Horizon Medicare Blue (PPO)

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.

• Reimbursement
• Care management
• Service

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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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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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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