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Utilization Management

Horizon'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 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'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 before rendering services to our members who require prior authorization.

Horizon 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 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 and will require a new review of the current clinical circumstances.

ONLINE AUTHORIZATIONS FOR PT AND OT SERVICES

In most cases, Horizon 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 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 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 and Horizon issued an authorization, the member's subsequent health insurer must honor the authorization.

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 is the subsequent carrier, Horizon 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 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 and will require a new review of the current clinical circumstances.

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

Horizon 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.

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's online utilization management request tool via NaviNet.

As part of the review of a request for home care services to be provided, Horizon 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 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 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

This application only applies to Fully Insured Commercial, New Jersey State Health Benefits Program (SHBP) or School Employees' Health Benefits Program (SEHBP), Medicare Advantage, Braven, Medicaid and DSNP plans. ADMINISTRATIVE SERVICES ONLY (ASO) accounts, with the exception of SHBP/SEHBP plans, are excluded.

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. 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

You can use our online Utilization Management Request tool for authorization requests. Log in to NaviNet.net and select Horizon BCBSNJ from the My Health Plans menu. Mouse over Referrals and Authorization then select Utilization Management Requests.

This tool allows you to 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.

The turnaround time for non-urgent prior authorization requests is up to 15 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: 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 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 registered nurse will be assigned to your facility to review clinical information on a daily, or as-needed, basis. Your Horizon 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 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 inpatient case manager for a retrospective review.

PEER-TO-PEER DISCUSSIONS

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

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

Horizon does not consider the discussion between the Horizon 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 issues a denial due to a lack of necessary information and subsequently receives a phone call or the required information, the Horizon 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.

Transportation for Horizon 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 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'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 Inpatient Case Management (ICM) nurse.
  • If you receive a request from Horizon 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 only when necessary.

Home Infusion Therapy

Magellan Rx Management and CareCentrix will have shared responsibilities for certain medical injectable drugs subject to the Horizon Medical Injectables Program depending upon where they will be administered, as follows:

  • For medical injectable drugs that are to be administered in the patient's home by a participating Horizon Care@Home ancillary service provider, please initiate a pre-service registration with CareCentrix.
  • For medical injectable drugs that are to be administered at a freestanding or hospital-based dialysis center, in an outpatient facility or in a doctor's office, please continue to contact Magellan Rx Management to initiate a medical necessity and appropriateness review.

For more information please visit HorizonBlue.com/care@home.

PROGRAMS ADMINISTERED BY EVICORE HEALTHCARE

Horizon contracts with eviCore healthcare, to manage nonemergency radiology services, Advanced Imaging Services (MRI, CT, PET Scans, Nuclear Medicine including Nuclear Cardiology), cardiac imaging services, radiation therapy and pain management services provided to members enrolled in many of the plans we offer.

eviCore healthcare helps ensure that medically necessary and appropriate services are provided to our members. eviCore healthcare also provides clinical consultation and support to ancillary providers. They help in scheduling radiology/imaging services for our members.

MEDICAL INJECTABLES PROGRAM (MIP)

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.

For more information please visit MIP, including an in-depth FAQ.

Plans Included in the MIP

The MIP applies to services provided to members 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 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.

AIM SPECIALITY HEALTH

Certain self-insured employer group health plans administered by Horizon 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.

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).

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 and Spinal/Pain 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.myturningpoint-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.