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Utilization Management

Horizon BCBSNJ’s.Utilization Management Program is based on the premise that quality medical care is the single most important element in delivering cost-effective care. Our Utilization Management Program is a coordinated and comprehensive program designed to achieve medically appropriate and cost-effective delivery of health care services to members within the parameters of the benefits available under each member’s benefit contract.

While there is recognition that there is a wide variation of appropriate medical practice, Utilization Management activities are intended to identify optimal modes of practice and, when possible, to help ensure ancillary providers manage care in a medically appropriate and cost-effective manner. We know that underutilization of appropriate services can be as detrimental to our member’s health status and our medical costs as overutilization.

Horizon BCBSNJ adheres to the following principles in the conduct of our Utilization Management Program:

  • Bases Utilization Management decisions on necessity and appropriateness of care and service within the parameters of the member’s benefit package.
  • Does not compensate those responsible for making Utilization Management decisions in a manner that encourages them to deny coverage for medically necessary and appropriate covered services.
  • Does not offer our employees or delegates performing Utilization Management reviews incentives to encourage denials of coverage or service and does not provide financial incentives to ancillary providers to withhold covered health care services that are medically necessary and appropriate.
  • Emphasizes the provision of medically necessary and cost-effective delivery of health care services to members and encourages the reporting, investigation and elimination of underutilization.

Horizon BCBSNJ’s Utilization Management Program functions under the HCAPPA definition in much the same way as it has previously (when applicable). Our medical policies and criteria used to help us reach decisions about medical necessity for coverage purposes have been revised for compliance with HCAPPA’s definition standard.

As required by HCAPPA, policies and criteria, information about the processing and reimbursement of claims is available at HorizonBlue.com.

REQUESTING AUTHORIZATION

You must contact Horizon BCBSNJ before rendering services to our members who require prior authorization.

Horizon BCBSNJ accepts requests for authorization for coverage of services from members and/or from providers acting on behalf of the member. This includes but is not limited to the attending/ordering physician or provider that is requesting the authorization as the member/claimant’s authorized representative.

Benefits will always dictate coverage; some services are subject to individual benefit limitations. The individual protocols and criteria that Horizon BCBSNJ uses to render utilization management decisions are available upon request.

Authorizations older than six months, in accordance with industry standards, will not be honored by Horizon BCBSNJ and will require a new review of the current clinical circumstances.

ONLINE AUTHORIZATIONS FOR PT AND OT SERVICES

In most cases, Horizon BCBSNJ authorizes the initial 12 visits of outpatient physical therapy or occupational therapy (PT/OT) services upon receipt of an initial claim from a participating physical therapist or occupational therapist.

Eligibility and benefits must be confirmed prior to providing the service.

A prior authorization must be obtained in the following situations:

  • Other PT or OT services have already been authorized in the current calendar year.
    • Need to review annual benefit limits.
  • Diagnosis-related temporomandibular joint (TMJ) disorders.
    • Need to review for benefit and medical necessity.
  • Treatment for work-related injuries.
  • Patients under 19 years of age.
    • Review for medical necessity.
  • More than 12 visits are required.
  • All services from nonparticipating providers.

Prior authorizations can be requested using our online Physical and Occupational Therapy Authorization tool available on NaviNet.net.

Please remember that you still must check member eligibility and benefits by logging onto NaviNet.net prior to treating the patient.

Claims processing and reimbursement for services provided are subject to member eligibility and all member and group benefits, limitations and exclusions.

Note: The PT/OT tool is for the use of rendering physical therapy and occupational therapy providers only. This tool cannot be used to create referrals for physical therapy or occupational therapy services.

Please include the CPT-4 procedure codes and the ICD-10 diagnosis codes when you fax the information.

Upon review of all routine, non urgent requests are determined not to exceed 17 days from our receipt of all required clinical information. Urgent requests are determined as soon as possible, not to exceed 72 hours from receipt, based on the medical urgency of the case.

If you receive a denial notification for a patient, you may discuss the determination with the physician who rendered the decision. The physician’s name and phone number will be on the denial notification.

Prior Authorization Procedure Search Tool

Our Prior Authorization Procedure Search tool allows you to enter a CPT® or HCPCS code and select a place of service (e.g., inpatient, outpatient, office, home) to determine if the particular service provided in the selected service setting requires a prior authorization.

The tool, as well as certain prior authorization lists for ASO member groups, is accessible on HorizonBlue.com/priorauthtool.

To determine if a patient is fully insured or part of an ASO member group, please refer to the back of the member’s ID card.

Fully insured members’ cards will state: “Insured by Horizon Blue Cross Blue Shield of New Jersey.”

ASO members’ cards will state: “Horizon Blue Cross Blue Shield of New Jersey provides administrative services only and does not assume financial risk for claims.”

TIME FRAMES FOR AUTHORIZATION/ ADDITIONAL INFORMATION REQUESTS

Horizon BCBSNJ follows HCAPPA-mandated time frames, where applicable, when responding to requests for authorization or when requesting additional information from an ancillary provider.¹

HCAPPA mandates that health insurers respond to requests for authorizations as soon as possible but not greater than 72 hours. Hours for current urgent care situations including inpatient admissions and within 15 calendar days for elective inpatient or outpatient services. However, Horizon BCBSNJ does not require authorization for emergency services and, therefore, our practices relating to emergency services have not changed as a result of HCAPPA.

Generally, all non emergent inpatient admissions and some outpatient services require an authorization.

For urgent admissions, HCAPPA requires that the hospital, physician or other health care professional respond to our request for additional information within 72 hours.

The law provides that if a hospital, physician or other health care professional does not respond within this time frame, the original authorization request within the HCAPPA time frame will be deemed withdrawn.

Conversely, if Horizon BCBSNJ fails to respond timely to an authorization request, it is deemed an approval of the request.

¹Members/covered persons enrolled in certain plans are not affected by HCAPPA and their authorization/additional information time frames may vary from what is described here. For example, authorization/additional information time frames for members/covered persons of certain plans such as ASO and self-insured accounts may vary from what is described here.

HONORING OTHER CARRIERS’ AUTHORIZATION

Under HCAPPA (where it applies), in the event a member is no longer eligible for coverage from Horizon BCBSNJ and Horizon BCBSNJ issued an authorization, the member’s subsequent health insurer must honor the authorization.1

However, HCAPPA also provides that the subsequent health insurer does not need to honor the authorization if the service is not covered under the member’s benefits contract with the subsequent health insurer.

In instances where Horizon BCBSNJ is the subsequent carrier, Horizon BCBSNJ will request adequate proof of the prior carrier’s authorization, and that it was obtained based on an accurate disclosure of the relevant medical facts and circumstances involved in the case.

Upon validation, Horizon BCBSNJ will honor the prior carrier’s authorization. However, in accordance with industry standards, authorizations more than six months old will not be honored by Horizon BCBSNJ and will require a new review of the current clinical circumstances.

¹Members/covered persons enrolled in certain plans, such as ASO and. self-insured accounts, are not affected by HCAPPA and their authorization information may not be honored by the subsequent carrier.

HORIZON CARE@HOME

Horizon BCBSNJ is committed to providing our members with access to high-quality home health care services. As part of that commitment, Horizon BCBSNJ collaborates with CareCentrix1, a home health benefits management company, to administer certain services for the Horizon Care@Home program.

¹Horizon BCBSNJ contracts with CareCentrix, Inc., a Delaware corporation and its subsidiary, CareCentrix of New Jersey, Inc., a New Jersey corporation licensed by the NJ Department of Banking and Insurance as an Organized Delivery System to administer certain services for the Horizon Care@Home program.

CareCentrix credentials, manages and maintains the Horizon Care@Home network of ancillary services providers, arranges for the delivery of and conducts the utilization management for these Horizon Care@Home services:

  • Durable medical equipment (includingmedical foods [enteral], and diabetic and other medical supplies)
  • Orthotics and prosthetics
  • Home infusion therapy
  • Diabetic and other medical supplies

Traditional home health (including in-home nursing services, physical therapy, occupational therapy and speech therapy) is managed by Horizon BCBSNJ.

