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Inquiries, Complaints and Appeals

Horizon's goal is to provide prompt responses to your inquiries and timely resolution of complaints brought to our attention. Call our Interactive Voice Response (IVR) system at 1-888-666-2535 to access the information you need concerning your inquiries or complaints.

In addition, our Centralized Service Center (CSC) Phone Unit is available to respond to your inquiries or complaints. at 1-888-666-2535, weekdays, between 8 a.m. and 5 p.m., ET.

You may also submit your inquiries or complaints in writing to:

Horizon BCBSNJ
Centralized Service Center
PO Box 1770
Newark, NJ 07101-1770

HOSPITAL INQUIRIES

An inquiry is a verbal or written request for administrative action or information, or an expression of opinion or comment regarding any aspect of Horizon's health care plans, or those of its Administrative Service Only (ASO) accounts.1

Inquiries can often be addressed or resolved by the Horizon BCBSNJ service representative at the point of contact. Examples of inquiries include, but are not limited to: questions regarding eligibility of members, benefits or claim status.

Certain ASO accounts handle inquiries and complaints related to their self-insured plans. In such cases, Horizon BCBSNJ will refer you to the proper person or office for you to pursue your inquiry or complaint.

HOSPITAL COMPLAINTS

A complaint is a verbal or written expression of dissatisfaction made by a hospital, on its own behalf, regarding any aspect of Horizon's health care plans, or the plans of its ASO accounts, including Horizon's administration of those plans generally or with respect to a specific action or decision made or taken by Horizon in connection with any of those health care plans.

Examples of complaints include, but are not limited to:

  • Administrative difficulties or communication problems
  • Claim issues
  • Credentialing

Complaints relating to claims may involve:

  • Contract benefit issues
  • CPT-4 code inconsistencies
  • Incorrect coding
  • Rebundling of charges
  • Reimbursement disagreements

Complaints do not include issues relating to specific utilization management determinations. The process for challenging utilization management determinations is described in the Utilization Management section in this manual. No hospital that exercises the right to file a complaint shall be subject to any sanction, disaffiliation and termination or otherwise penalized solely due to such action.

TIME LIMITS FOR INQUIRY OR COMPLAINT FILING

You may submit a written or verbal complaint within 18 months from the date of the Horizon decision or action with which you are dissatisfied. There is no time limit for hospitals to make an inquiry. However, an inquiry related to a specific claim cannot be made beyond the timely claims filing time period requirement within your contract or the relevant covered person's underlying benefit contract, whichever is longer.

There is also no limit applicable for the filing of a complaint relating to matters in general with which you are dissatisfied that do not involve a specific decision or action taken by Horizon BCBSNJ.

RESOLVING YOUR INQUIRIES AND COMPLAINTS

Horizon BCBSNJ will attempt to address your inquiries and complaints immediately, whenever possible.

Inquiries and complaints will typically be responded to no later than 30 days from Horizon's receipt. If an inquiry or complaint involves urgent or emergent care issues, responses are expedited consistent with the circumstances and patient need involved. Our final response will describe what further rights you may have concerning the matter in question.

Those who remain dissatisfied with the outcome of their inquiries and complaints at the conclusion of the internal inquiry and complaint process have the right to contact the following state agency:

Department of Banking and Insurance
Division of Enforcement and
Consumer Protection
PO Box 329
Trenton, NJ 08625-0329

Phone: 1-609-292-5316

PROVIDER CLAIM REIMBURSEMENT APPEAL PROCESS

The Health Claims Authorization, Processing and Payment Act (HCAPPA) affects only insured products offered by Horizon and its subsidiaries. The law does not apply to Administrative Services Only (ASO) plans, the New Jersey State Health Benefits Program and federal programs, including the Federal Employee Program (FEP) and Medicare. As such, claims for hospitals provided to individuals covered under such plans are not affected by HCAPPA.

If your complaint involves a specific Claim Payment Determination that relates to your treatment of an insured member, written appeals must be initiated on the New Jersey Department of Banking and Insurance (DOBI) required form on or before 90 calendar days following receipt of the health insurer's claim determination.

