Policies, Procedures and General Guidelines
Failure to comply with any of the following policies, procedures and guidelines may constitute a breach of your Agreement(s).
All benefits are subject to contract limits and Horizon’s policies and procedures, including, but not limited to, prior authorization and medical management requirements.
Participating ancillary providers are required to refer Horizon patients and/or send Horizon patients’ testing samples to participating clinical laboratories. Failure to comply with this requirement may result in your termination from the Horizon networks.
Horizon’s Managed Care laboratory network includes Quest Diagnostics in addition to Laboratory Corporation of America® (LabCorp®). LabCorp and Quest provide national in-network clinical laboratory services for your Horizon managed care patients (i.e., members enrolled in Horizon HMO, Horizon EPO, OMNIA Health Plans, Horizon Direct Access, Horizon POS or Horizon BCBSNJ Medicare Advantage plans¹).
You may refer members enrolled in Horizon PPO and Indemnity plans (and/or send their testing samples to LabCorp, Quest Diagnostics and/or BioReference Laboratories, Inc., or to one of our other participating clinical laboratories or hospital outpatient laboratories at network hospitals).
As a reminder, our networks include a number of participating laboratories that can provide a variety of specialized laboratory services. To view a full listing of our participating clinical laboratories, visit HorizonBlue.com/doctorfinder and:
- Select Other Healthcare Services from the Browse by Category menu.
- Select Laboratory – Patient Centers or Laboratory – (Physician Access Only)
You may refer a Horizon patient who has out-of-network benefits (or send his or her testing sample) to a nonparticipating clinical laboratory, if that patient chooses to use his or her out-of-network benefits and you follow the guidelines in our Out-of-Network Referral Policy.
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 network use requirements.
Participating physicians and other health care professionals agree that LabCorp is authorized to release the results of all laboratory tests performed for Horizon members to Horizon.
Note: Certain self-insured employer groups for whom we administer health care benefits have established special benefit arrangements that allow their enrolled members to use the non participating clinical laboratory affiliated with each employer group as exceptions to the guidelines of our Out-of-Network Consent Policy. These special benefit arrangements apply ONLY to members/dependents enrolled in these employer group plans.
¹Pathology 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 network use requirements.
ATLANTICARE CLINICAL LABORATORIES
Participating physicians and other health care professionals treating managed care members in southern NJ counties may also refer their Horizon BCBSNJ patients to Atlanticare Clinical Laboratories.
LabCorp maintains a collaborative relationship with AtlantiCare Clinical Laboratories that helps reduce members’ out-of-pocket costs. This arrangement applies to routine tests, as well as the most contemporary and sophisticated reference tests.
To learn more about locations:
- Access the Online Doctor & Hospital Finder on HorizonBlue.com/doctorfinder.
- Visit LabCorp.com or call 1-888-LabCorp(522-2677).
- Visit AtlantiCare.org.
LabCorp Contact Information
For questions or service, please call LabCorp at 1-800-631-5250.
For specimen pick-up, please call LabCorp at 1-800-253-7059.
BioReference Laboratories Contact Information
For questions or service, or for specimen pickup, call BioReference Laboratories at 1-800-229-5227.
Quest Diagnostics Contact Information
For questions or service, call Quest at 1-866-MYQUEST (697-8378).
The Horizon Specialty Pharmaceutical Program can help you obtain office-based and administered specialty medications from a contracted specialty pharmacy provider that will directly supply your office or facility, at your convenience.
When you participate in this voluntary program, you’ll obtain specialty pharmaceuticals directly from a specialty pharmacy.
Under this program, your office should not submit claims for specialty medications when obtained from our specialty pharmacy providers. These specialty pharmacy providers will bill Horizon directly for the cost of the medication.
To access information about the Specialty Pharmaceutical Program for office-based therapies, visit HorizonBlue.com/specialtyrx.
Specialty pharmacy claims must be sent to the Blue Plan in the service area where the ordering physician is located. The claim will process according to the pharmacy’s relationship with that Blue Plan. For example, if the ordering physician is located in New Jersey, send the claim to Horizon and the claim will process according to the pharmacy’s participating status with Horizon. However, if the ordering physician is located in Pennsylvania, the claim must be sent to the Blue Plan in Pennsylvania and will process according to the pharmacy’s contractual relationship with the Pennsylvania Blue Plan and consistent with the member’s Home Plan benefits.
MEDICAL NECESSITY DETERMINATIONS FOR INJECTABLE MEDICATIONS
To help ensure that our members receive the appropriate and medically necessary care regarding the use of certain intravenous immunoglobulin (IVIG), oncology and rheumatoid arthritis injectable medications, Horizon collaborates with Magellan Rx Management for the Medical Injectable Program (MIP).
You must obtain a Medical Necessity and Appropriateness Review (MNAR) prior to administering certain injectable medications to avoid a delay or denial of claims pending receipt of information needed to determine medical necessity. You may not balance bill the member for denied or pended claims that result from your noncompliance with our MNAR program.
BEHAVIORAL HEALTH CARE
You may call Horizon Behavioral Health directly at 1-800-626-2212 for behavioral health or substance use disorder care. A referral is not required.
AUDIOLOGY AND HEARING AID BENEFITS
Audiology Distribution, LLC, doing business as HearUSA, works with Horizon to administer hearing benefits and provide related products and services through their network of independently practicing audiologists, hearing care professionals and company-owned hearing centers.
Horizon works with HearUSA and their HearUSA Centers to provide audiology services, hearing aids and discounts on certain services to our enrolled members. The following information outlines the role that HearUSA plays in various member benefits.
Note: The benefit information provided here is not a guarantee of reimbursement. Claim reimbursement is subject to member eligibility and all member and group benefit limitations, conditions and exclusions. Please confirm member -audiology benefits and hearing aid benefit amounts before providing services.
For members enrolled in Horizon Medicare Advantage plans that include audiology/hearing benefits receive audiology/hearing aid benefits:
- In-network routine hearing services (including annual routine hearing exam, hearing aids that are medically necessary, hearing aid batteries, and/or the evaluation for fitting hearing aids) must be coordinated through HearUSA. Members must call HearUSA at 1-800-442-8231 to schedule all in-network routine hearing services.