Prior Authorization/Pre-service Registration

CareCentrix is responsible for ensuring certain Horizon Care@Home services are medically necessary and appropriate through its utilization management activities, including:

  • Durable medical equipment (including medical foods [enteral], and diabetic and other medical supplies)
  • Orthotics and prosthetics
  • Home infusion therapy
  • Diabetic and other medical supplies

For home health services (including in-home nursing services, physical therapy, occupational therapy and speech therapy), you must obtain prior authorization using Horizon BCBSNJ’s online Utilization Management Request Tool via NaviNet.

Rendering Providers

Participating Horizon Care@Home ancillary services providers of home care services are required to complete a pre-service registration for certain services, including:

  • Durable medical equipment (including medical foods [enteral], and diabetic and other medical supplies)
  • Orthotics and prosthetics
  • Home infusion therapy
  • Diabetic and other medical supplies

Registrations can easily be submitted by calling CareCentrix at 1-855-243-3324 between 8 a.m. and 6 p.m., ET. When you refer a patient to a participating Horizon Care@Home ancillary services provider, that rendering provider will work with CareCentrix to ensure that the appropriate prior authorization/pre-service registration is performed.

Referring/Ordering Providers

Physicians, other health care professionals, hospital discharge planners and care managers may initiate a prior authorization/pre-service registration by calling CareCentrix at 1-855-243-3324 between 8 a.m. and 6 p.m., (ET) for:

  • Durable medical equipment (including medical foods [enteral], and diabetic and other medical supplies)
  • Orthotics and prosthetics
  • Home infusion therapy
  • Diabetic and other medical supplies

You may also call CareCentrix at 1-855-243-3324 to find a Horizon Care@Home participating ancillary services provider.

For home health services (including in-home nursing services, physical therapy, occupational therapy and speech therapy), you must obtain prior authorization using Horizon BCBSNJ's online utilization management request tool via NaviNet.

As part of the review of a request for home care services to be provided, Horizon BCBSNJ or CareCentrix may contact your office for information required to conduct/complete their review.

Members with BlueCard Coverage

As a reminder, you have the ability through NaviNet to access the online prior authorization tools of other Blue Plans to review/initiate prior authorizations online for BlueCard members.

Members with BlueCard coverage who are enrolled through another Blue Cross and/or Blue Shield Plan and are receiving care in New Jersey would access in-network home care services through a participating Horizon Care@Home provider; however, prior authorization requirements may vary based on the member’s benefits.

Simply log in to NaviNet.net and:

  • Mouse over Referrals and Authorization.
  • Select Pre-Service Review for Out-of-Area Members.

After entering the member’s prefix, you’ll be routed to the member’s Home Plan. You can then follow the prompts to review a member’s pre-service authorization requirements as well as submit a prior authorization request, if necessary.

Find A Provider

Participating Horizon Care@Home providers may be located by visiting our Online Doctor & Hospital Finder. Select Other Healthcare Services from the What are you looking for? Drop down menu.

Choose one of the services from the Service Type drop down menu, select a plan and click Search.

Online listings of Horizon Care@Home providers who provide home health services, including in-home nursing services, physical therapy, occupational therapy and speech therapy, include the provider’s physical address and phone number. If you provide these services and are interested in participating in the Horizon Care@Home program, please call 1-800-624-1110.

Online listings of Horizon Care@Home providers who provide services for Durable Medical Equipment (DME), including medical foods (enteral), and diabetic and other medical supplies; orthotics and prosthetics (O&P) and home infusion therapy (HIT) services, for conditions including hemophilia, include the provider’s actual physical address, but display CareCentrix’s phone number, 1-855-243-3324. If you provide these services and are interested in participating in the Horizon Care@Home program, call CareCentrix at 1-855-243-3324 for information between 8 a.m. and 6 p.m., ET.

Non participating Home Health Care Service Providers

We remind participating physicians and other health care professionals that you are required to adhere to our Out-of-Network Referral Policy. This policy requires that you, whenever possible, refer Horizon BCBSNJ members to participating providers (including participating ancillary services providers) unless the member has, and wishes to use, his or her out-of-network benefits, understands that a much greater member financial liability may be involved and signs a completed copy of our Out-of-Network Consent Form.

Participating physicians and other health care professionals who do not comply with our Out-of-Network Referral Policy will be at risk of an audit regarding their compliance with Horizon BCBSNJ policies and procedures.

To access our Out-of-Network Referral Policy, registered NaviNet users affiliated with participating practices should log on to NaviNet.net, select Horizon BCBSNJ within the My Health Plans menu and:

  • Select Provider Reference Materials.
  • Mouse over Policies & Procedures.
  • Select Policies, then Administrative Policies.
  • Select Out-of-Network Referral Policy.

Note that prior authorization requirements still apply (for home health care services that require prior authorization) to services provided by a home  health care provider that is not participating in the Horizon Care@Home program.

Services Requiring Prior Authorization

Providers must contact Horizon BCBSNJ before rendering services or providing supplies to our members who require prior authorization.

Please use our Prior Authorization Procedure Search Tool to determine if services require prior authorization for your Horizon BCBSNJ patients.¹

Our Prior Authorization Procedure Search tool allows you to enter a CPT® or HCPCS code and select a place of service (e.g., inpatient, outpatient, office, home) to determine if the particular service provided in the selected service setting requires a prior authorization.

This tool can also be accessed through on the Horizon BCBSNJ plan central page of NaviNet, or by visiting HorizonBlue.com/providers and

  • Clicking Policies & Procedures
  • Clicking Utilization Management
  • Clicking Services Requiring Prior Authorization

Note that our Prior Authorization Procedure Search Tool presently will only display results for insured Horizon BCBSNJ plans. Prior authorization information for members enrolled in self-insured, Administrative Services Only (ASO) plans, Medicare or Medicaid products cannot be accessed through this tool.

The information provided by this tool is not intended to replace or modify the terms, conditions, limitations or exclusions contained within health benefit plans issued or administered by Horizon BCBSNJ. In the event a conflict between the information contained on the tool and member plan documents, member plan documents shall prevail.

This application is intended for informational purposes only. The results provided by this tool are not a guarantee of payment. Claim processing is subject to member eligibility and all member and group benefit limitations, conditions and exclusions.

Obtaining Authorization

Physicians and other health care professionals can obtain online authorizations easily and securely for most services using the online Utilization Management Request Tool. This tool should be used to submit and/or check the status of authorization and predetermination requests, access the online Utilization Management Request Tool.

To access this tool, log on to NaviNet.net, select Horizon BCBSNJ within the My Health Plans menu and:

  • Under Workflows for this Plan, mouse over Referrals and Authorizations.
  • Click Utilization Management Requests.

Using the online Utilization Management Request Tool, providers can submit authorization, predetermination and specialty pharmacy requests securely over the Internet using a data entry form that captures pertinent client-defined data. It also allows for early identification of case and disease management candidates, focusing on better health outcomes and lower costs.

Authorization for services such as home care, Durable Medical Equipment purchases or rentals, surgical procedures and inpatient admissions are also available through the online Utilization Management Request Tool.

The turnaround time for nonurgent prior authorization requests is up to 14 calendar days of receipt. The turnaround time for urgent prior authorization requests is within 72 hours of receipt.

For questions, call the Utilization Management Department at 1-800-664-BLUE (2583).

Note: As a participating physician or other health care professional, it is your responsibility to make sure all authorization procedures are followed.

If authorization is needed for services you are rendering and no authorization is obtained, claim reimbursement may be limited or denied, and if denied, the member may not be billed for the service for behavioral health providers.

BLUECARD MEMBERS: PRECERTIFICATION/PRIOR AUTHORIZATION

Out-of-state Blue Cross and/or Blue Shield Plan members are responsible for obtaining precertification and prior authorization for services as defined by their contract.

Ancillary providers must contact the Blue Cross and/or Blue Shield Plan where the patient is enrolled to obtain the precertification, prior authorization or any other type of authorization required services. To do so, refer to the patient’s ID card for phone number information or call 1-800-676-BLUE (2583).

INPATIENT CARE

Time frames for Authorization Requests

Horizon BCBSNJ responds to all submitted information for inpatient admissions authorization within 24 hours of receipt of all required information.

