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Service

We understand you may have questions or need information about patients’ health care plans outside of our regular business hours. We strive to have systems and processes in place that allow you to contact us in ways that are efficient, flexible and compatible with your practice.

INTERACTIVE VOICE RESPONSE (IVR) SYSTEM

The Interactive Voice Response (IVR) system expands your options for contacting us, allowing you to obtain the information you need in a more convenient manner. You can access information 24 hours a day, seven days a week, generally including weekends and holidays, and get instant answers to many questions previously handled only by our service representatives.

Our speech recognition technology gives you the option of speaking your request in a natural manner, much like you would when speaking with a service representative.

We encourage you to access the easy-to-use IVR system by calling 1-800-624-1110 and exploring all the information and services that it has to offer.

IVR

Use your natural voice or the touchtone keypad to enter the patient’s ID number or navigate through the call, whichever is right for the environment you’re in.

Here are some tips to help you navigate our IVR system:

  • Speak clearly in your natural tone.
  • If accessing the IVR from a noisy environment, please mute your phone and use the keypad to enter your responses.
  • Say numbers one digit at a time.
  • When speaking numbers, say zero rather than O.
  • You may return to the main menu at any time by saying main menu. You may also say repeat or help.
  • You don’t have to listen to all the options. Go directly to the option you want by using the following voice prompts. Just say ...
    Eligibility and Benefits to verify that a patient is enrolled under a Horizon BCBSNJ plan or to check their benefits (FEP® benefits and eligibility are separate menu options).
    Authorizations to check the status of an authorization.
    Referrals to refer a patient for a treatment or check the status of an existing referral (if needed).
    Duplicate Vouchers to request a duplicate voucher.

Physician Services Representatives are available to help you and provide information that you may not be able to access through our IVR system. Call 1-800-624-1110, Monday through Friday, between 8 a.m. and 5 p.m., ET.

REFERRAL SUBMISSIONS THROUGH THE IVR SYSTEM

Primary Care Physicians (PCPs), Ob/Gyns and specialists participating in our managed care network may use our IVR system to submit referrals for their Horizon BCBSNJ managed care patients.

OTHER SERVICE AREAS

Horizon BCBSNJ has a number of more specialized service areas that provide more specific information and assistance with authorizations and prior authorizations. For the representative in these specialized service areas to perform their functions efficiently and effectively, it’s important that their time is not spent responding to basic benefits, enrollment and eligibility inquiries.

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 prior authorization, a Physician Services Representative can provide both the information you need and a service reference number that documents the information you were provided.

  • BlueCard® Dedicated Unit – phone: 1-888-435-4383
  • BlueCard/Out-of-state members (eligibility, benefits and prior authorizations) – phone: 1-800-676-BLUE (2583)
  • CareCentrix – phone: 1-855-243-3321
  • eviCore healthcare (prior authorization/medical necessity determinations) – phone: 1-866-496-6200 (radiology and cardiology): 1-866-241-6603
    (pain management): 1-844-224-0493
    (molecular and genomic testing): 1-866-241-6603
    (musculoskeletal program for spine surgery services): 1-866-241-6603
  • fax: 1-800-637-5204 (radiology services) 1-888-785-2480 (cardiology services) 1-800-649-4548 (pain management) 1-800-649-4548 (musculoskeletal)
  • Dental inquiries – phone: 1-800-4-DENTAL (433-6825)
  • EDI Service Desk – e-Business (online capabilities inquiries and help) Provider_Portal@HorizonBlue.com phone: 1-888-777-5075
  • EDI Service Desk - Electronic Data Interchange (EDI) (data feed issues) HorizonEDI@HorizonBlue.com phone: 1-888-334-9242
  • Home care and/or Home IV infusion – fax: 1-800-492-2580
  • Magellan Rx Management (medical necessity and appropriateness reviews of specific injectable medications) – phone: 1-800-424-4508
  • National Provider Identifier (NPI) submission – fax: 1-973-274-4416
  • NaviNet® NaviNet.net – phone: 1-888-482-8057
  • Notices of admission for out-of-state and non-network facilities – phone: 1-888-621-5894

BRAVEN HEALTH PLAN CONTACT INFORMATION

  • Service – 1-833-272-8360
  • Provider Services – 1-888-444-0501
  • Behavioral Health – 1-888-444-0422
  • eService – 1-888-444-0545

UTILIZATION MANAGEMENT CONTACT INFORMATION

If you need to obtain prior authorization for a Horizon BCBSNJ member, you can submit your request via the Utilization Management Request Tool on NaviNet or call 1-800-664-BLUE (2583).