- Members enrolled in Horizon Medicare Blue (PPO) or Horizon Medicare Blue Group (PPO) plans have no benefits for routine hearing exams and/or hearing aids.
- Members enrolled in Horizon Medicare Advantage plans that do not include out-of-network benefits have no benefits for routine hearing services that are not coordinated through HearUSA.
- Those members enrolled in Horizon Medicare Advantage plans that include out-of-network benefits who choose to use their out-of-network benefits (understanding that they will incur more cost sharing responsibility) may obtain an annual routine hearing exam from a non-HearUSA provider without first calling HearUSA.
These members have no similar OON benefits for hearing aids that are medically necessary, hearing aid batteries, and/or the evaluation for fitting hearing aids. These services must be coordinated through HearUSA.
Members enrolled in any other Horizon managed care plan (Horizon HMO, Horizon Direct Access, Horizon EPO and Horizon POS, etc.) may receive audiology/hearing aid benefits through HearUSA as follows:
- Though not required, these members may choose to use HearUSA or any other participating Horizon Managed Care Network audiologist on an in-network basis.
- Benefits for audiology and hearing aids for members enrolled in other Horizon managed care plans may vary. Please confirm member benefits before providing services.
- Members who choose to use their out-of-network benefits (understanding that they will incur more cost sharing responsibility) may obtain services from a non-HearUSA provider.
Members enrolled in any other Horizon plan may receive audiology/hearing aid benefits through HearUSA as follows:
- Any enrolled Horizon member is entitled to receive a 15 percent discount on the cost of a hearing aid purchased from HearUSA.
They can use our Doctor & Hospital Finder to locate a HearUSA Center and:
- Click Medical.
- Choose their plan.
- Click Browse by Category, select Other Healthcare Services and click Audiology
- Click Search.
New Jersey health plans must provide coverage for mammograms at specified intervals for women based on age and/or medical necessity. Coverage for female members includes:
- One baseline mammogram examination for women who are at least 35 years of age.
- A mammogram examination every year for women age 40 and over.
- A mammogram examination at ages and intervals deemed medically necessary by a woman’s doctor in the case of a woman who is under 40 years of age and has a family history of breast cancer or other breast cancer risk factors.
- An ultrasound evaluation, a magnetic resonance imaging (MRI) scan, a three- dimensional (3D) mammography and other additional testing of an entire breast or breasts, after a baseline mammogram examination, if:
- The mammogram demonstrates extremely dense breast tissue;
- The mammogram is abnormal within any degree of breast density including not dense, moderately dense, heterogeneously dense or extremely dense breast tissue; or if
- The patient has additional risk factors for breast cancer, including but not limited to, family history of breast cancer, prior personal history of breast cancer, positive genetic testing, extremely dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology or other indications as determined by the patient’s doctor.
The coverage required for an ultrasound evaluation, MRI scan, 3D mammography or other additional testing may be subject to utilization review, including periodic review of the medical necessity of the additional screening and diagnostic testing. Expanded coverage may not be available to members enrolled in Administrative Services Only (ASO) health insurance plans that have opted not to adopt the New Jersey breast cancer screening mandate.
Participating Ob/Gyn services cover treatment of routine gynecological and obstetrical conditions without a referral from a PCP. However, prior authorization is still required for certain services.
Routine gynecological and obstetrical conditions do not include infertility-related services. Members who have infertility benefits must access those benefits in accordance with their contracts.
Participating obstetricians may directly provide or refer members to participating providers for the following services when these services are medically necessary (and authorized as appropriate):
- Home uterine monitoring (Maternity Management).
- Elective hysterectomies.
- Fetal non-stress tests (authorization required after the first three).
- Terbutaline pump.
- All pregnancy ultrasounds (Medical Necessity Determination required after the first two ultrasounds).
Certain professional services and all hospital activity needed during the pregnancy (except outpatient radiology and same-day surgeries) must receive prior authorization.
The Ob/Gyn may not refer to another specialist if the subsequent visit is not Ob-related.
You must notify Horizon and obtain approval for certain infertility treatments. This applies to Horizon HMO, Horizon POS and Horizon Direct Access plans. It is your responsibility to obtain this approval where required.
For additional information, please call an Institutional Services Representative (UB-04 submitters) at 1-888-666-2535, Monday through Friday, between 8 a.m. and 5 p.m., ET.
OUT-OF-NETWORK REFERRAL POLICY AND PROCEDURE
Our Out-of-Network Referral Policy* encourages our members to use participating physicians, other health care professionals and facilities, and helps ensure that our members fully understand the increased out-of-pocket expense they will incur for out-of-network care.
* The Out-of-Network Referral Policy does not apply to members enrolled in plans that do not include out-of-network benefits [e.g., Horizon HMO, Horizon EPO, OMNIA Health Plans, Horizon Medicare Blue Value (HMO) etc.].
Our Out-of-Network Referral Policy applies to referrals made to any nonparticipating physician, other health care professional or facility (including clinical laboratories and ambulatory surgery centers). All physicians and other health care professionals who participate in our managed care and/or PPO networks are required to adhere to our Out-of-Network Referral Policy.
Horizon expects participating physicians and other health care professionals to ensure that, whenever possible, their Horizon patients and patients enrolled through other Blue Cross and/or Blue Shield Plans are referred to participating physicians, other health care professionals or facilities unless the member wishes to use his or her out-of-network benefits and understands that higher out-of-pocket expenses will be incurred.
You should contact us for authorization if you believe that the necessary expertise does not exist within our network or that there is no available participating physician, other health care professional or facility to provide services to the member. If Horizon agrees that a providers is not available, the member’s in-network coverage will apply to the out-of-network referral.
Prior to referring a Horizon member for out-of-network services, you must do the following:
- Advise the member of the nonparticipating status of the physician, other health care professional or facility, the out-of-network benefit level that will apply to those services and the member’s responsibility for increased out-of-pocket expenses (including deductible, coinsurance and any amount that exceeds the plan’s allowance).
- Advise the member of a participating physician, other health care professional or facility that could provide the same services, unless one does not exist within our network.
- Advise of any financial interest in, or compensation made by, the nonparticipating physician, other health care professional or facility.