Timeframes for Additional Information Requests

If Horizon BCBSNJ requests additional clinical information to approve or deny an authorization request, the post-acute facility must respond to our request within 72 hours.

If additional information is not received within 72 hours, the Post-Acute Facility Case

Management Department or the physician will be advised, in writing, of case closure via the daily log. When additional information is received, a review for medical necessity will occur.

INITIAL AND CONCURRENT REVIEW

A Horizon BCBSNJ registered nurse will be assigned to your facility to review clinical information on a daily, or as-needed, basis. Your Horizon BCBSNJ case manager will also help your facility plan for and obtain the necessary authorizations for discharge planning and transition of care needs.

Nationally recognized guidelines are used to assess the medical appropriateness of inpatient admissions and continued stays. These guidelines include, but are not limited to, the Milliman Care Guidelines®. We will provide a copy of the criteria used for an individual determination upon request. Cases failing to meet the guidelines for medical necessity are reviewed by a licensed Medical Director.

Timeframes

A daily post-acute facility UM log will be provided to the post-acute facility’s designated representative, noting the case numbers and approval status for reviewed inpatient admissions. To access a copy of our Post-Acute Facility Request form (5336), visit HorizonBlue.com/providers and:

  • Mouse over the Forms tab and select Forms by Type.
  • Click Authorizations.
  • Select Request Form - Authorization for Post-Acute Facility Intake.

After Hours Access

On weekends, holidays and after regular business hours, Horizon BCBSNJ staff are available to provide utilization management services and help with basic discharge planning.

During these times, do not call your facility- assigned registered nurse. Instead, please call our After Hours Access Line at 1-888-223-3072.

No Notice of Admissions/Lack of Clinical Information Determinations

If additional clinical information is needed, the Post-Acute Facility Case Management Department will be notified, verbally of the information needed. If additional information is not received within 72 hours, the Post-Acute Facility Case Management Department or the physician will be advised, in writing, of case closure via the daily log. When additional information is received, a review for medical necessity will occur.

When complete admission/concurrent review information is:

  • Received, an approval, denial or determination of an alternate level of care will be communicated to the Post-Acute Facility Case Management or Utilization Review Department within 24 hours of receipt.
  • Not received prior to the patient’s discharge  due to the member not providing correct or complete insurance information to the hospital, the hospital should contact their assigned Horizon BCBSNJ inpatient case manager for a retrospective review.

PEER-TO-PEER DISCUSSIONS

Horizon BCBSNJ provides post-acute facilities with the opportunity to informally discuss any non-behavioral health utilization management medical necessity denial decision with a Horizon BCBSNJ physician or other appropriate reviewer. A peer-to-peer discussion must be requested within 72 hours of notification of the adverse determination.

Horizon BCBSNJ notifies each facility how to contact Horizon BCBSNJ‘s physician or other appropriate reviewer to discuss a denial.

Horizon BCBSNJ does not consider the discussion between the Horizon BCBSNJ physician and or other appropriate reviewer and the member’s treating practitioner to be an initiation of a formal appeal request, although a formal appeal based on the outcome of the discussion may be requested.

If Horizon BCBSNJ issues a denial due to a lack of necessary information and subsequently receives a phone call or the required information, the Horizon BCBSNJ practitioner who issued the initial denial may review the case with the new information and overturn it.

On weekends, holidays and after regular business hours, treating practitioners should submit peer-to-peer requests to our After Hours Access Line at 1-888-223-3072.

Transportation

Reimbursement for ambulance transportation at the end of any post-acute facility stay varies and  is subject to benefit and medical necessity determinations by Horizon BCBSNJ.

Transportation for Horizon BCBSNJ members can  be reviewed with the assigned case manager.

POST ACUTE SERVICES

Authorizations

Although the services that require authorization vary from product to product and plan to plan, the following will require authorization:

  • All acute rehabilitation hospital, sub-acute, skilled nursing facility and transitional care services.
  • Non-emergent ambulance transport.
  • Transfers to another facility (in or out-of-network).
  • Other services as listed in guidelines. If prior authorization is not obtained when required, payment may be denied or reduced.

Note: Some services are subject to individual benefit limitations. It is extremely important to verify a patients’ coverage for Post Acute Care, even if a patient believes they have Medicare as their primary coverage.

The patient may have a Horizon BCBSNJ plan that is actually their primary coverage and if appropriate prior authorization is not obtained, an admission will not be covered.

Post Acute Rehabilitation Criteria

A patient at this level of rehabilitation should demonstrate the following criteria:

  • Medium to high endurance.
  • Good rehabilitation potential based on pre-morbid/prior level of function status.
  • Cognitive status does not preclude the individual from active participation in a treatment plan.
  • Co-morbid medical conditions do not inhibit the individual from active participation in therapeutic activity.
  • The patient must be able to tolerate two to three hours of therapy per day, that includes two or more modalities one of which must be physical therapy.

Skilled Nursing Facility Rehabilitation Criteria

  • Require daily rehabilitation, six days per week.
  • 1 to 1-1/2 hours per day (one to two disciplines).
  • Therapy is geared towards gait training, transfer training and ADL training.
  • Needs intermittent nursing service assessments (e.g., vs. monitoring, lung sounds, O2, IV, etc.).
  • Needs skilled therapeutic intervention(e.g., enteral feedings, trach suctioning, wound care, etc.).
  • Specific treatment plan and attainable goals in a defined period of time.
  • Anticipation of community reentry in a defined period of time or move to another level of care (home with home care services or to custodial LTC).
  • Average length of stay depends on the intensity of care.
  • Wound care: multiple Stage I or II with other comorbidities or Stage III and IV with daily treatment.
  • Enteral feedings (guideline for Medicare: more than 501cc per day G tubes, J tubes).
  • Established/routine trach care.
  • Pulmonary toilet and/or suctioning more than three times per day.

Ambulance Transportation

Most Horizon BCBSNJ plans cover ambulance transport under the following conditions. The patient:

  • Has an ambulance benefit.
  • Is being transferred to the nearest approved acute care facility.
  • Is bedbound.
    • Unable to get out of bed.
    • Unable to sit in a chair or wheelchair.
    • Unable to ambulate.
  • Requires emergency medical care that can’t be provided by the post acute care facility.
  • Needs two or more persons for transfers.

POST ACUTE FACILITY (PAF) REFERRAL PROCESS

Horizon BCBSNJ’s post acute facility referral process is outlined below.

  • The hospital discharge planner at the acute care facility is notified that a patient’s discharge plan includes rehabilitation.
  • The hospital discharge planner notifies the post acute facility (PAF) intake unit. For subacute level and SNF level of care the request will be called into the PAF intake unit.
  • Physical, occupational and/or speech therapy evaluations are faxed to the PAF intake coordinator by the hospital discharge planner or social worker.
  • The information is reviewed and an approval or denial is issued.
    • If approved, the PAF nurse will contact the hospital discharge planner or social worker with the authorization number; level of care and length of stay, as well as the PAF case manager’s name and number. The case will then be sent to the PAF Case manager who will follow the case in the rehabilitation facility.
    • If denied, the PAF nurse will notify the discharge planner or social worker at the hospital. A denial letter will be sent to the acute care hospital requesting the authorization, together with the member and physician. Alternate discharge options will be offered.

Reviews

Horizon BCBSNJ requires the following reviews from a PAF:

  • History, physical and initial evaluations are due within 24 hours of admission to the rehabilitation facility.
  • Update reviews will consist of current therapy notes, any medical updates, discharge plan and estimated date of discharge.
  • As a result of facility ongoing case management, each clinical update received shall include a request for continued number of days required to reach realistic goals with supporting rationale provided.
  • Each request shall be submitted on the form designed by the PAF team to help you provide us with concise and accurate medical information regarding a patient’s continued stay.

To access a copy of our Post Acute Facility Continued Stay Request form (6637), visit HorizonBlue.com/providers and:

  • Mouse over the Forms tab and select Forms by Type.
  • Click Authorizations.
  • Select Post Acute Facility Continued Stay Request form (6637)

Discharge Planning

PAFs should begin:

  • Family training before the patient is ready for discharge.
  • To provide documentation of steps being taken to achieve realistic discharge plan with secondary options being noted.
  • Step training before patient is ready for discharge.