The DOBI form, Health Care Provider Application to Appeal a Claims Determination Form can be found

within the Forms section of HorizonBlue.com/providers. The form can also be found on the DOBI's website at state.nj.us/dobi.

Hospitals should include all pertinent information and documents necessary to help us understand your position on why you dispute our determination of the claim. Claim appeals should be mailed to:

Horizon BCBSNJ
Appeals Department
PO Box 10129
Newark, NJ 07101-3129

Note: Appeals cannot be of a medical necessity determination. Medical necessity disputes should be appealed through the Independent Health Care Appeals Program (IHCAP).

Health insurers are required by law to make a determination (either favorable or unfavorable) and notify the hospital of its decision on or before 30 calendar days following its receipt of the appeal form.

  • If a favorable determination is made for the hospital, the health insurer must make reimbursement within 30 calendar days of notification of the appeal determination together with any applicable prompt pay interest, which shall accrue from the date the appeal was received.
  • If an unfavorable determination is made for the hospital, the health insurer must provide the hospital instructions for referral to external arbitration.
  • If the hospital is not timely notified of the determination, or disagrees with the final decision, the hospital may refer the dispute to external arbitration.

What is an HCAPPA Claim Payment Determination?

A Claim Payment Determination is Horizon's decision on a submitted claim or a claims related inquiry or complaint.

A claim dispute that concerns a utilization management determination, where the services in question are reviewed against specific guidelines for medical necessity or appropriateness to determine coverage under the benefits plan, may not be appealed under this process. These decisions are considered adverse utilization management determinations and follow a different process.

HCAPPA External Appeals Arbitration

The New Jersey Department of Banking and Insurance (DOBI) awarded the independent arbitration organization contract to MAXIMUS, Inc. As of July 2007, parties with claims eligible for arbitration may complete an application and submit it, together with required review and arbitration fees, directly to MAXIMUS, Inc. External appeals are not submitted through Horizon BCBSNJ.

Visit njpicpa.maximus.com for additional information and applications. Hospitals must initiate a request for an external appeal of their claim within 90 calendar days of their receipt of the health insurer's internal appeal decision.

However, to be eligible for this second level arbitration appeals process, disputes must be in the amount of $1,000 or more. Hospitals may aggregate claims (by carrier and covered person or by carrier and CPT code) to reach the $1,000 threshold. The independent arbitrator's decision must be issued on or before 30 calendar days following receipt of the required documentation. The decision of the independent arbitrator is binding. Reimbursement must be issued within 10 business days of the arbitrator's decision.

HCAPPA Third-Party Representation

Network and non-network hospitals may wish to use the services of a third-party organization or service to file a Claim Appeal on their behalf. If so, Horizon BCBSNJ has specific requirements that must be met to safeguard the patient health information entrusted to us by our members or covered persons. Call the Appeals Unit at 1-888-666-2535 for more details on these requirements.

Inquiries, Complaints and Appeals on Behalf of Members

In addition to the rights you have as hospital staff, Horizon BCBSNJ offers complaint and appeal processes for members/covered persons. These member-based processes relate to our utilization management decision-making as well as all other nonutilization management issues. As with our hospital-based processes, these processes are designed to handle our members' or covered persons' concerns in a timely manner. From time to time, our members or covered persons may seek their health care professionals' help in pursuing an inquiry, complaint or appeal on their behalf. Hospital staff may only pursue these avenues on behalf of their patients if the consent of the patient is obtained.

Utilization Management Member Inquiries and Complaints

Horizon BCBSNJ's process for handling member inquiries and complaints is similar to the manner in which Horizon BCBSNJ handles hospital-based issues. However, our member inquiries and complaints are handled through our Member Services Department, which members can reach by calling 1-800-355-BLUE (2583).