- Complete our Out-of-Network Consent Form (2180), signed and dated by the member, and retain that document as part of the patient’s medical record. In the event of an audit, this form must be provided within 10 business days.
Note: You must obtain the appropriate approval from Horizon BCBSNJ for those services that require prior authorization.
To access our Out-of-Network Referral Policy, registered NaviNet users should log on to NaviNet.net, select Horizon BCBSNJ from the My Health Plans menu, and:
- Mouse over References and Resources and click Provider Reference Materials
- Mouse over Policies & Procedures
- Select Policies, then Administrative Policies
- Select Out-of-Network Referral Policy
Call your Ancillary Contracting Specialist if you have questions or would like copies of the above-referenced information mailed to you.
When out-of-network claims are received, the participating ordering and/or rendering physician or ancillary provider is sent a letter and asked to provide us with a copy of the member’s signed Consent for Referral to an Out-of-Network Provider Form (2180).
Specialists are not to balance bill members for any administrative charges related to the Consent for Referral to an Out-of-Network Provider Form (2180).
If a signed form is not provided within 10 business days or if a participating physician otherwise fails to abide by our policy, he or she may be subject to loss or restriction of network participation and/or termination.
Horizon reserves the right to audit a provider’s medical records pertaining to, but not limited to, the member’s signed Out-of-Network Consent Form (2180) as well as claims to out-of-network facilities.
INPATIENT CARE SERVICES
To maximize their benefits, members should use network facilities (e.g., residential treatment centers or skilled nursing facilities). Inpatient care will be provided in semi-private accommodations.
When medically necessary, members can be referred to a nonparticipating facility if their need for medical treatment cannot be accommodated through our ancillary provider network. Such referrals must be made to fully licensed, accredited facilities and must be authorized by Horizon if treatment is to be covered for plans with no out-of-network benefits, or covered at an in-network level for plans that do have out-of-network benefits.
You must obtain authorization for all elective inpatient stays. An authorization number must be given to the member to present to the facility upon admission.
Facility authorizations cover all inpatient services, including preadmission testing, anesthesia, laboratory, pharmacy and other specialty services related to the admission.
In emergency situations, you must notify us at 1-800-664-BLUE (2583).
REFERRING TO NONPARTICIPATING PHYSICIANS AND ANCILLARY PROVIDERS
On rare occasions, you may need to refer a patient to a nonparticipating physician or ancillary provider. Doing so requires authorization for members enrolled in Horizon plans with no out-of-network benefits and for members enrolled in Horizon POS plans, if benefits are to be accessed on an in-network basis. Please keep in mind that these requests are handled on an individual basis and require medical review.
Access our Online Doctor & Hospital Finder on our website, HorizonBlue.com, for information about the participation status of specific physicians or ancillary providers.
COPAYMENTS AND ALLOWED AMOUNTS
Copayment amounts vary from plan to plan. It is possible that a member’s copayment may turn out to be greater than our allowance for the services provided.
You are permitted to collect the copayment indicated on the member’s ID card at the time of service, but if our allowed amount for the service you provided (indicated on your EOP) is less than the copayment amount collected, you may need to refund the difference to the member.
Ancillary providers may only collect applicable office visit copayments at the time of service, according to the Agreement(s) signed with Horizon.
Copayments, coinsurance or deductibles may be collected in advance, but not as a condition for the provision of services by the provider.
However, in certain situations, the copayment listed on a Horizon member ID card should not be collected at the time of service.
When a Patient Does Not See a Health Care Professional
When a patient enters the office site but does not see a physician, specialty care physician or other health care professional, the copayment should not be collected. Examples of these visits include, but are not limited to, allergy injections, blood pressure and weight checks.
Patients Enrolled in Consumer-Directed Healthcare (CDH) High-deductible Plans
High-deductible health insurance plans offered in conjunction with a Health Savings Account (HSA) are required to apply all services, excluding preventive care services, toward the plan’s deductible. The high-deductible health insurance plans we offer to employer groups for use in conjunction with Health Reimbursement Arrangements (HRAs) follow this same plan design.
Copayments for members enrolled in CDH plans only apply after a patient’s deductible has been satisfied.
Please submit your claims and wait until you receive our Explanation of Payment (EOP) and CDH EOP (for those members enrolled in HRA plans) before billing the member for any amount, including copayments.
Copayments and Dual Eligible Patients
Patients enrolled in any Horizon plan who have secondary coverage through Horizon NJ Health (New Jersey Medicaid benefits) are not responsible, and should not be billed, for any copayment or coinsurance amounts under their primary coverage.
Ancillary providers agree not to bill or seek to collect any copayment or coinsurance from any such person, but to seek payment from Horizon NJ Health for any remaining balances.
Patients Enrolled in Plans Without Copayments
Some Horizon plans, including Horizon Medicare Blue TotalCare (HMO SNP), do not include a member copayment. If the member ID card does not indicate a copayment, please do not collect any amount from the patient at the time of service.
COPAYMENTS AND PREVENTIVE CARE SERVICES
As mandated by the ACA, most health insurance plans allow members to receive preventive care services without copayments or other cost sharing. This means that preventive services, including screenings, checkups and counseling, are covered with no out-of-pocket costs if the member sees an in-network ancillary provider and receives only preventive care services during the visit. Please do not collect preventive care copayments from your Horizon patients.
However, based upon the services that are provided during the course of a scheduled preventive visit, it may be appropriate for you to collect a nonpreventive copayment from a Horizon member. We encourage you, in such circumstances, to discuss with your patients the nonpreventive treatment/services that they received.
Note: The ACA allows group health plans offering custom benefits to opt to retain a copayment for preventive care services.
For more information about preventive services, please visit HealthCare.gov.
MAKING ARRANGEMENTS FOR THE PAYMENT OF DEDUCTIBLE LIABILITY AT THE TIME OF SERVICE
Although we prefer that participating practices submit claims and wait for our Explanation of Payment (EOP) prior to collecting any member liability amounts other than copayments, we understand the challenges that participating practices are facing in regard to the collection of amounts that are applied toward deductibles.
Participating practices are no longer prohibited from making arrangements with members for the payment of amounts that will be applied toward deductibles.