Helpful Hints

  • Initial therapy evaluations should include prior level of function assessment, goals and estimated length of stay.
  • When providing rehabilitation notes on physical therapy, occupational therapy, speech therapy or cognitive therapy, parameters for reporting functionality in each category should be the same as those categories previously reported. This will facilitate more effective tracking and measurement of patient’s progress.
  • Report any changes in the patient’s medical status and any impact they may have on the patient’s ability to participate in rehabilitation  therapies.
  • Short-term and long-term goals should be specific and measurable. It is the facility’s responsibility to know the patient’s last covered day and to provide updates in a timely fashion.
  • Updates may be required more frequently than on a weekly basis particularly as a patient is nearing a point of being able to be discharged.
  • Copies of actual progress notes may be requested when updates are inadequate.

ADVANCE DISCHARGE NOTICE FROM A POST ACUTE FACILITY FOR MEDICARE ADVANTAGE MEMBERS

Medicare Advantage members will receive a Notice of Medicare Non-Coverage prior to the date the coverage for the post acute stay ends. The Notice of Medicare Non-Coverage must be presented to the member when issued, signed and the signed letter must be returned to the PAF case manager within 24 hours.

Right to Appeal a Decision for Medicare Advantage Members

A member has the right to an immediate, independent medical review (appeal), while their services continue, of the decision to end Medicare coverage of these services.

  • If a member chooses to appeal, the independent reviewer will ask for the member’s opinion. The reviewer will also look at their medical records and/or other relevant information. Members do not have to prepare anything in writing, but they have the right to do so if they wish.
  • If a member chooses to appeal, the member and the independent reviewer will each receive a copy of the detailed explanation about why the coverage for services should not continue. The member will receive this detailed notice only after they have requested  an appeal.
  • If a member chooses to appeal and the independent reviewer agrees that services should no longer be covered after the effective date indicated above, neither Medicare nor the member’s Medicare

Advantage plan will pay for these services after that date.

  • If a member stops services no later than the effective date indicated above, the member will avoid financial liability.
  • Immediate Appeal Requests for Medicare Advantage Members
  • The member must make their request to your Quality Improvement Organization (also knowm as a QIO). A QIO is the independent reviewer authorized by Medicare to review the decision to end these services.
  • The member’s request for an immediate appeal should be made as soon as possible, but no later than noon of the day before the effective date.
  • The QIO will notify the member of its decision as soon as possible, generally by no later than the effective date of this notice.
  • The member can call their assigned QIO to appeal, or if they have questions.

Other Appeal Rights for Medicare Advantage Members

If the member misses the deadline for requesting an immediate appeal with the QIO, they still may request an expedited appeal from their Medicare Advantage plan. If their request does not meet the criteria for an expedited review, the member’s Medicare Advantage plan will review the decision under its rules for standard appeals.

DEDICATED MEDICAL RECORDS ADDRESSES

Horizon BCBSNJ is improving services for participating providers. To help ensure effective and efficient processes, we have created a dedicated address for medical records and medical documentation. Please use the address below when sending medical documentation for Utilization Management determinations:

Horizon BCBSNJ Medical Documentation
PO Box 1268
Newark, NJ 07101-1268

Please forward the following information to the dedicated address:

  • Information to complete a clinical review of an inpatient stay
  • Required documentation to make a determination on a service
  • Emergency Room records for Horizon HMO and Horizon Medicare Advantage members
  • In vitro fertilization records
  • Physical therapy records
  • Home care records
  • Home infusion records
  • Post acute facility records

Addresses for Determination Appeals

If you are appealing a determination, please send documentation to the appropriate address for your location.

Northern Region: providers in northern New Jersey (Bergen, Essex, Hudson, Hunterdon, Middlesex, Morris, Passaic, Somerset, Sussex, Union and Warren counties) and New York may send documentation to:

Horizon BCBSNJ
PO Box 420, PP-14E Newark, NJ 07101-0420

Southern Region Providers: providers in southern New Jersey (Atlantic, Burlington, Camden, Cape May, Cumberland, Gloucester, Mercer, Monmouth, Ocean and Salem counties), Pennsylvania and Delaware may send documentation to:

Horizon BCBSNJ
PO Box 110, MT-03W
Mount Laurel, NJ 08054-1121

  • If you have additional medical documentation on a current or retrospective inpatient stay, please work directly with your allocated Horizon BCBSNJ Inpatient Case Management (ICM) nurse.
  • If you receive a request from Horizon BCBSNJ for medical records, please submit them to the post office box indicated on the request.
  • Billing departments at the facility should work closely with the Case Management department to ensure records are sent to Horizon BCBSNJ only when necessary.

Home Infusion Therapy

HorizonBlue.com/directory or by calling eviCore healthcare Radiology Scheduling at 1-866-969-1234.

Participating Rendering Site Responsibilities

Participating rendering sites have a responsibility to ensure that the guidelines/protocols of our eviCore healthcare program are followed:

  • Prior to scheduling a service, the rendering site must validate that a member’s plan requires a PA/MND. To validate that a member’s plan requires a PA/MND, use the Authorization/ Eligibility Lookup feature on eviCore healthcare’s website, eviCore.com or call 1-866-496-6200.

    If a PA/MND is required and has not been obtained, the service should be rescheduled and the rendering site must advise the patient to contact the referring provider. Once a PA/MND has been obtained the patient can schedule a new appointment for services.

  • Prior to rendering services, the rendering site must verify that a PA/MND has been obtained and the site location is accurate. To verify this information, visit eviCore.com or call 1-866-496-6200.

    Services provided without a PA/MND in place may result in claim denials. Participating facilities or hospitals may not seek payment from the member in these instances. A retroactive benefit review will not be conducted.

  • After rendering services, the rendering site must notify eviCore healthcare if there was a change to the procedure performed. Rendering sites must notify eviCore healthcare within two days if a service provided differs from the service indicated on the PA/MND (for example, if an MRI of the brain without contrast was performed, but an MRI of the brain with contrast is indicated on the PA/MND). If services are performed after hours, leave a voice mail message for eviCore healthcare, include patient information and changes, if applicable.
  • All AIS claim submissions, including claims for professional components, for services provided to members enrolled in plans that require PA/MND, must include eviCore healthcare’s PA/MND number.
  • Prior authorizations are effective from the clinical approval date only, not from the date of the request.

Actual benefit determination cannot be made until the claim is received and will be subject to the provisions of the patient’s present health benefits contract, including any applicable deductible, coinsurance and/or coordination of benefits.

Reimbursement is dependent on the patient being an eligible Horizon BCBSNJ member at the time the services are incurred. This authorization will be affected should the claim submitted differ from the information provided at the time of this request.

Helpful Hint: When using eviCore healthcare’s website, print out the screen shot that shows the patient’s eligibility.

The information on the screen is the most current eligibility information. eviCore healthcare’s website does not store past eligibility information.

RADIOLOGY PROGRAM

eviCore healthcare works with Horizon BCBSNJ to manage the radiology services and AIS (CT/CTA/CCTA scans, MRI/MRAs, PET/CT scans, nuclear medicine studies, including nuclear cardiology) provided to our members through prior authorization/medical necessity determinations (PA/MNDs) with the providers.

  • Services provided include:
  • Scheduling of radiology services.
  • Claim correct coding and privileging assistance. A variety of forms are available to  help you with claims processing. Please visit HorizonBlue.com/providers and mouse over Products & Programs and click eviCore healthcare.

Contact Information

Advanced Imaging Services (AIS) – Radiology Program: Call 1-866-496-6200 or visit eviCore.com.

AIS that Require PA/MND

Prior authorization (PA) or Medical Necessity Determination (MND) is required for several Horizon BCBSNJ products (e.g., Horizon HMO, Horizon POS, NJ DIRECT, NJ PLUS, Horizon Direct Access, insured Horizon PPO and Medicare Advantage plans) for the following services:

  • CT/CTA scans.
  • MRI/MRA.
  • PET scans.
  • Nuclear medicine studies (including nuclear cardiology).