To access our Utilization Management Department after business hours and on weekends, you should call our after-hours emergent clinical issues phone number, 1-888-223-3072.

BEHAVIORAL HEALTH (MENTAL HEALTH AND SUBSTANCE USE DISORDER) CARE

Please check the back of your patient’s ID card for the phone number for behavioral health coverage details. Whether it is an emergency or a request for inpatient or outpatient services, either you or the member should call the behavioral health care number.

With few exceptions, Horizon Behavioral Health coordinates members’ behavioral health benefits. Call 1-800-626-2212 to speak with a Care Manager who can inform you of your patient’s treatment plan and progress. This service is available 24 hours a day, seven days a week.

If Horizon Behavioral Health does not administer your patient’s behavioral health benefits, please contact the behavioral health administrator listed on the back of your patient’s ID card.

COPIES OF AGREEMENTS

As a participating physician or other health care professional, you may request a copy of your AGREEMENT WITH PARTICIPATING PHYSICIANS AND HEALTHCARE PROFESSIONALS or HORIZON HEALTHCARE OF NEW JERSEY, INC. AGREEMENT WITH PARTICIPATING PHYSICIANS AND OTHER HEALTHCARE PROFESSIONALS by emailing a request to EnterprisePDM@horizonblue.com or by mailing a request to:

Horizon BCBSNJ
Three Penn Plaza East, PP-14C
Newark, NJ 07105-2200

NETWORK SPECIALISTS

Your Network Specialist is your primary point of contact for Horizon BCBSNJ products and administrative policies and procedures. He or she is accessible to you when and where you need him or her by phone, email and visits to your office, upon request.

Each Network Specialist faces off to the participating physicians and other health care professionals our local service area (New Jersey and certain counties in New York, Pennsylvania and Delaware)

Medical Professionals:

Network Specialist assignments are available by logging on to NaviNet.net. From My Health Plans menu, select Provider Reference Materials, then:

  • Mouse over Resources and select Network Specialists.

Behavioral Health Professionals:

Behavioral Health Network Specialist assignments are available.

To speak with your Network Specialist, call 1-800-624-1110, and select More Options, then select Network Relations. Behavioral Health professionals can also call 1-800-626-2212.

NAVINET.NET

All participating physicians and health care professionals are required to register for NaviNet within 30 days of your effective date of participation.

Through NaviNet, a multi-payer web portal, your office has access to the important Horizon BCBSNJ information (eligibility, benefits, claims status, online explanations of payments, submit and check status of UM authorization requests etc.) that you need to conduct business with us on a day-to-day basis.

By using NaviNet, your office will have access to Horizon BCBSNJ information, as well as the online information of many other New Jersey health plans.

To learn more about NaviNet, visit NaviNet.net

To access a NaviNet Information Demo, select Provider Reference Materials and mouse over Resources

  • Select Training, then Education
  • Select NaviNet Information Demo

Billing Company Access to NaviNet

If you employ the services of a billing company, we want to remind you that you can help increase their effectiveness and efficiency by encouraging them to register and use NaviNet to carry out their day-to-day responsibilities on your behalf.

To register for NaviNet, the billing company should:

  1. Visit NaviNet.net and click Sign Up.
  2. Follow the instructions and complete the online NaviNet New Registration Request Application using your company’s tax ID number. Ensure that Yes is selected in response to the question: Is your office a billing agency?

    Upon submission of the NaviNet New Registration Request Application, a NaviNet enrollment specialist emails an authorization form and instructions to the billing company contact.

  3. Complete the authorization form. The billing company will need to obtain a signature from your office to grant them access to the information on your behalf.
  4. Fax the completed and signed authorization forms to NaviNet to the fax number provided.

Following the receipt of a completed authorization form, NaviNet processes the enrollment request and emails NaviNet login credentials to the billing company contact.

If your billing company is registered for NaviNet and does not have access to your information, please ask them to forward a copy of the authorization form (see step 3 on the previous section) they originally received from NaviNet for you to sign. For help registering, call NaviNet Customer Care at 1-888-482-8057.