Participating practices may choose to establish a “time-of-service” payment arrangement policy for the collection of amounts that will be applied to member deductibles.
Participating practices may NOT seek amounts that will be applied to member deductibles at the time of service from:
- Members enrolled in Horizon Medicare Advantage plans.
- Members enrolled in high-deductible health insurance plans that work in conjunction with an employer-sponsored Health Reimbursement Arrangement (HRA).
Participating practices may NOT seek any projected coinsurance amounts at the time of service from these members. Participating practices are required to submit claims and wait for our EOP prior to collecting coinsurance amounts.
Guidelines for Practices
Participating practices that choose to implement a “time-of-service” collection policy must comply with the following guidelines:
- In no case shall treatment be refused to a Horizon member if he or she is not able to pay a requested amount at the time of service.
- Practices may make arrangements for the payment of an amount that is determined to be accurate with reasonable certainty based on:
- Our allowance for the service(s) provided;
- Your validation of the members’ estimated deductible liability.
Please keep in mind that the deductible information displayed on NaviNet is based on finalized claims as of the date that NaviNet is accessed. Claims that are processed or adjusted following your review of this information and prior to the processing of claims to be submitted might alter the patient’s true deductible liability.
- Practices should work with members to establish fair and appropriate payment plan options and to take certain circumstances into consideration when establishing those payment arrangements (for example, members who may visit multiple doctors and/or health care professionals on a single day, or members who may bring multiple dependents for services on the same day).
- In the event that an amount collected by a participating practice needs to be refunded to a member, we expect that refund to occur no later than 30 days after a member overpayment is identified.
NON-WAIVER OF MEMBER LIABILITY
Participating physicians, other health care professionals and practices shall not waive any appropriately applied member liability (including copayments, coinsurance or deductible amounts, as well as other amounts associated with exclusions or limitations contained within a covered person's health benefit plan).
Ancillary providers should not recommend any treatment they feel is unacceptable. You have sole responsibility for the quality and type of health care service you provide to your patients. You should refer patients to other ancillary providers as medically appropriate and medically indicated.
You are free to communicate openly with a member about all appropriate diagnostic testing and treatment options, including alternative medications, regardless of benefit coverage limitation.
CREDENTIALING AND RECREDENTIALING OBLIGATIONS
You are required to comply with the standards of participation identified in the Horizon BCBSNJ’s Credentialing/Recredentialing Policy for Ancillary Providers.
We strongly encourage you to review this policy online at HorizonBlue.com/credentials.
Participating ancillary providers are also required to report any changes in their credentialing information, including, for example, any disciplinary action by the applicable licensing authority, any criminal conviction and the pendency of any investigation for matters related to their professional practice.
Ancillary providers who fail, at any time, to meet any of the standards, as determined by our Credentialing Committee, are subject to loss or restriction of network participation and termination of their Agreement.
Ancillary providers are subject to loss or restriction of network participation and termination of their contract if (among other circumstances):
- They are subject to disciplinary action, including, but not limited to, voluntarily and involuntarily submission to censure, reprimand, nonroutine supervision, nonroutine admissions review, monitoring or remedial education or training;
- Their license, accreditation or certification is restricted, conditioned, reclassified, suspended or revoked, whether active or stayed, and whether by the applicable authority, or any federal or state agency, or any hospital, managed care organization or similar entity;
- They are the subject of an investigation for matters related to their professional practice; or
- They are convicted of a criminal offense.
Credentialing Doctors and Other Health Care Professionals
To access information we require to add doctors or other health care professionals to an existing practice please visit HorizonBlue.com/whyjoin.
On this page you will find links to our Requirements for Physicians and our Requirements for Other Health Care Professionals.
These documents provide instructions and access to all the necessary forms and information we require to complete initial credentialing of a doctor or other health care professional in either our Horizon Managed Care Network or our Horizon PPO Network.
Other Ancillary providers such as Ambulance, ASC, Comprehensive Outpatient Rehab Facilities, Dialysis Centers, Family Planning Centers,Federally Qualified Health Centers, Home Health, Hospice, Inpatient Acute Rehab Facilities, Skilled Nursing and Subacute Facilities, Sleep Laboratories, Laboratories and Urgent Care Centers, should contact the Ancillary Contracting Specialist for more information on Credentialing.
Horizon does not credential doctors or other health care professionals in more than one specialty.
As required by New Jersey state guidelines and accreditation bodies, all health care professionals must be recredentialed every 36 months. Our recredentialing process begins approximately six months prior to the recredentialing date. Ancillary providers who fail to provide the necessary information in a timely manner are subject to termination of their Agreement(s).
Standards for participation may be reviewed online in our Horizon BCBSNJ Credentialing/ Recredentialing Policy for Ancillary Providers.
We work with andros, a leader in technology solutions for the management of health care provider information, to help us carry out our recredentialing process, broadly outlined as follows:
- Six months prior to your recredentialing due date, andros begins the recredentialing process by searching for current information on the Council for Affordable Quality Healthcare’s (CAQH) online data-collection service ProView™. If your information is up to date on ProView, the recredentialing process will continue.
- If information is either not on CAQH ProView, or not updated on CAQH ProView, andros will reach out to you by phone, fax and mail to request that you provide updated and/or missing information.
- If andros not receive a response, andros will email, fax or mail three requests to your office. You will receive the first notification 90 days before the recredentialing cycle ends, the second notification 60 days before the recredentialing cycle ends. And the final notification 30 days before the recredentialing cycle ends.
- If andros does not receive a response from these attempts by the 5th business day of the month you are due to be recredentialed, you will be terminated from Horizon BCBSNJ’s networks at the end of that month. No additional requests will be sent and no information will be accepted after the first of that month.
If you have questions, call andros at 1-866-688-8881, ext. 2.
You will be provided a copy of the Ancillary Recredentialing Application form in the Horizon recredentialing notification package.
Hard copy recredentialing information and required source documents may be submitted to Horizon by mail at:
Provider Data Management, PP-14C 3 Penn Plaza East
Newark, NJ 07105
To ensure that the recredentialing process runs smoothly for you, please confirm that:
- All questions are answered.
- All information and required source documents are current and included (for example, your proof of malpractice insurance – the item most frequently missing or expired).