Prior authorizations are effective from the clinical approval date only, not from the date of the request. The PA/MND is valid for 45 days.

Prior authorization for AIS does not apply to services rendered during Emergency Room visits or inpatient stays.

Prior to rendering services, the rendering site must verify that a PA/MND has been obtained by the referring physician and that the site location is accurate. To verify that a PA/MND has been obtained, visit eviCore.com or call 1-866-496-6200.

Services provided without a PA/MND in place may result in non payment of services. If prior authorization is not obtained for services, those services will not be eligible for reimbursement. Participating facilities may not seek payment from the member in these instances. A retroactive benefit review will not be conducted.

Diagnostic Radiology Quality Standards

Horizon BCBSNJ has compiled a set of diagnostic radiology quality standards to help ensure that all of our members consistently receive high levels of care in imaging throughout our network. Our quality standards are reviewed and approved by a Radiology Advisory Committee comprised of participating physicians from a variety of specialties.

eviCore healthcare performs site visits of radiology centers and offices on our behalf to ensure compliance with our diagnostic radiology quality standards.

Please review our quality standards and initiate any corrective actions to comply with our standards.

Please pay special attention to the approved accreditation agencies that apply to your office and to the equipment/modality requirements. The approved accreditation agencies will specify personnel educational requirements for the covered modalities.

To review our diagnostic radiology quality standards online, visit HorizonBlue.com/providers and:

  • Click Search Medical Policies in the I Want To...section.
  • Click Medical Policy Manual.
  • Search for and click Standards for Diagnostic Radiology/Imaging Facilities/Freestanding-Office including Surgi-Centers and Diagnostic Dental Radiographic Imaging.

Medical Criteria

Medical criteria are posted publicly and can be found on eviCore healthcare’s website, https://www.evicore.com/resources/pages/providers.aspx#ReferenceGuidelines.

Additional forms can be found on our website. Please visit HorizonBlue.com/providers, and mouse over Products & Programs and select eviCore healthcare National.

These documents describe correct coding logic for billing CPT code combinations and the applied recognized sources or standards defined by CPT definition, CMS edits, etc.

Relative value units (RVUs) are available on the CMS website. Visit https://www.evicore.com/resources/pages/providers.aspx#ReferenceGuidelines.

Radiology Scheduling Line

  • Referring physicians can call eviCore healthcare at 1-866-496-6200, Monday through Friday, between 7 a.m. and 7 p.m., ET, or go to eviCore.com to obtain a prior authorization or medical necessity determination (PA/MND). At the end of the review, the referring physician is given a case number.
  • Upon approval, eviCore healthcare will contact the member by phone and schedule the procedure at a participating Horizon BCBSNJ facility. If eviCore healthcare cannot get in touch with the member, eviCore healthcare will assign a site based on a mile radius of the member’s ZIP code.
  • Members can call eviCore healthcare directly at 1-866-969-1234 for scheduling assistance. Members can change their radiology site locations any time prior to services being rendered.
  • The referring physician is faxed a notice that includes the PA/MND number and the site location.

All other non-AIS radiology/imaging services can be scheduled through the Scheduling Line.

A tracking number will be issued to the caller for all services scheduled at radiology facilities.

CARDIAC IMAGING PROGRAM

eviCore healthcare works with Horizon BCBSNJ to manage the Cardiac Imaging Program for our members through prior authorization/medical necessity determinations (PA/MNDs) with physicians. eviCore healthcare helps ensure that medically necessary and appropriate cardiac imaging services are provided for our members, provides clinical consultation to our participating physicians, facilities and ancillary providers and helps schedule cardiac imaging services.

All participating physicians, facilities and ancillary providers that perform any cardiac procedures should visit HorizonBlue.com to review our quality  standards and initiate any necessary corrective actions to come into compliance with our standards.

  • Services provided by eviCore healthcare include:
    • - Echocardiogram studies
    • - Pediatric cardiology.
    • - Credentialing and privileging
    • - Online cardiology prior authorization  program.

Contact Information

AIS – Cardiac Imaging Program:

Call 1-866-496-6200, or fax 1-888-785-2480 or visit eviCore.com.

Cardiac Imaging Services that Require PA/MND

An ordering physician must request a PA/MND which is required for several Horizon BCBSNJ products (e.g., Horizon HMO, Horizon POS, NJ DIRECT, NJ PLUS, Horizon Direct Access, insured Horizon PPO and Medicare Advantage plans) for the services listed below.

  • Diagnostic studies.
  • Nuclear medicine studies (including nuclear cardiology).
  • Echo stress.
  • Diagnostic left heart catheterization.
  • Cardiac PET.
  • Cardiac MRI.
  • Coronary CT angiography (CCTA).
  • Echocardiograms.

Prior authorization for AIS does not apply to services rendered during Emergency Room visits or inpatient stays.

Prior to rendering services, the rendering site must verify that a PA/MND has been obtained and that the site location is accurate.

To verify that a PA/MND has been obtained, visit eviCore.com or call 1-866-496-6200. Services provided without a PA/MND in place may result in non payment of services.

If prior authorization is not obtained for services, those participating facilities may not seek payment from the member in these instances. A retroactive benefit review will not be conducted.

Echocardiography

  • PA/MND is required for all members who are referred for an echocardiogram.
  • Refer to the current year Radiology/Imaging CPT codes requiring PA. These codes are listed on eviCore.com or on HorizonBlue.com.

Note: eviCore healthcare will not accept a request for a PA/MND from the rendering radiology site/hospital. However, the rendering provider must verify if PA was given or a pre-service medical necessity determination was made, by calling eviCore healthcare at 1-866-496-6200 or via eviCore healthcare’s website, eviCore.com.

Pediatric Cardiology Notification Process

This notification process only relates to pediatric cardiology since the patient encounter differs from adult cardiology patient encounters. To avoid issues with mismatched authorization numbers, claims or possible imaging setbacks, please ensure that eviCore healthcare identifies your physicians as pediatric cardiologists.

Pediatric cardiologists may contact eviCore healthcare for notification before performing diagnostic cardiac imaging exams or post diagnostic cardiac imaging exams, providing it is done on the same day.

Pediatric Pre-service Notification Procedure

If a cardiologist performs a screening echocardiography as part of the pediatric patient evaluation, then a pre-service notification must be called into eviCore healthcare when a pediatric patient evaluation appointment is scheduled.

The physician’s office calls eviCore healthcare before the patient comes in for the appointment and advises that the echocardiogram is for a pediatric patient.

When the physician’s office calls eviCore healthcare, the following information must be available:

  • Patient demographics, including insurance information.
  • Clinical rationale for the exam, as well as the specific CPT code(s) that will be performed.

A notification number will be given to the physician’s office at the time of the call.

If upon review of the patient’s information, the cardiologist needs to change the approved procedure, the physician’s office must notify eviCore healthcare of the new procedure code within 48 hours after the procedure is performed.

If the exam is performed on a Friday or after hours, then you may enter the information through the eviCore healthcare Physician’s Portal at eviCore.com.

You may also leave a message with the date of service that exam was performed, or you may call back the next business day to report the procedure.

If this change to service is not recorded, the claim will be denied because the new CPT code will not match the approved CPT code.

The notification number is time stamped and must correspond to the date the service was performed. If there is a discrepancy, the claim will be denied. If authorization is not obtained for services, those participating facilities may not seek payment from the member in these instances. A retroactive benefit review will not be conducted.

Pediatric Post-service Notification Procedure

In situations when the pediatric cardiologist deems it necessary to perform an echocardiography on the patient during the patient’s exam, the physician may scan the patient and then notify eviCore healthcare.

When the physician’s office calls eviCore healthcare, the following information must be available:

  • Patient demographics, including insurance information.
  • Clinical rationale for the exam, as well as the specific CPT code that was performed.

eviCore healthcare will provide the pediatric cardiology notification number, which is linked to the CPT code requested.

Applicable CPT codes are available at eviCore.com or HorizonBlue.com.

Pediatric cardiology notification may be made by  calling eviCore healthcare at 1-800-918-8924, faxing 1-888-785-2480 or visiting eviCore.com.

