Horizon Behavioral Health℠

To help you better manage our members’ behavioral health care, we have a dedicated team of professionals that manage the administration and clinical management of behavioral health services available for eligible members and covered dependents enrolled in Horizon BCBSNJ’s commercial and Medicare Advantage plans.

Coordination of medical care and behavioral health care is a best practice model. Collaboration improves the safety and efficacy of services for members. Horizon BCBSNJ collects data on the accuracy, sufficiency, timeliness and frequency of information exchanged.

To assist you in you in day-to-day questions and provide a quick reference to information, please review the information below and visit HorizonBlue.com/providershbh.

BEHAVIORAL HEALTH CARE MANAGEMENT

Providers can call Horizon Behavioral Health Care Management at:

• 1-800-626-2212
• 1-800-991-5579 (for the State Health Benefits Program (SHBP) and the School Employees’ Health Benefits Program (SEHBP) Program only)
• 1-888-444-0422 (for Braven Health℠ plans only)

If there is a request for a referral and/or information about providers in the member’s location, Behavioral Health Clinicians may conduct a brief screening to evaluate whether there is a need for urgent or emergent care. Referrals are made to participating providers, while considering member preferences such as geographic location, hours of service, cultural or language requirements, ethnicity, type of degree the provider holds and gender. Additionally, the member may require a clinician with a specialty such as treatment of eating disorders. In all cases, where available, the clinicians will assist in arranging care for the member. The name, location and phone number of at least three participating providers will be given to the member.

CLAIMS

We strongly encourage behavioral health providers to submit claims to Horizon BCBSNJ electronically via NaviNet®. Electronic claims can also be submitted through a vendor or clearinghouse.

Acute care facilities should submit through clearinghouses only.

Horizon BCBSNJ Electronic Payor ID is 22099

Braven Health Electronic Payer ID is84367.

You must establish separate EDI capabilities with Braven Health to submit claims and receive reimbursement for Braven Health members. If you haven’t already done so, we encourage providers, vendors and clearinghouses to establish EDI capabilities immediately.

Claims Inquiries:

Call:

1-800-624-1110

Or

1-800-626-2212

1-800-991-5579 (for the State Health Benefits Program (SHBP) and the School Employees’ Health Benefits Program (SEHBP) Program only)

If you need to mail claims (including claims for Braven Health):

Horizon BCBSNJ

Horizon Behavioral Health

PO Box 10191 Newark, NJ 07101-3189

Claims for Federal Employee Program® (FEP®) Members:

PO Box 656, Newark, NJ 07101-0656

Claims for BlueCard® Members:

PO Box 1301, Neptune, NJ 07754-1301

When providing care, check the patient’s ID card for behavioral health coverage information.

UTILIZATION MANAGEMENT

Horizon Behavioral Health Utilization Management encompasses management of care from the point of entry through discharge using objective, standardized and widely distributed clinical protocols and outlier management programs. Providers are required to comply with utilization management policies and procedures and associated review processes.

Examples of review activities included in the Horizon Behavioral Health Utilization Management program are determinations of medical necessity, preauthorization, notification, concurrent review, retrospective review, care/case management, discharge planning and coordination of care.

All behavioral health authorization requests should be submitted electronically to Horizon BCBSNJ via our online Utilization Management Review Tool accessed on NaviNet.®

The Horizon Behavioral Health Utilization Management program includes processes to address:

• Easy and early access to appropriate treatment
• Delivery of quality care according to accepted best-practice standards while working collaboratively with providers
• Needs of special populations, such as children and the elderly
• Identification of common illnesses or trends of illness
• Identification of high-risk cases for intensive care management
• Prevention, education and outreach

Objective, scientifically based clinical criteria and treatment guidelines, in the context of provider- or member-supplied clinical information, direct the utilization management processes.

MCG Health’s Care Guidelines (MCG) is used to make behavioral health care coverage determinations for members enrolled inall Horizon BCBSNJ plans.