- Information on the application matches the information on your source documents.
- Your Attestation has not expired.
PROVIDER DIRECTORY MANAGEMENT POLICY
It’s critical that the provider file information we maintain and display is accurate and up-to-date as this information is used to populate our Online Doctor & Hospital Finder. Inaccurate or outdated information may result in a misrepresentation of your practice to patients and referring physician or other health care professionals searching our Online Doctor & Hospital Finder.
Horizon BCBSNJ’s Provider Directory Management administrative policy addresses situations in which we are unable to validate whether information included within our provider files is current and accurate.
Our Provider Directory Management administrative policy outlines the process Horizon BCBSNJ staff and business partners acting on our behalf will take as they work to ensure that the information within our provider files is correct. This revised policy also outlines actions that will be taken in regard to provider directory inclusion and continued participation of practice location(s) and/or practitioners whose information we are unable to validate.
Based on the guidelines within our Provider Directory Management administrative policy:
Horizon validates practitioner Physician Office Manual 89 Policies, Procedures and General Guidelines information every 90 days through outreach efforts conducted by our business partners, CAQH and Atlas Systems. These outreach efforts seek to validate that the information we have on file is accurate.
Our business partners will pursue their outreach for a period of 90 days.
If the initial outreach efforts of our business partner(s) are not successful, Horizon staff will conduct a secondary 90-day outreach effort to validate that the information we have on file is accurate.
While this secondary outreach is conducted, the information pertaining to practitioners in question will be suppressed from appearing within our Online Doctor and Hospital Finder.
- If, at the end of this second 90-day period, we are unable to validate that the information we have on file is accurate, the practice location(s) and/or practitioner in question will be terminated from all Horizon networks. We encourage you to review our Provider Directory Management administrative policy online. To access this information, registered NaviNet users may sign in to NaviNet.net, select Horizon BCBSNJ from the My Health Plans menu and:
- Mouse over References and Resources and click Provider Reference Materials.
- Mouse over Policies & Procedures and click Policies.
- Click Administrative Policies.
- Click Provider Directory Management.
PRODUCTS THAT USE TIERING AND/OR A SUBSET OF AN EXISTING HORIZON NETWORK
Horizon has revised our policy that outlines our process for selecting physicians and other health care who will be included for participation in one or more of the products that use tiering and/or a subset of an existing network.
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.
MEMBERS WITHOUT PROPER ID CARDS
If a member is unable to present an ID card at the time of service, there are several ways to verify eligibility:
- If you are a registered NaviNet user, you may check patient eligibility on NaviNet.net.
- You may ask the member for a copy of his or her signed application or, for Medicare Advantage members, a copy of their confirmation of enrollment letter.
- Your patient may present a proof of coverage letter or virtual ID card, obtained by visiting HorizonBlue.com. Please treat the proof of coverage letters and virtual ID cards as you would any other Horizon ID card.
If the member’s status is unclear after reasonable attempts to verify coverage, you have the option of billing the member for the visit. If the member is actively enrolled, we will ask that you reimburse the member.
ASKING A MEMBER TO SELECT ANOTHER ANCILLARY PROVIDER
The patient/provider relationship is essential to the delivery of quality, coordinated health care. In rare instances, this relationship can become seriously eroded if, for example, a member does not comply with treatment regimens or is abusive to you or your staff.
In such situations, you may initiate a discussion with your patient, asking him or her to choose another ancillary provider.
If the member does not select a new ancillary provider, please follow up with a letter to the member personally signed by your facility or office.
NONSOLICITATION OF OUR CUSTOMERS
Horizon provides information on our customers and health benefit plans (and administrative services arrangements) to enable ancillary providers to provide services to our members. This information is proprietary to Horizon.
As a participating ancillary provider, you may not infringe on Horizon’s relationship with any of our customers, including groups or members, by (directly or indirectly) soliciting any customer, member or group to enroll in any other health benefits plan (or administrative services arrangement).
Nor may you use any information as to Horizon’s benefit plans (or administrative services arrangements) or customers for any competitive purpose or provide it to any person or entity for financial gain.
TERMINATING YOUR PARTICIPATION IN THE NETWORK
There are certain policies and procedures you must follow when your Ancillary Agreement(s) are terminated. Following these policies and procedures will help to ensure that your patients continue to receive care by a participating ancillary provider.
You are also required to notify us if you are retiring or moving your practice out of the area pursuant to the termination provisions under your Agreement
If you decide to terminate your Agreement(s), please send a request for termination notice to your Ancillary Contracting Specialist.
Effective Date of Termination
Your effective date of termination (unless another date is agreed upon by you and Horizon) will be:
- 90 days following the receipt of your termination letter from Horizon networks without cause.
- 60 days following receipt of your termination letter from Horizon networks with cause.
Patients Undergoing a Course of Treatment
You are required to notify us of any Horizon members undergoing a course of treatment. Please prepare a list of members and send it to your Ancillary Contracting Specialist. We, in turn, notify those members who are receiving a course of treatment of your termination from the Horizon Managed Care Network or Horizon PPO
Network prior to the effective date of your termination.
Authorizations are established for any members who require continued care.
Our Request for Continuity of Practitioner Care for Medical Benefits form is available online and may be completed by a member or by your office on behalf of a member.
To access this form, visit HorizonBlue.com/cocmedicalform.
Continued Provision of Care
In most instances, you must treat existing Horizon patients for up to four months beyond your effective date of termination if they are in the midst of an ongoing course of treatment.
Members undergoing certain courses of treatment are granted longer periods of care as indicated below:
- Psychiatric treatment: Up to one year.
- Pregnancy, through postpartum evaluation: six weeks after delivery.
- Post-operative care: Up to six months.
- Oncological treatment: Up to one year.
You are required to accept our reimbursement for services provided during these extended periods as payment in full, less any applicable copayments, coinsurance or deductible amounts. All benefits shall be subject to contract limits and Horizon BCBSNJ’s policies and procedures, including, but not limited to, payment at Horizon BCBSNJ’s fee schedule, prior authorization and medical management requirements.
If you have questions, please contact your Ancillary Contracting Specialist.
Rescinding a Request to Terminate
If you decide to rescind a recently submitted termination request, please contact your Ancillary Contracting Specialist in writing before the effective date of termination.