Note: This excludes AIS which require Prior Authorization or pre-service Medical Necessity Review.

MUSCULOSKETAL AUTHORIZATION PROGRAM

Horizon BCBSNJ is committed to helping ensure that the health care provided to our members is  of high quality and consistent with nationally recognized clinical guidelines. With this commitment in mind, and in conjunction with eviCore healthcare, we have implemented an enhanced medical management prior authorization program for musculoskeletal pain management or spine surgery services.

  • Services provided by eviCore healthcare include:
    • Online pain management prior authorization (PA) program.
    • Online pain management resources, including Horizon BCBSNJ’s Medical Policies.

Contact Information

Pain Management Authorization Program: Call 1-866-241-6603 or fax 1-800-649-4548 or visit eviCore.com.

Musculoskeletal Program Medical Policies

The Horizon BCBSNJ medical policies on pain management were developed using recognized evidence-based guidelines, and incorporate criteria derived from published materials that are supported by nationally recognized agencies, such as the American Academy of Pain Management and the National Institutes of Health. Horizon BCBSNJ medical policies reflect current community standards of practice and recognized medical practice guidelines.

Musculoskeletal Program Services that Require PA

A list of musculoskeletal pain management or spine surgery services requiring PA and guidelines for various services are available online.

To access this information, visit HorizonBlue.com/providers, and:

  • Mouse over Products & Programs and select eviCore healthcare.
  • Select Musculoskeletal Program.

Musculoskeletal Program Services PA Exclusions

The prior authorization requirement does not apply to services rendered in the Emergency Room or during an inpatient stay.

You may verify if a member’s benefit plan requires PA by using eviCore healthcare’s website, eviCore.com.

Musculoskeletal Program PA Process

If musculoskeletal pain management or spine surgery services are prescribed, our subscribers and their dependents must contact Horizon BCBSNJ before services are provided to ensure that they are eligible for reimbursement.

If prior authorization (PA) is not obtained for musculoskeletal pain management or spine surgery services, those services will not be eligible for reimbursement. You may not seek payment from the member in these instances.

A retroactive benefit review will not be conducted.

RADIATION THERAPY PROGRAM

eviCore healthcare works with Horizon BCBSNJ to help coordinate the radiation therapy services provided to Horizon BCBSNJ members who are diagnosed with cancer.

eviCore healthcare works with the treating radiation oncologist and reviews his or her treatment plan to determine the medical necessity and appropriate level of care for radiation therapy services.

This program offers clinicians the necessary flexibility to render appropriate quality care in a timely manner and it ensures safety by requiring technologies used in radiation therapy to conform to appropriate standards established by a national board of recognized radiation oncologists.

  • Services provided include:
    • Radiation therapy utilization management.
    • Online tools.

Radiation Therapy Benefit Management tutorials are available at eviCore.com.

Contact Information

Radiation Therapy Program: Call 1-866-242-5749 or visit eviCore.com.

Radiation Therapy Program Criteria

eviCore healthcare’s extensive evidence-based criteria is based on the National Advisory Committee review of evidence-based literature and is in alignment with existing American College  of Radiology (ACR) and American Society for Therapeutic Radiology and Oncology (ASTRO) guidelines.

Radiation Therapy Services that Require MND

MND is required for the following radiation therapy services that treat the following conditions:

  • Adrenal Cancer
  • Anal Cancer
  • Bile Duct Cancer
  • Bladder Cancer
  • Bone Metastases
  • Brain Metastases
  • Breast Cancer
  • Cervical Cancer
  • Endometrial Cancer
  • Esophagus Cancer
  • Extracranial Oligometastases
  • Gallbladder Cancer
  • Gastric Cancer
  • Head/Neck Cancer
  • Hepatobiliary Cancer
  • Hodgkin's Lymphoma
  • Kidney Cancer
  • Liver Cancer
  • Multiple Myeloma
  • Non-Cancerous Diagnosis
  • Non-Hodgkin's Lymphoma
  • Non-Small Cell Lung Cancer
  • Other Metastases (Non-Bone/Brain)
  • Pancreatic Cancer
  • Primary Central Nervous System Lymphoma
  • Primary Central Nervous System Neoplasms
  • Prostate Cancer
  • Rectal Cancer
  • Skin Cancer
  • Small Cell Lung Cancer
  • Soft Tissue Sarcoma
  • Testicular Cancer
  • Urethral Cancer
  • Vulva Cancer

Plans that Require MND for Radiation Therapy

MND applies to radiation therapy services provided to members enrolled in the following plans:

  • Horizon HMO.
  • Horizon HMO Access.
  • Horizon Point of Service (POS).
  • Horizon Direct Access.
  • Indemnity.
  • Horizon PPO.
  • Horizon BCBSNJ Medicare Advantage plans.
  • New Jersey State Health Benefits Program (SHBP) or School Employees’ Health Benefits Program (SEHBP) plans.
  • Small group plans, regardless of product.

Radiation Therapy MND Exclusions

MND does not apply to, and is not required for, radiation therapy services provided to:

  • BlueCard members
  • Members enrolled in self-funded groups
  • Members enrolled in Horizon NJ Health
  • Members enrolled in the Federal Employee Program (FEP)
  • Members enrolled in Medigap plans
  • Members whose Horizon BCBSNJ coverage is  secondary to another insurance plan
  • Services rendered during an Emergency Room visit or inpatient stay

Radiation Therapy Program MND Process

To initiate a radiation therapy request, the physician providing the radiation treatment plan must complete all questions on the specific worksheet. The worksheet can be downloaded from eviCore healthcare’s website.

Requests must be submitted via eviCore.com, or by phone at 1-866-242-5749. No requests may be faxed.

Submitting a Clinical Appeal

If a request does not demonstrate medical necessity, you will be notified in writing.

This notice will provide detailed instructions on how to submit clinical appeals.

If a pre-service MND is not obtained, reimbursement may be delayed pending a post-service medical necessity review.

  • This post-service medical necessity review will be conducted by eviCore healthcare, applying the same medical policies used during a pre-service MND.
  • The time limit for initiating a post-service MND is 18 months from the date of service.

Worksheets

eviCore healthcare makes worksheets specific to each cancer type available on their website, eviCore.com. The worksheets help the physician ordering the radiation therapy treatment by outlining the clinical and treatment plan information that is required when submitting a request for a MND, including:

  • The cancer type being treated with radiation therapy.
  • Patient information.
  • Ordering physician information.
  • Rendering site information.
  • Patient history.
  • Recent test results.
  • Work-up information.
  • Current clinical condition.
  • Treatment plan specifics (which may include):
    • Immobilization techniques.
    • Fractions.
    • Treatment technique.
    • Boost.
    • Fields.

Requesting an MND for Radiation Therapy

  1. If MND is required by Horizon BCBSNJ, the physician or other health care professional must initiate a case online by going to eviCore.com or calling eviCore healthcare at 1-866-242-5749.

    Some Horizon BCBSNJ health plans are not reviewed by eviCore healthcare (see previous page). In those cases, the physician or other health care professional must contact Horizon BCBSNJ directly.

  2. A determination will be forwarded via fax and/or by non-certified mail, if approved, to the referring radiation oncologist who initiates the case. The MND will include:
    • Patient demographics.
    • Facility name.
    • MND number.
    • Type of therapy approved.
    • Number of fractions/angles approved.
    • Any special procedures requested.
  3. When the case has an MND and the treatment plan changes because additional services, fractions, dosimetry or port films are required, the facility must contact eviCore healthcare to update the clinical information and MND approval prior to billing for these procedures. If this is not completed, then the services will be denied for No MND.
  4. If the patient has been treated and claims submitted for the treatment are denied due to insufficient clinical information to establish a MND for the services rendered, the clinical rationale and/or updated treatment form should be submitted to eviCore healthcare. The ancillary provider may also call eviCore healthcare to provide the medical rationale for services rendered.
  5. Any claim that denies for procedure(s) rendered which were excluded from the original approved treatment plan, benefit or eligibility reason is considered a claims appeal.
  6. Clinically related appeals with additional clinical  information and the associated MND number can be faxed to eviCore healthcare at 1-866-699-8128, Attention: Radiation Therapy Appeal.
  7. Horizon BCBSNJ’s Claim Appeal Department contact information may be found on the patient’s Horizon BCBSNJ EOB and/or health care professional’s EOP forms.