Horizon BCBSNJ uses American Society of Addiction Medicine (ASAM) criteria when making coverage determinations for services related Substance Use Disorders.

Horizon BCBSNJ will provide the clinical rationale for the determination(s) in the adverse determination letter. The MCG Care Guidelines used in making the specific determination are available free of charge upon request.

TREATMENT PLANNING

Providers must develop individualized treatment plans that use assessment data, address the member’s current problems related to the behavioral health diagnosis and actively include the member and significant others, as appropriate, in the treatment planning process. Behavioral Health Clinicians review the treatment plans with the providers to ensure that they include all elements required by the provider agreement, applicable government program, and at a minimum:

• Set specific measurable goals and objectives
• Reflect the use of relevant therapies
• Show appropriate involvement of pertinent community agencies
• Demonstrate discharge planning from the time of admission
• Reflect active involvement of the member and significant others as appropriate

Providers are expected to document progress toward meeting goals and objectives in the treatment record and to review and revise treatment plans as appropriate.

PROVIDER GRIEVANCES AND COMPLAINTS

Behavioral health provider complaints regarding issues related to performance (e.g., service complaints) should be directed to the Horizon Behavioral Health Customer Service Department at 1-800-626-2212, weekdays, between 8 a.m. and 8 p.m., ET, or in writing to:

Horizon BCBSNJ

Horizon Behavioral Health

Attention: Complaints and Appeals

PO Box 10191

Newark NJ 07101-3189

Horizon Behavioral Health will acknowledge receipt of provider complaints verbally or in writing, and thereafter will investigate and attempt to reach a satisfactory resolution of the complaint within 30 calendar days of receipt of the complaint. Horizon Behavioral Health will notify the provider verbally or in writing of the proposed resolution to the complaint, along with the procedure for filing an appeal (if applicable) should the provider or hospital not be satisfied with the proposed resolution.

SUBSTANCE USE DISORDER CLAIMS AND INFORMATION

Providers that treat or diagnose patients for Substance Use Disorders or refer patients for Substance Use Disorder treatment may be subject to the Confidentiality of Substance Use Disorder Patient Records Rule (42 C.F.R. Part 2) as a Part 2 Program. These providers must comply with the Consent and Notice provisions below with respect to any claim or other communication it submits through the Horizon Behavioral Health program that contains Patient Identifying Information (PII). You must comply with these requirements in order to be reimbursed for claims.

For purposes of this section, the capitalized terms “Part 2 Program,” “Patient Identifying Information,” and “Substance Use Disorder” shall have the meanings provided in 42 C.F.R. § 2.11.

Consent. Providers are prohibited by law from disclosing PII without obtaining the patient’s consent. Your patient must consent to releasing their PII before you submit any claim (or other record) that contains PII.

Notice. When PII is included with a claim or other record submission, you must include a specific statement that the information is subject to Substance Use Disorder confidentiality restrictions (the “Part 2 Disclaimer”).

Horizon Behavioral Health program may deny payment of any claim (and refuse to process other information) if you do not comply with these Consent and Notice provisions.

Audits and Evaluations. Upon request, you may be required to provide PII to Horizon Behavioral Health in order for Horizon BCBSNJ to perform evaluations and audits, including, utilization review, quality assessment and improvement activities (such as collection of HEDIS data), and reviewing qualifications of health care professionals.

Quality of Care Concerns

Our quality improvement program includes review of quality-of-care concerns and adverse outcome occurrences to assure the safety and well-being of Horizon members. The Quality Management teams collaborate at the individual practitioner and facility level to conduct an objective and systemic review. This enables us to identify opportunities for improvement to prevent similar events in the future. The Quality Peer Review Committee (QPRC) is responsible for case review when deviations from standards of care are identified. The QPRC may issue sanctions based on the severity of potential or actual harm and may require corrective action by the provider.

Failure to demonstrate meaningful improvement may result in further review by our Credentialing Committee and may result in action. This may include further corrective action, change in referral/admission eligibility status, or termination from the network.