SPECIALTY MEDICAL SOCIETY RECOMMENDATIONS
Horizon BCBSNJ recognizes that from time to time, specialty societies will issue recommendations for new or updated technologies or treatments. To submit a new recommendation for consideration by Horizon’s Medical Policy Department, please provide the following information:
- A detailed description of the technology or treatment and the recommendation on the specialty society’s letterhead.
- A list of the references and/or case studies used to determine the recommendation.
- The contact information for a representative of the specialty society who can respond to questions related to this recommendation.
This information should be submitted as soon as possible to
Medical Policy Department
3 Penn Plaza East, PP-12S
Newark, NJ 07105-2200
A medical emergency is a medical condition manifesting itself by acute symptoms of sufficient severity including, but not limited to, severe pain, psychiatric disturbances and/or symptoms of substance use disorder such that a prudent lay person, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:
- Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy.
- Serious impairment to bodily functions.
- Serious dysfunction of a bodily organ or part.
With respect to a pregnant woman who is having contractions, an emergency exists where:
- There is inadequate time to effect a safe transfer to another hospital before delivery.
- The transfer may pose a threat to the health or safety of the woman or unborn child.
When you refer a member to the Emergency Room (ER), you must contact us within 48 hours. Members who use the ER for routine care may be responsible for all charges except the medical emergency screening exam.
If emergency care is obtained with the assumption that the member’s health is in serious danger, but it is later determined that it was not an emergency, the medical emergency screening exam would still be covered.
Urgent care is defined as a non-life-threatening condition that requires care by a physician or health care professional within 24 hours.
In situations requiring urgent care, members are instructed to contact their Primary Care Physician, who can then assess the situation and coordinate the appropriate medical treatment.
If you recommend urgent treatment at your facility or office and the member goes to a hospital ER instead, the resulting charges will be the member’s responsibility.
URGENT CARE CENTERS
Urgent Care Centers (UCC) provide an alternative to the Emergency Room (ER) for an injury or illness that requires immediate care but is not life threatening. Treatment often costs considerably less than care in an ER and an average visit usually lasts less than one hour.
The UCCs in Horizon’s network have extended and weekend hours. Treatment is available for wounds, sprains and other conditions that require attention within 24 hours, but do not pose a danger to a person’s life or long-term health. All UCCs participating with Horizon can perform essential medical services, diagnosis illness and treat emergent conditions.
Routine office visits, including preventive care, sports physicals, routine obstetric services, occupational medicine and physical therapy are not covered at UCCs. Members may access UCCs without a referral. Specialist copay applies for this service.
COLLECTION OF MEMBER LIABILITY: DEDUCTIBLE AND COINSURANCE
At the time of service you may collect copayment amounts as indicated on the member’s ID card.
Additionally, you are expected to bill members for the appropriate member liability (deductible and/or coinsurance), as indicated on the Explanation of Payment (EOP) you receive.
You are required to accept our allowance for eligible services as payment in full.
To protect our members, Horizon forbids participating ancillary providers from adding a collection fee, interest or other amount to the member liability until the member has had a reasonable opportunity to pay (e.g., a minimum of 30 days).
We encourage you to inform our members in advance of your billing practices for the collection of member liability and of any fees or interest that you charge when member liabilities are not paid in a timely manner.
CONFIDENTIALITY OF MEDICAL RECORDS AND PERSONAL INFORMATION
Ancillary providers are responsible for complying with all applicable state and federal laws and regulations regarding confidentiality of medical records and individually identifiable health information, including, without limitation, the privacy requirements of HIPAA (the federal Health Insurance Portability and Accountability Act of 1996, Pub. L. 104-19, and any regulations promulgated thereunder) no later than the effective date of those state and federal laws.
MEDICAL RECORDS REQUESTS BY PATIENTS
Members have the right to request and receive a copy of their medical records and request that the records be amended or corrected.
We reprint, on the following pages, an excerpt of the actual regulation of the State of New Jersey Board of Medical Examiners on the preparation and release of information if requested by the patient or an authorized representative.
From the State Board of Medical Examiners Statutes and Regulations
(13:35-6.5) Preparation of patient records, computerized records, access to or release of information; confidentiality, transfer or disposal of records.
The following terms shall have the following meanings unless the context in which they appear otherwise: Authorized representative means, but is not necessarily limited to, a person who has been designated by the patient or a court to exercise rights under this section. An authorized representative may be the patient’s attorney or an employee of an insurance carrier with whom the patient has a contract which provides that the carrier be given access to records to assess a claim for monetary benefits or reimbursement. If the patient is a minor, a parent or guardian who has custody (whether sole or joint) will be deemed to be an authorized representative, except where the condition being treated relates to pregnancy, sexually transmitted disease or substance use disorder.
Examinee means a person who is the subject of professional examination where the purpose of that examination is unrelated to treatment and where a report of the examination is to be supplied to a third-party.
Licensee means any person licensed or authorized to engage in a health care profession regulated by the Board of Medical Examiners.
Patient means any person who is the recipient of a professional service rendered by a licensee for purposes of treatment or a consultation relating to treatment.
- Licensees shall prepare contemporaneous, permanent professional treatment records. Licensees shall also maintain records relating to billings made to patients and third-party carriers for professional services. All treatment records, bills and claim forms shall accurately reflect the treatment or services rendered. Treatment records shall be maintained for a period of seven years from the date of the most recent entry.
- To the extent applicable, professional treatment records shall reflect:
- The dates of all treatments;
- The patient complaint;
- The history;
- Findings on appropriate examination;
- Progress notes;
- Any orders for tests or consultations and the results thereof;
- Diagnosis or medical impression;
- Treatment ordered, including specific dosages, quantities and strengths of medications including refills if prescribed, administered or dispensed and recommended follow up;
- The identity of the treatment provider if the service is rendered in a setting in which more than one provider practices;
- Documentation when, in the reasonable exercise of the physician’s judgment, the communication of test results is necessary and action thereon needs to be taken, but reasonable efforts made by the physician responsible for communication have been unsuccessful; and
- Documentation of the existence of any advance directive for health care for an adult or emancipated minor and associated pertinent information. Documented inquiry shall be made on the routine intake history form for a new patient who is a competent adult or emancipated minor. The treating doctor shall also make and document specific inquiry of or regarding a patient in appropriate circumstances, such as when providing treatment for a significant illness or where an emergency has occurred presenting imminent threat to life, or where surgery is anticipated with use of general anesthesia.