MND Timeframes

If/when all necessary clinical information is provided and it meets the clinical criteria, physicians who:

  • Submit an online request can obtain an MND online in real time.
  • Call eviCore healthcare and receive an MND number by the end of the call.

Determinations will be made as soon as possible and in urgent circumstances no later than 72 hours from the receipt of all required clinical information.

Episodes of Care

An MND is valid for the treatment plan (an episode of care) requested by the physician. A new MND must be established to provide the member with another episode of care.

Modifying an Approved Treatment Plan

If during a course of treatment you wish to modify an approved treatment plan, call 1-866-242-5749 and speak to a eviCore healthcare Medical Director. The treatment plan modifications that are determined to be medically necessary will be communicated during the call. If a member changes physicians/facilities in the middle of a treatment plan, a new MND must be established.

Partial Approval Notice

A partial approval notice informs the facility of approved and non-approved services for the requested treatment plan. It also contains clinical appeal information. If you receive a partial approval, you will need to submit additional clinical information to eviCore healthcare to support the medical necessity of the remainder of the treatment plan.

Claim Denials

Claims may be denied for a variety of reasons. Please review denial reason code and description on the Explanation of Payment (EOP) you receive to help determine your next steps.

  • If your claim is denied due to a lack of an MND, submit an MND request right away.
  • If your request does not demonstrate medical necessity, you will be notified in writing. This notice will provide detailed instructions for submitting clinical appeals.

For any other issues with radiation therapy claims, please call eviCore healthcare Customer Service at 1-866-242-5749.

MEDICAL INJECTABLES PROGRAM (MIP)

Horizon BCBSNJ is committed to providing our members with access to high-quality health care that is consistent with nationally-recognized clinical criteria and guidelines. As part of that commitment, we collaborate with specialty pharmaceutical management company, Magellan Rx Management (formerly known as ICORE Healthcare, LLC), to administer our Medical Injectables Program (MIP). Magellan Rx Management (MRxM) conducts medical necessity and appropriateness reviews (MNARs) for specific injectable medications.

MRxM conducts reviews of injectable medications administered:

  • At a freestanding or hospital-based dialysis center.
  • In an outpatient facility.
  • In a patient’s home.
  • In a physician’s office.

MRxM will not perform MNARs on injectable medications administered:

  • During an inpatient stay;
  • In an observation room; or
  • In an Emergency Room.

Reimbursement of claims will be delayed or denied if an MNAR determination is not obtained prior to the administration of any of the medical injectables included in this program.

Online Information

To access online information about the MIP, visit HorizonBlue.com/providers, mouse over Products & Programs and select Medical Injectables Program.

Injectable Medications Included in the MIP

Visit HorizonBlue.com/mipfor information about the MIP including a list of medical injectables included as part of this program.

Plans Included in the MIP

The MIP applies to services provided to memberes enrolled in the following Horizon BCBSNJ products/plans:

  • HMO.
  • EPO.
  • POS.
  • Direct Access.
  • PPO.
  • Indemnity/Traditional.
  • BlueCard Home.
  • New Jersey State Health Benefits Program (SHBP)
  • School Employees’ Health Benefits Program (SEHBP) plans.
  • Medicare Advantage plans (including members enrolled in Horizon Medicare Blue (PPO) and Medicare Blue TotalCare (HMO SNP) plans).

MIP Exclusions

The MIP does not apply to, and MNAR determination is not required for, those injectable medications provided to:

  • Members enrolled in Horizon NJ Health.
  • Members enrolled in the Federal Employee Program (FEP).
  • Members enrolled in Medigap plans.
  • Members whose Horizon BCBSNJ coverage is secondary to another insurance plan.
  • Members receiving services rendered during an Emergency Room visit or in an observation room, or during an inpatient stay.

Magellan Rx Management Contact Information

Visit ih.magellanrx.com or call MRxM at 1-800-424-4508.

MNAR Process

Ordering physicians may obtain an MNAR online at ih.magellanrx.com.

To access MRxM’s online tool, please visit ih.magellanrx.com, click the Health Plan Partners icon, log in and:

  1. Click Get an Authorization, read the overview and click Continue.
  2. Enter the Member/Patient information, Click Search.
  3. Select a provider from the drop-down menu.
  4. Enter the Brand Name/Generic Name or Procedure Code and click Search. Then select the appropriate drug brand link in the results list.
  5. Select the Yes or No radio button to add (or not add) additional medication(s). Then click Continue.
  6. Click the ICD-10 Code lookup icon, enter your  search criteria, click Search and then select the appropriate ICD-10 code. On the Reason Selection page, enter remaining details and then click Continue.
  7. On the Question and Answer page, answer clinical questions and select Next.
  8. On the Submission Confirmation page, click Submit after confirming that the information entered is correct.

Urgent MNAR requests

Urgent requests to obtain a MNAR determination may be initiated by calling MRxM at 1-800-424-4508.

A request is considered urgent if:

  • Following the standard MNAR process may seriously jeopardize the life or health of the member, or the ability of the member to regain maximum function.
  • Following the standard MNAR process would subject the member to severe pain that could not be adequately managed without the medical pharmaceutical treatment being requested.

Information required to complete an MNAR

Ordering physicians should have the following information available when contacting MRxM to obtain a pre-service MNAR determination:

  • Ordering provider name, address and office telephone and fax numbers.
  • Rendering provider name, address and office telephone and fax numbers (if different from ordering provider).
  • Member name, date of birth, gender and identification number.
  • Member height, weight and/or body surface area.
  • Anticipated start date of treatment (if known).
  • Requested injectable medication(s).
  • Dosing information and frequency.
  • Diagnosis (ICD-10 code) and disease state severity.
  • Past therapeutic failures (if applicable).
  • Concomitant medications.

Additional information may be required depending on the injectable medication.

MNAR Timeframes

Once all the required information is provided to MRxM, a determination can be issued. The request may be delayed if additional clinical documentation is required.

Urgent requests will be completed as soon as possible following the receipt of all necessary information.

Nonurgent requests will be completed as soon as possible based on the medical urgency of the case, but in no more than three business days of receiving all necessary information.

Tracking and Determination Record Numbers

A MRxM tracking number (which consists of only numbers) is assigned at the initiation of an MNAR request. A MRxM determination record number (which can be identified by the letter I as the second to last character) is assigned when a final determination is a made.

MNAR Denials and Appeals

MRxM will issue a letter for all adverse decisions of f requests for MNAR. Appeal instructions will be included in all denial letters.

Generally, a provider may dispute an adverse decision that was based on medical necessity by following the instructions below.

  • For non-Medicare members, providers should call MRxM at 1-800-424-4508.
  • For Medicare members, the appeal must be submitted in writing to:

    Magellan Rx Management
    Attn: Appeals Department
    PO Box 1459
    Maryland Heights, MO 63043
    Appeal Fax: 1-888-656-6805

Peer-to-Peer Consultations

Physicians who do not agree with MRxM’s determination may discuss the case in detail with a MRxM Medical Director by calling 1-800-424-4508, Monday through Friday, between 8 a.m. and 5 p.m., ET.

AIM SPECIALITY HEALTH

Certain self-insured employer group health plans administered by Horizon BCBSNJ will implement an integrated advanced imaging and sleep management program for their members.

Horizon BCBSNJ has contracted with AIM Specialty Health® to provide evidence-based clinical guidelines for elective, outpatient CT, MRI, nuclear cardiology, PET, echocardiography exams and sleep management exams for educational and quality purposes. This is not a formal utilization management program.

Imaging studies performed in conjunction with Emergency Room services, inpatient hospitalization, outpatient surgery (hospitals and free-standing surgery centers), urgent care centers or 23-hour observations are not included in this program.

The goal of this program is to provide you and certain Horizon BCBSNJ members with information to make informed choices. The program could mean significant savings for certain members who have coinsurance plans and pay a percentage of costs out of pocket.