NaviNet Online Capabilities

The online capabilities you can access through NaviNet include:

  • Answers to Frequently Asked Questions
  • Capitation Reports
  • Claim Inquiry (local and out-of-state members)
    • Blue Exchange Claims Appeal
    • Claim Attachments
    • Explanation of Payment (EOP)
  • Claim Submission (CMS 1500 and UB04)
  • Clear Claim Connection
  • COB Questionnaire Submission
  • EFT Registration
  • Eligibility and Benefits Inquiry (local and out-of-state members)
  • Fee Schedule Inquiry
  • Horizon Healthcare Innovations
  • ITS Host Claim Appeal Submission
  • Medical Attachment Submission
  • Payment Status Inquiry
  • PCP Panel Inquiry
  • Physical and Occupational Therapy Authorization
  • Pre-existing Condition Attachment Submission
  • Provider Reference Materials
  • Referral/Authorization Inquiry
  • Referral Submission
  • Statement of Payment Inquiry

New features and improvement made to our Online Services options accessed through NaviNet will be communicated in Blue Review.

Frequently Asked Questions

Horizon BCBSNJ makes answers to questions you might have about your Horizon BCBSNJ patients’ eligibility, benefits, claims and more available to registered NaviNet® users.

To view the Frequently Asked Questions (FAQs) section on NaviNet simply:

  • Sign in to NaviNet.net.
  • Click Help.
  • Select Horizon BCBSNJ within the Health Plans dropdown menu.

Our online FAQs are organized so you can quickly find information about these topics and more:

  • Claims & Payments – View the status of a claim or payment, including how to enroll in Electronic Funds Transfer (EFT).
  • Eligibility & Benefits – Look up which services are covered benefits for a specific Horizon BCBSNJ patient.
  • Provider Resources – Check which plans you participate in and update your demographic information.
  • Referrals & Authorizations – Access Horizon BCBSNJ’s Medical Policies or prior authorization process.
  • Office & Provider Management – Access reports, including capitation and panel reports.

Check out our online FAQs often, as we will continue to add more answers to frequently asked questions.

Capitation Reports

Registered NaviNet users may click Capitation Reports within the Eligibility & Benefits tab to access capitation reports.

This can help you better reconcile your rosters and quickly verify that a patient is, or is not, on your roster in real-time.

  • Primary Care Physicians (PCPs) and their office staff now have access to 12 months of practitioner or group capitation report information.
  • Capitation report information may be generated based on any of the following criteria:
    • Health insurance plan/product
    • Member
    • Month
    • Physician
  • Capitation report information may be downloaded in the format of your choice:
    • HTML
    • Microsoft® Excel
    • PDF

Clear Claim Connection

To help you navigate the health care system, Horizon BCBSNJ offers the Change Healthcare Clear Claim ConnectionTM, a web-based code editing disclosure solution. Clear Claim Connection is designed to help ensure our claim reimbursement policies, related rules, clinical edit clarifications and clinical sourcing information are easily accessible and transparent for our participating physicians and health care professionals. Clear Claim Connection displays Horizon BCBSNJ’s code auditing rules for various code combinations and the corresponding clinical rationale.

To access Clear Claim Connection, log on to NaviNet.net, select Horizon BCBSNJ from the My Health Plans Menu and:

  • Mouse over Claim Management and select Clear Claim Connection.

Within Clear Claim Connection, enter the required data to obtain the appropriate code auditing results. Clear Claim Connection will provide your office with the ability to identify Horizon BCBSNJ’s code auditing rules.

Note: This auditing reference tool will provide results that reflect the reimbursement policies on the current date, not necessarily the service date. Displayed results are not a guarantee of how your actual claim will be processed. Claim reimbursement is subject to member eligibility and all member and group benefit limitations, conditions and exclusions.

Eligibility and Benefits Inquiry

The Eligibility and Benefits Inquiry transaction allows you to access eligibility and benefits information for active local (Horizon BCBSNJ) as well as BlueCard and FEP members.

The Eligibility & Benefits Detail screen displays:

  • Current Primary Care Provider Information (if applicable)
  • Plan information
  • Patient Gender and Date of Birth
  • Patient’s relationship to Subscriber
  • Group Information (if applicable)
  • Service Type information section
  • Benefit Accumulation
  • Prior Authorization Indicator
  • Status (identifies subsidized members who are delinquent on their premium payment)

Service Type Information Section

The Service Type Information section displays various service type product information for the patient.