- Corrections/additions to an existing record can be made, provided that each change is clearly identified as such, dated and initialed by the licensee.
- A patient record may be prepared and maintained on a personal or other computer only when it meets the following criteria:
- The patient record shall contain at least two forms of identification, for example, name and record number or any other specific identifying information;
- An entry in the patient record shall be made by the physician contemporaneously with the medical service and shall contain the date of service, date of entry and, full printed name of the treatment provider. The physician shall finalize or sign the entry by means of a confidential personal code (CPC) and include date of the signing;
- Alternatively, the physician may dictate a dated entry for later transcription. The transcription shall be dated and identified as preliminary until reviewed, finalized and dated by the responsible physician as provided in (b)3ii above;
- The system shall contain an internal permanently activated date and time recordation for all entries, and shall automatically prepare a back-up copy of the file;
- The system shall be designed in such a manner that, after signing by means of the CPC, the existing entry cannot be changed in any manner. Notwithstanding the permanent status of a prior entry, a new entry may be made at any time and may indicate correction to a prior entry;
- Where more than one licensee is authorized to make entries into the computer file of any professional treatment record, the physician responsible for the medical practice shall assure that each such person obtains a CPC and uses the file program in the same manner;
- A copy of each day’s entry, identified as preliminary or final as applicable, shall be made available promptly:
- To a physician responsible for the patient’s care;
To a representative of the Board of Medical Examiners, the Attorney General or the Division of Consumer Affairs as soon as practicable and no later than 10 days after notice; and
- To a patient as authorized by this rule within 30 days of request (or promptly in the event of emergency); and
- To a physician responsible for the patient’s care;
A licensee wishing to continue a system of computerized patient records, which system does not meet the requirements of (b)3i through vii above, shall promptly initiate arrangements for modification of the system which must be completed by October 19, 1993.
In the interim, the licensee shall assure that, on the date of the first treatment of each patient treated subsequent to October 19, 1992, the computer entry for that first visit shall be accompanied by a hard copy printout of the entire computer- recorded treatment record. The printout shall be dated and initialed by the attending licensee. Thereafter, a hard copy shall be prepared for each subsequent visit, continuing to the date of the changeover of computer program, with each page initialed by the treating licensee. The initial printout and the subsequent hard copies shall be retained as a permanent part of the patient record.
- To the extent applicable, professional treatment records shall reflect:
- Licensees shall provide access to professional treatment records to a patient or an authorized representative in accordance with the following:
- No later than 30 days from receipt of a request from a patient or an authorized representative, the licensee shall provide a copy of the professional treatment record, and/or billing records as may be requested. The record shall include all pertinent objective data including test results and x-ray results, as applicable, and subjective information.
- Unless otherwise required by law, a licensee may elect to provide a summary of the record in lieu of providing a photocopy of the actual record, so long as that summary adequately reflects the patient’s history and treatment. A licensee may charge a reasonable fee for the preparation of a summary which has been provided in lieu of the actual record, which shall not exceed the cost allowed by (c)4 below for that specific record.
- If, in the exercise of professional judgment, a licensee has reason to believe that the patient’s mental or physical condition will be adversely affected upon being made aware of the subjective information contained in the professional treatment record or a summary thereof, with an accompanying notice setting forth the reasons for the original refusal, shall nevertheless be provided upon request and directly to:
- The patient’s attorney;
- Another licensed health care professional;
- The patient’s health insurance carrier through an employee thereof; or
- A governmental reimbursement program or an agent thereof, with responsibility to review utilization and/or quality of care.
- Licensees may require a record request to be in writing and may charge a fee for:
- The reproduction of records, which shall be no greater than $1 per page or $100 for the entire record, whichever is less. (If the record requested is less than 10 pages, the licensee may charge up to
$10 to cover postage and the miscellaneous costs associated with retrieval of the record.) If the licensee is electing to provide a summary in lieu of the actual record, the charge for the summary shall not exceed the cost that would be charged for the actual record; and/or
- The reproduction of X-rays or any material within a patient record which cannot be routinely copied or duplicated on a commercial photocopy machine, which shall be no more than the actual cost of the duplication of the materials, or the fee charged to the licensee for duplication, plus an administrative fee of the lesser of $10 or 10 percent of the cost of reproduction to compensate for office personnel time spent retrieving or reproducing the materials and overhead costs.
- The reproduction of records, which shall be no greater than $1 per page or $100 for the entire record, whichever is less. (If the record requested is less than 10 pages, the licensee may charge up to
- Licensees shall not charge a patient for a copy of the patient’s record when:
- The licensee has affirmatively terminated a patient from practice in accordance with the requirements of N.J.A.C. 13:35-6.22; or
- The licensee leaves a practice that he or she was formerly a member of, or associated with, and the patient requests that his or her medical care continue to be provided by that licensee.
- If the patient or a subsequent treating health care professional is unable to read the treatment record, either because it is illegible or prepared in a language other than English, the licensee shall provide a transcription at no cost to the patient.
- The licensee shall not refuse to provide a professional treatment record on the grounds that the patient owes the licensee an unpaid balance if the record is needed by another health care professional for the purpose of rendering care.
- Licensees shall maintain the confidentiality of professional treatment records, except that:
- The licensee shall release patient records as directed by a subpoena issued by the Board of Medical Examiners or the Office of the Attorney General, or by a demand for statement in writing under oath, pursuant to N.J.S.A. 45:1-18. Such records shall be originals, unless otherwise specified, and shall be unedited, with full patient names. To the extent that the record is illegible, the licensee, upon request, shall provide a typed transcription of the record. If the record is in a language other than English, the licensee shall also provide a translation. All X-ray films and reports maintained by the licensee, including those prepared by other health care professionals, shall also be provided.
- The licensee shall release information as required by law or regulation, such as the reporting of communicable diseases or gunshot wounds or suspected child abuse, etc., or when the patient’s treatment is the subject of peer review.