Member Services Representatives are available to respond to member inquiries or complaints, or those made by a hospital on behalf of a member with their consent. Our service staff is often able to immediately resolve questions at the point of contact. Member Services is available Monday through Wednesday and Friday, between 8 a.m. and 6 p.m., and Thursday, between 9 a.m. and 6 p.m., ET.

Inquiries or complaints may also be submitted in writing to:

Horizon BCBSNJ
Member Services
PO Box 820
Newark, NJ 07101-0820

Hospitals are reminded that to pursue an inquiry or complaint on behalf of a member through Member Services, hospital staff must have the consent of the member. The time frame for submission and response to member inquiries is similar to those under the hospital-based process. Member inquiries and complaints are typically responded to within 15 days from receipt when they involve any claims for a benefit that requires Horizon BCBSNJ's approval in advance prior to receipt of services (a pre-service determination), and 30 days from receipt in all other instances (a post-service claim).

If a member inquiry or complaint involves urgent or emergent care issues, responses are expedited consistent with the circumstances and specific patient need. Our final response will describe what further rights the member may have concerning the matter in question.

Filing an Appeal on Behalf of a Member

Prior to receiving services, a covered person or a person designated by the covered person may sign a consent form authorizing a hospital acting on the covered person's behalf to appeal a determination by the carrier to deny, reduce or terminate benefits. The consent is valid for all stages of the carrier's informal and formal appeals process and the Independent Health Care Appeals Program.

The covered person shall retain the right to revoke his or her consent at any time. When appealing on behalf of the member, HCAPPA requires that the hospital provide the member with notice of the appeal whenever an appeal is initiated and again at each time the appeal is continued to the next stage, including any appeal to the Independent Utilization Review Organization (IURO).

NONUTILIZATION MANAGEMENT DETERMINATION APPEALS

Member Appeals – Requesting an Appeal

Following the receipt of the complaint determination, in appropriate instances, the member/covered person, or a hospital on behalf of, and with the consent of the member or covered person, may request an appeal either verbally, in-person or by telephone, or in writing as instructed by Horizon BCBSNJ in its complaint determination.

Note: Members/covered persons in some plans do not have the appeal rights described here. For example, members/covered persons of certain plans such as ASO and self-insured accounts may not have the appeal rights described here.

Horizon BCBSNJ's written complaint determinations will detail the member's appeal rights. Members are directed to send their appeal requests whether by phone or in writing to the Appeals team at the address and phone number supplied. An Appeals Coordinator investigates the case and collects the information necessary to forward the case to the Appeals Committee. The Appeals Coordinator sends a letter to the member/covered person (within five calendar days of receiving the appeal request), acknowledging the request for appeal, describing the Appeals Committee process and advising of the actual hearing date.

Resolving the Member's Appeal

Cases are scheduled within five days of receiving the request for an appeal related to a pre-service determination and within 10 days for an appeal related to a post-service claim. Appeals that involve requests for urgent or emergent care may be expedited.

The member/covered person is given the option of attending the hearing in person or via telephone conference. The Appeals Coordinator makes the appropriate arrangements. Members/covered persons or hospitals, physicians and other health care professionals on behalf of and with the consent of members or covered persons, who participate in the hearing are notified of the Committee's decision verbally, on the day of the hearing whenever possible. Written confirmation of the decision is sent to the member/covered person and/or the hospital staff, physician or other health care professional who pursued the appeal on their behalf, within two business days of the decision.

Members/covered persons who choose not to appear are notified of the Committee's decision in writing within two business days of the decision. Appeals are decided within 15 days of receipt for pre-service determinations and 30 days of receipt for post-service claims. Letters of decision advise members of what other remedies may be available to them if they are dissatisfied with the resolution reached through the internal complaint system.

Expedited Complaints and Appeals

Member complaints and appeals may be expedited if the complaint or appeal involves a request for urgent or emergent care. Horizon BCBSNJ reserves the right to decide if the complaint or appeals process should be expedited in instances where the member/covered person or their representative is not hospital staff, physician or other health care professional. Expedited complaint review determinations are made as soon as possible, in accordance with the medical emergencies of the case, which in no event shall exceed 72 hours.