Benefit Accumulation

Making arrangements to collect amounts that will be applied to a member’s deductible requires that you validate the amount applied to the members’ deductible to date.

To view the deductible amount a member has satisfied to date within Eligibility & Benefits Inquiry.

  • Enter the requested Subscriber Information and click Search. Note: In rare cases, you may see a listing of dependents in instances when multiple matches are found.
  • From the list of dependents that displays, double click the member in question.
  • The annual deductible amount as well as the amount remaining to be satisfied will be displayed in the Health Benefit Plan Coverage section.

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.

Online Credentialing Application

If you’re adding health care professionals to your practice, you can use Horizon BCBSNJ’s online credentialing application.

To use the online credentialing application, log in to NaviNet.net, and select Horizon BCBSNJ on the My Health Plans menu. Select Provider Data Maintenance.

Our credentialing application is accessible to those registered NaviNet users who have

Security Officer rights. If you don’t see Provider Data Maintenance within References and Resources, you may not be set up as the Security Officer for your practice. Call NaviNet Customer Care at 1-888-482-8057 for assistance.

To use our online credentialing application, the health care professional joining your practice must be recognized by our systems. This means that at least one claim must have been previously submitted to Horizon BCBSNJ for the health care professional joining your practice. If the health care professional joining your practice has never submitted a claim to us, visit HorizonBlue.com/whyjoin to print an application.

The online credentialing application:

  • Is integrated with the Council for Affordable Quality Healthcare’s online Universal Provider Datasource® to speed processing and eliminate input errors.
  • Will generate automated email messages to advise you:
    • That your application was received and provides a confirmation number for easier follow up.
    • When your application is approved.
  • Allows you to check the status of your credentialing application online.

Fee Schedule Inquiry Information Online Fee Schedule

Horizon BCBSNJ makes fee information (for most specialties) available to you online immediately. To access online fee schedule information, including Injectable Medication Fee Schedule Information, log in to NaviNet.net and select Horizon BCBSNJ from the My Health Plans menu and:

  • Mouse over Claim Management and select
  • Fee Schedule Inquiry.
  • On the Fee Schedule Inquiry page, select your Billing (Tax) ID number and your county.
  • Then, based on the information you’re seeking, you may either:
    • Select your specialty to view our fees for the most common CPT codes for that specialty, or
    • Enter specific CPT codes to view our allowances for those specific services.

Injectable Medication Fee Information is updated on a quarterly basis (on or around the first day of February, May, August and November).

Fee information for the following services/specialties is not yet available in this immediate electronic format:

  • Anesthesia services
  • Services provided by:
    • Certified nurse specialists
    • Nurse practitioners
    • Physician assistants
    • Registered nurse first assistants

To access the Fee Schedule Inquiry Form, log in to NaviNet.net, select Horizon BCBSNJ from the My Health Plans menu, mouse over Claim Management and select Fee Schedule Inquiry.

Complete the required fields and select Submit Request. The fee schedule information will be emailed to you within 15 days.

HORIZONBLUE.COM

Horizon BCBSNJ makes most of our administrative information and important forms available online so that you have access to what you need when you need it.

Our website provides the tools and resources you need to do business with us, including the ability to:

  • View and print the most commonly used forms, including the:
  • W-9 Tax Form
  • Fax Prior Authorization Request (8319) Form
  • Capitation Adjustment Request (2801) Form
  • Inquiry Request and Adjustment (579) Form
  • Review the Claims Information Quick Reference Guide that highlights service phone numbers, claims and inquiry addresses and appeals/predetermination information for specific prefixes and suffixes.

Online Forms

Horizon BCBSNJ makes most of our forms available. Select Forms and form type. You may also download a blank, printable W-9 form and submit it by mail or fax. Our forms are organized into the following sections:

  • Forms by Plan Type
  • Forms by Specialty Type
  • Forms by Type
  • Frequently Used Forms
  • Miscellaneous
  • W9 Form-Dental
  • W9 Form-Medical

ONLINE EDUCATION RESOURCES

We now offer an online educational resource where information, job aids and training materials are available to you anytime.

