Services Representative can provide both the information you need and a service reference number that documents the information you were provided.

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Appeals

Medical appeals

Generally, we have 60 days to process an appeal pertaining to post-service denial of claim payment (appeal for payment) and 30 days to process an appeal pertaining to denial of a requested service (pre-service appeal for service). Expedited appeals are processed within 72 hours.

Please note that a completed Appointment of Representative (AOR) form or other court-appointed document indicating the member’s consent may be required for a provider to pursue post-service appeals on behalf of the member.

To file an expedited appeal, the member may call Member Services at 1-800-365-2223.

To request an appeal in writing, members should write to or fax:

Horizon Medicare Advantage
Appeals Coordinator
Three Penn Plaza East, PP-12L
Newark, NJ 07105-2200

Pre-service appeal requests may be faxed to 1-609-583-3021.

Post-service appeals (appeals for reimbursement) may be faxed to 1-732-938-1340.

Medicare Part D prescription appeals

Generally we have up to seven days to process an appeal pertaining to a post-service denial of coverage decision or claim for a Medicare Part D prescription drug and up to 72 hours to process an appeal pertaining to a coverage decision of a Medicare Part D prescription drug the member has not yet received. Expedited appeals are processed within 24 hours.

To file an expedited Medicare Part D appeal, the member may call 1-800-693-6651.

To request a Medicare Part D prescription drug appeal in writing, members should write to or fax:

Prime Therapeutics LLC
Attn: Medicare Appeals Department
1305 Corporate Center Drive, Bldg N10
Eagan, MN 55121

Fax expedited (24-hours) or standard (72 hour) appeal requests to 1-800-693-6703.