Check your Horizon BCBSNJ patient’s ID card to verify if your patients are included in the program.

You can request a review of anticipated services at aimspecialtyhealth.com/goweb or by calling 1-866-766-0250. This number is also displayed on  the back of the member's ID card.

AIM, on behalf of Horizon BCBSNJ, will also use the Blue Cross and Blue Shield Association's National Consumer Cost Transparency (NCCT) data set for transparency purposes. AIM will share NCCT imaging facility cost information with staff during the clinical review process to promote awareness.

AIM also makes outbound phone calls to members to inform them of the imaging facility options available.

It is important to note that Horizon BCBSNJ members will not be denied access to services if they do not choose the lower-cost option and outreach will exclude pediatric and cancer patients.

This Horizon BCBSNJ program through AIM Specialty Health is applicable only to beneficiaries enrolled in certain National Account self-insured groups. It does not replace our existing programs with eviCore healthcare, which serve the majority of our insured membership, including the New Jersey State Health Benefits Program (SHBP).

Musculoskeletal Program

The AIM Specialty Health Musculoskeletal Program engages providers in the management of the complexities associated with musculoskeletal and interventional pain management services.

The program is only available to members of ASO/self-insured groups who have opted in at this time.

The Musculoskeletal Program covers services in the outpatient setting, using evidence based clinical guidelines to help reduce inappropriate care, overtreatment, and excessive costs while helping to ensure safe and effective care.

The program offers a prospective review of certain services to promote improved quality of care for all plan beneficiaries and to assess whether the proposed services are medically necessary and appropriate when evaluated against AIM Specialty Health’s evidence-based clinical criteria and guidelines.

To maximize the benefits achieved by this program, doctors and other health care professionals ordering outpatient musculoskeletal services for their patients must call AIM prior to such services being rendered to allow AIM’s prospective review to occur and for the doctors and other health care professionals to receive the qualitative feedback afforded by these AIM quality improvement programs.

If the planned services do not meet AIM’s guidelines for medical necessity, AIM may suggest that the doctor or other health care professional consider offering an alternative service or withdraw the requested service entirely.

SURGICAL AND IMPLANTABLE DEVICE MANAGEMENT PROGRAM

Horizon BCBSNJ collaborates with TurningPoint Healthcare Solutions, LLC (TurningPoint) to administer our Surgical and Implantable Device Management Program. As part of this program, TurningPoint conducts Prior Authorization & Medical Necessity Determination (PA/MND) reviews of certain Orthopedic services and Cardiac Services (many of which include implantable devices), and other related services, requested by participating and nonparticipating physicians when rendered in the following settings:

  • Inpatient
  • Outpatient
  • Ambulatory Surgical Center
  • Physician’s Office

Services rendered in the observation setting or the Emergency Room (ER) do not require PA/MND.

TurningPoint will conduct PA/MND reviews of  certain orthopedic and cardiac services to:

  • Determine medical necessity of the services to be provided
  • Ensure appropriate conservative therapies are attempted prior to invasive procedures
  • Help to ensure that the most appropriate surgery is performed in the most appropriate setting using the most appropriate device(s)
  • Help to improve provider best practices

Obtaining an approved PA/MND from TurningPoint will ensure that the services in question will be considered medically necessary.

Physicians are strongly encouraged to obtain a pre-service MND from TurningPoint for services to be provided to patients whose benefits do not require PA of services rendered in an outpatient setting or in a physician’s office.

As part of our Surgical and Implantable Device Management Program, TurningPoint will review professional and facility claims submitted. Services that TurningPoint deems not medically necessary as part of this review may not be eligible for coverage or payment by Horizon BCBSNJ. Horizon BCBSNJ reserves the right to adjust claims based on TurningPoint’s recommendations.

View more information about this program, including a full listing of the procedures/impacted services and CPT codes that are subject to PA/MND review under this program on HorizonBlue.com/turningpoint.

PA and Pre-Service MND Review

Through the Surgical and Implantable Device Management Program, TurningPoint will conduct PA/MND review for orthopedic services and any related device.

Physicians must obtain PA for services rendered in the inpatient setting and for members whose benefits also require PA for services rendered in an outpatient setting and in the physician’s office.

For members whose benefits do not require PA for services rendered in an outpatient setting or in the physician’s office, physicians are strongly encouraged to obtain a pre-service MND from TurningPoint prior to the surgery to ensure that services will be considered medically necessary and that coverage for the procedure will be provided. Services deemed not medically necessary when claims are received or reviewed may not be eligible for coverage or payment by Horizon BCBSNJ.

Rendering hospitals and ambulatory surgical centers are responsible for confirming that an approved PA or pre-service MND has been obtained.

  • You may log on to NaviNet to confirm the status of a PA/MND request.
  • If you do not have access to NaviNet, you can confirm the status of a PA/MND request using TurningPoint’s web portal at https://www.turningpoint-healthcare.com/. To register for access to TurningPoint’s web portal, call TurningPoint at 1-833-436-4083, Monday through Friday, between 8 a.m. and 5 p.m., Eastern Time (ET).
  • You may also call TurningPoint at 1-833-436-4083 to confirm the status of a PA/MND.
  • If an out-of-network co-surgeon or assistant surgeon will be participating in the surgical procedure, it is the referring/rendering physician’s responsibility to notify TurningPoint at the time of the PA/MND request.

How to Obtain PA/MND for Orthopedic Services

  • A physician may log on to NaviNet.net to submit a request.
  • Practices that do not have access to NaviNet can submit a request via TurningPoint’s web portal at https://www.myturningpoint- healthcare.com. You must register to obtain access credentials by calling TurningPoint at 1-833-436-4083, Monday through Friday between 8 a.m. and 5 p.m., ET.
  • You may also call TurningPoint at 1-833-436-4083 to submit PA/MND requests.

TurningPoint must be provided with:

  • The member’s:
    • Horizon BCBSNJ ID number
    • First and last names
    • Date of birth
  • The rendering, referring or ordering  physician’s:
    • First and last names
    • National Provider Identifier (NPI)
    • Tax Identification Number (TIN)
    • Fax number
    • The above information should also be provided for any co-surgeon or assistant surgeon deemed necessary to perform the  requested procedure(s)
  • The rendering facility’s:
    • Name
    • NPI
    • TIN
    • Street address
    • Fax number
  • CPT codes and diagnosis codes
  • Place of service
  • All relevant clinical notes, imaging/X-ray  reports and any anticipated implant, technology or hardware to be used.

TurningPoint will use this information to make determinations for PA/MND requests and to perform claim reviews.

Medical Policy Criteria and Guidelines

The medical policy criteria and guidelines that TurningPoint will use to conduct PA/MND reviews as part of this program were effective December 3, 2018. TurningPoint’s medical policy criteria and guidelines pertain only to Horizon BCBSNJ fully insured members.

Physicians and facilities can access the medical policy criteria and guidelines TurningPoint will use to conduct PA/MND reviews online. To access this  information, sign in to NaviNet.net, select Horizon BCBSNJ from the My Health Plans menu, and:

  • Mouse over Referrals & Authorization and select TurningPoint PA/MND Requests
  • Select Help from the menu bar of TurningPoint’s home page
  • Select Medical Policies and Clinical Guidelines within the Helpful Articles section

Physicians and facilities can also request the medical policy criteria and guidelines by calling TurningPoint at 1-833-436-4083, Monday through Friday, between 8 a.m. and 5 p.m., ET.

Questions?

Horizon BCBSNJ values your participation in our network and the care you provide to our members. If you have any questions, call TurningPoint at 1-833-436-4083, Monday through Friday, between  8 a.m. and 5 p.m., ET.

¹ Services rendered in the observation setting and the Emergency Room (ER) are excluded.

² Horizon BCBSNJ members enrolled in plans that include BlueCard benefits who receive care outside of Horizon BCBSNJ’s service area which includes the State of New Jersey, contiguous counties in DE, NY and PA (as well as Lehigh County, PA).

³ To determine member eligibility and benefits, physicians can call the phone number on the back to the member’s ID card. For BlueCard benefit inquiries call 1-800-676-2583.