We have created an easy-to-use training and education page that will be your starting point to access a variety of information you need to know to conduct business with us. This webpage includes:

  • Horizon BCBSNJ new physician orientation.
  • A collection of online demos and webinars.
  • Horizon BCBSNJ product knowledge courses and assessments.
  • Online user guides, including physician office manuals and information on the BlueCard® program.
  • A section for quick and concise updates and highlights on new features.
  • A section for frequently asked questions and answers.
  • Central, organized and easily accessed locations for:
    • - Newsletters and other communication
  • Horizon BCBSNJ forms
  • Policies and Agreements To access this page:
  • Log in to NaviNet.net and select Horizon BCBSNJ from the My Health Plans menu.
  • Select Provider Reference Materials.

Physician Training Webinars

Our Network Specialists will host online training webinars to introduce new products, reinforce existing product knowledge, highlight our self-service features and more. Visit our online educational resources to learn more.

Interactive Online Classes

Online courses are available to provide valuable information about Horizon BCBSNJ products, initiatives and other topics. Courses are available to all participating physicians, other health care professionals, their office managers and staff.

Courses include assessments to help validate and reinforce understanding of the material presented. We use the assessment data to help us improve the course content and direct other training and education efforts.

If you have questions, contact your Network Specialist.

DOCTOR & HOSPITAL FINDER

Visit use our Doctor & Hospital Finder to locate participating physicians/other health care professionals, hospitals and other health care services providers.

Within the provider profile information of our Doctor & Hospital Finder you can review:

  • Plans providers participate with
  • OMNIA Tier Status
  • Location address
  • Phone number
  • Specialty information
  • Physician hospital affiliations
  • and more

In addition, the Doctor & Hospital Finder provides the NPI number for participating specialists, which is useful when submitting referrals online and via the IVR system.

We also provide a value-added feature offering street maps and detailed directions to physician offices.

You should check your details on our website to ensure your information is accurate. Updates to your demographic information may be performed online or by fax request.

Provider File Change Request Form

To initiate a provider file change request, please do one of the following:

Email EnterprisePDM@HorizonBlue.com with the practitioner’s name in the subject line, attach any supporting documentation with the request and indicate the applicable network(s);

or

Mail:

Horizon BCBSNJ Provider Files
3 Penn Plaza East, PP-14C
Newark, NJ 07105-2200

ELECTRONIC DATA INTERCHANGE

Our EDI Service Desk supports all of the most common Electronic Data Interchange (EDI) transactions. All of our transactions are based on the nationally accepted American National Standard Institute (ANSI) format. Some of the transactions are set as a real-time process, providing responses within seconds, while others run in a batch format.

Transactions We Handle

  • Physician, Hospital and Dental Claims (837)
  • Eligibility Inquiry and Response (270/271)
  • Request for Authorization/Review (278)
  • Referrals (278)
  • Claim Status and Response (276/277)
  • Benefit Enrollment and Maintenance (834)
  • Claim Payment Advice (835)
  • Premium Payment (820)

Benefits of EDI

  • Faster exchange of information
  • Improved accuracy
  • Reduced postage cost
  • Reduced administrative cost
  • Elimination of paper documents
  • Timely postings
  • Reduced handling
  • Reduced reimbursement cycle
  • Tracking capabilities
  • More efficient means of conducting business
  • Minimize possibility of lost or misrouted documents

If you have questions about EDI transactions, or for more information, call the EDI Service Desk team at 1-888-334-9242, Monday through Friday, between 7 a.m. and 6 p.m., Eastern Time, or send an email to HorizonEDI@HorizonBlue.com.

RENDERING, REFERRING AND ATTENDING PHYSICIAN NPI REQUIREMENT

Horizon BCBSNJ captures National Provider Identifier (NPI) information for rendering, referring and attending physicians.

Submit NPI information on all appropriate electronic and paper copy claim submissions. Ensure that your claim submissions include rendering, referring and attending physician NPI information to avoid claim transaction rejections and/or delays in the processing of your claim submissions.

If you have technical questions about NPI or questions regarding electronic transactions, call our EDI Service Desk at 1-888-334-9242, Monday through Friday, between 7 a.m. and 6 p.m., ET. Or, email your inquiry to HorizonEDI@HorizonBlue.com