HOSPITAL APPEALS

Horizon BCBSNJ offers network hospitals a form al process to appeal an adverse utilization management determination (e.g., denial of procedures or services; denial of inpatient admissions; denial of day(s) within an admission; or assignment of alternate level of care). The appeal must be received within 180 calendar days of the date of the written adverse determination and must contain the information outlined in this section. Horizon BCBSNJ retains the right to accept only those appeals submitted by a hospital or contracted third party acting on behalf of the hospital if the procedures outlined in this section are followed.

Once an appeal request is received, Horizon BCBSNJ conducts a full and fair investigation of the issue and provides a timely written response. If appealing on behalf of a member, please ensure the letter of appeal clearly states “appealing on behalf of member” and proper member consent is attached to the appeal request. Information Required for UM Appeals The appeal must be submitted in writing. It must be written and signed by a health care professional (doctor or RN) and include the following information:

  • Member's full name and date of birth
  • Horizon BCBSNJ member ID number (including all prefixes)
  • Hospital name and division/location
  • Admission and discharge date(s)
  • Specific date(s) being appealed
  • Nature and reason for the appeal for each denied day
  • Remedy sought for each day being appealed
  • Copy of complete medical record (must be legible and organized)

UM Appeal Submission

Mail medical UM appeals to:

Horizon BCBSNJ Appeals Department
Utilization Management Appeals
Mail Station PP-12E
PO Box 420
Newark, NJ 07101-0420

Mail behavioral health UM appeals to:

Horizon BCBSNJ Appeals Department
Horizon Behavioral Health
Utilization Management Appeals
Mail Station PP-12J
PO Box 110
Newark, NJ 07101-0110

Utilization Management

Submission of Appeals by a Third Party

Hospitals must follow the procedures below for Horizon BCBSNJ to consider an appeal submitted on their behalf by a third party. The network hospital must forward a completed copy of our Third Party Vendor Information Form to their Horizon BCBSNJ Network Hospital Relations representative. This form, available from your Network Hospital Relations representative, provides information about the third party including:

  • Full name of the contracted third party
  • Effective date of the contracted relationship
  • Vendor relationship with the contracted third party
  • Assurance that the contracted third party is in compliance with all applicable state and federal laws onconfidentiality, including, but not limited to, HIPAA.

The third party must follow Horizon BCBSNJ's utilization management policies, including, but not limited to the following:

  • Guidelines on appeal submissions must contain the information outlined in this article.
  • Third parties must identify themselves correctly on all phone inquiries and correspondence. Allresponses to appeals by a third party representing the hospital will be communicated to that third party.

Appeals Related to Medical Necessity/Appropriateness Determinations

Level 1 Appeals

This appeal is reviewed by a Horizon BCBSNJ Medical Director who did not participate in the original determination. The appeal is completed within 30 calendar days of receipt of the appeal and the determination is communicated in writing to the facility. The communication will contain information and directions for requesting a level 2 appeal, as applicable.

Level 2 Appeals

This appeal must be received within 60 calendar days of the date of the level 1 determination letter. It must include the reason a second review is requested and must be for the same dates and services indicated on the level 1 appeal. The request should not include a second copy of the medical record.

The Provider Appeal Subcommittee reviews all documentation submitted for the level 2 appeal, as well as the original case file. The Provider Appeal Subcommittee is comprised of Horizon BCBSNJ Medical Directors and other health care professionals. The Provider Appeal Subcommittee members who participated in the original determination or level 1 appeal do not vote on the level 2 appeal.

The Provider Appeal Subcommittee may seek guidance from consultant practitioners who are trained or who practice in the same or similar specialty that typically manage the case at issue or such other licensed health care professionals. The consulting physician or other health care professional(s) participate in a nonvoting capacity in the Provider Appeal Subcommittee's review of the case.

The Provider Appeal Subcommittee issues a determination within 30 calendar days of receipt of the level 2 appeal. The determination is communicated to the facility in writing.