- The licensee, in the exercise of professional judgment and in the best interests of the patient (even absent the patient’s request), may release pertinent information about the patient’s treatment to another licensed health care professional who is providing or has been asked to provide treatment to the patient, or whose expertise may assist the licensee in his or her rendition of professional services.
- The licensee, in the exercise of professional judgment, who has had a good faith belief that the patient because of a mental or physical condition may pose an imminent danger to himself or herself or to others, may release pertinent information to a law enforcement agency or other health care professional in order to minimize the threat of danger. Nothing in this paragraph, however, shall be construed to authorize the release of the content of a record containing identifying information about a person who has AIDS or an HIV infection, without patient consent, for any purpose other than those authorized by N.J.S.A. 26:5C-8. If a licensee, without the consent of the patient, seeks to release information contained in an AIDS/HIV record to a law enforcement agency or other health care professional in order to minimize the threat of danger to others, an application to the court shall be made pursuant to N.J.S.A. 26:5C-5 et seq.
- Where the patient has requested the release of a professional treatment record or a portion thereof to a specified individual or entity, in order to protect the confidentiality of the records, the licensee shall:
- Secure and maintain a current written authorization, bearing the signature of the patient or an authorized representative;
- Assure that the scope of the release is consistent with the request; and
- Forward the records to the attention of the specific individual identified or mark the material Confidential.
- Where a third-party or entity has requested examination, or an evaluation of an examinee, the licensee rendering those services shall prepare appropriate records and maintain their confidentiality, except to the extent provided by this section. The licensee’s report to the third party relating to the examinee shall be made part of the record. The licensee shall:
- Assure that the scope of the report is consistent with the request, to avoid the unnecessary disclosure of diagnoses or personal information which is not pertinent;
- Forward the report to the individual entity making the request, in accordance with the terms of the examinee’s authorization; if no specific individual is identified, the report should be marked Confidential; and
- Not provide the examinee with the report of an examination requested by a third party or entity unless the third party or entity consents to its release, except that should the examination disclose abnormalities or conditions not known to the examinee, the licensee shall advise the examinee to consult another health care professional for treatment.
- If a licensee ceases to engage in practice or it is anticipated that he or she will remain out of practice for more than three months, the licensee or designee shall:
- Establish a procedure by which patients can obtain a copy of the treatment records or acquiesce in the transfer of those records to another licensee or health care professional who is assuming responsibilities of the practice. However, a licensee shall not charge a patient, pursuant to (c)4 above, for a copy of the records, when the records will be used for purposes of continuing treatment or care.
- Publish a notice of the cessation and the established procedure for the retrieval of records in a newspaper of general circulation in the geographic location of the licensee’s practice, at least once each month for the first three months after the cessation; and
- Make reasonable efforts to directly notify any patient treated during the six months preceding the cessation, providing information concerning the established procedure for retrieval of records.
Note: The Medical Record fee does not apply to Horizon BCBSNJ’s request for medical records.
CLINICAL PRACTICE GUIDELINES
Horizon BCBSNJ’s clinical practice guidelines (CPGs) are available to all participating ancillary providers.
These guidelines were adopted from nationally known organizations such as the Advisory Committee on Immunization Practices, the American Academy of Pediatrics, the American Academy of Family Physicians, the American Psychiatric Association, the Agency for Health Care Policy and Research, the American Society of Addictive Medicine and the American Diabetes Association. They also include Healthcare Effectiveness Data and Information Set (HEDIS®) technical specifications.
Horizon BCBSNJ CPGs
Registered users of NaviNet can view, print or download our CPGs. To view this information online:
- Log in to NaviNet.net.
- Select Horizon BCBSNJ from the My Health Plans menu.
- Mouse over References and Resources click Provider Reference Materials.
- Under Additional Information, click Clinical Practice Guidelines.
Copies of our CPGs can also be mailed to you. Email your request to: QualityManagement_Coordinator@HorizonBlue.com.
Note: The Horizon CPGs do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of reimbursement. The CPGs are confidential and proprietary. They are to be used only as authorized by Horizon and its affiliates. The contents of these CPGs are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of these CPGs may be updated or changed without notice. However, benefit determinations are made in the context of CPGs existing at the time of the decision, and are not subject to later revision as the result of a change in guidelines.
NEVER EVENTS GUIDELINES
The term “never events” is used to reference adverse events or errors in medical care that are clearly identifiable, preventable and present serious consequences to patients. Never events include hospital-acquired conditions and wrong surgeries.
Horizon BCBSNJ follows the Centers for Medicare & Medicaid Services’ (CMS) reimbursement policy for never events, including certain conditions identified by the state of New Jersey. Horizon BCBSNJ will not reimburse hospitals for any services related to wrong surgeries and may reduce reimbursements to hospitals for services to treat hospital-acquired conditions that were not present on admission. Members must be held harmless for any reimbursement for services related to never events, including hospital-acquired conditions and wrong surgeries. Horizon BCBSNJ will conduct a clinical quality review of all claims with the identified never events and hospital-acquired conditions listed below. Any claim issues identified during our review will be presented to the hospital for further review, as appropriate.
Hospital medical records may be requested to facilitate the review. Hospitals should include a Present on Admission (POA) indicator on all claims.
Never Events Subject to Review
Hospital-Acquired Conditions (HACs)
- Pressure ulcers, stages III and IV.
- Catheter-associated urinary tract infections.
- Vascular catheter-associated infection.
- Surgical site infection, mediastinitis, following coronary artery bypass graft (CABG).
- Air embolism.
- Blood incompatibility.
- Foreign object retained after surgery.
- Falls and trauma (fracture, dislocation, intracranial injury, crashing injury, burn, electric shock).
- Surgical-site infections following certain orthopedic procedures.
- Surgical-site infections following bariatric surgery for obesity.
- Manifestations of poor glycemic control.
- Deep vein thrombosis and pulmonary embolism following certain orthopedic procedures.
- Surgery performed on a wrong body part.
- Surgery performed on a wrong patient.
- Wrong surgical procedure performed.
Note: HACs were included on CMS’ list of never events as of October 1, 2008. Wrong surgeries were adopted by CMS on January 15, 2009.