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Policies, Procedures and General Guidelines

INPATIENT TRANSFER FROM A NONPARTICIPATING HOSPITAL TO A PARTICIPATING HOSPITAL

Members emergently admitted to a nonparticipating hospital will be transferred to a participating hospital as soon as they are medically stable and a participating hospital is able to accept the patient. In these instances, one of our Concurrent Review Nurse Coordinators (CRNC) will assist in transferring the patient to a participating hospital.

The CRNC will contact the:

  • Utilization Review Department of the nonparticipating hospital.
  • Attending physician at the nonparticipating hospital.
  • Member’s PCP, and encourage regular contact between the PCP and the attending physician.

When the member is ready for transfer to your hospital, the CRNC will:

  • Provide the PCP with a list of participating specialists at the receiving hospital.
  • Contact the member and explain the reason for the transfer.
  • Contact the nonparticipating hospital’s social worker.
  • Arrange for ambulance transport to the receiving hospital.

The attending physician and PCP must maintain regular contact to determine the status of the patient and to follow the procedures for transfer, which include:

  • Contacting the receiving hospital and arranging for admission.
  • Arranging for an attending physician at the receiving hospital (if the PCP will not be the attending physician).

In the case of surgical admissions, burn unit patients, critically ill neonates or cases where child delivery has already taken place, no immediate transfer will be initiated. Note: If the patient is not stable for transfer, the PCP and/or the attending physician must advise the CRNC of the medical necessity for the transfer not to occur.

CULTURAL COMPETENCY

Horizon BCBSNJ’s membership represents many cultural, ethnic, linguistic and racial backgrounds. To meet the needs of our members, including those that have limited English proficiency or reading skills, you are required to ensure that all clinical and nonclinical services are accessible to all members in a manner that:

  • Honors and is compatible with their cultural health beliefs and practices,
  • Is sensitive to cultural diversity and
  • Fosters respect for their cultural backgrounds.

We use the AT&T Language Line service to help our service representatives communicate with callers in more than 140 languages, 24 hours a day, seven days a week.

MEMBER NONDISCRIMINATION

Neither Horizon BCBSNJ nor practitioner shall discriminate in the delivery of health care services based on race, color, creed, ethnicity, national origin, religion, sex, age, behavioral or physical disability, medical condition, sexual orientation, pregnancy, gender identity, marital status, claims experience, medical or behavioral health history or status, pre-existing medical/health conditions, need for or receipt of health care services, evidence of insurability, geography, genetic information, actuarial class, source of payment or any other unlawful purpose.

Hospitals must have policies to prevent discrimination in health care delivery and implement procedures to monitor and ensure it does not occur.

HOSPITAL AND OTHER INPATIENT CARE

You must obtain authorization for all elective inpatient stays. An authorization number must be given to the member to present to the hospital upon admission. Hospital authorizations cover all inpatient services, including pre-admission testing, anesthesia, laboratory, pharmacy and other specialty services related to the admission.

Managed care members should be referred to network hospitals or facilities (e.g., residential treatment centers or skilled nursing facilities). Inpatient care will be provided in semi-private accommodations.

When medically necessary, managed care members can be referred to a nonparticipating hospital if their need for medical treatment cannot be accommodated through our network.

Such referrals must be made to fully licensed, accredited facilities and must be authorized by Horizon BCBSNJ if treatment is to be covered for plans with no out-of-network benefits, or covered at an in-network level for plans that do have out-of-network benefits.

In emergency situations, you must notify Horizon BCBSNJ at 1-800-664-BLUE (2583) immediately upon admission or within 24 hours of the admission (or on the next business day if the admission occurs on a weekend or holiday).

Hospitals must give Notice of Admission (NOA) via Horizon BCBSNJ’s Electronic Data Interchange (EDI) system anytime an eligible person is admitted as an inpatient. The NOA must be submitted immediately upon admission or within 24 hours of the admission (or on the next business day if the admission occurs on a weekend or holiday). All NOAs shall be accompanied, or promptly followed by the next business day, by all applicable medical records by fax or other agreed upon means.

COPAYMENTS AND ALLOWED AMOUNTS

Copayment amounts vary from plan to plan. You are permitted to collect the copayment indicated on the member’s ID card at the time of service, but not as a condition for the provision of services. If our allowed amount for the service you provided (indicated on the EOP you receive) is less than the copayment amount collected, you may

need to refund the difference to the member. It is possible that a member’s copayment may turn out to be greater than our allowance for the services provided.

COPAYMENTS AND DUAL ELIGIBLE PATIENTS

Patients enrolled in any Horizon BCBSNJ plan who have secondary coverage through Horizon NJ Health (New Jersey Medicaid benefits) are not responsible, and should not be billed, for any copayment or coinsurance amounts under their primary coverage.

Participating physicians and other health care professionals agree not to bill or seek to collect any copayment or coinsurance from any such person, but to seek payment from Horizon NJ Health for any remaining balances.

COLLECTION OF MEMBER LIABILITY: COPAYMENTS, COINSURANCE AND DEDUCTIBLE

At the time of service you may collect copayments, coinsurance and deductibles, or other amounts associated with exclusions or limitations noncovered benefits. All copayments, coinsurance and deductibles must be based upon Horizon BCBSNJ’s allowed amount. However, any overpayment must be returned promptly to the member. If you do not collect member liability up front, then you are required to bill members for the appropriate member liability (deductible and/or coinsurance), as indicated on the Explanation of Payment (EOP) you receive. Hospitals cannot waive or rebate such member liability amounts.

You are required to accept our allowed amount for eligible services as reimbursement. To protect our members, Horizon BCBSNJ participating hospitals shall not add a “collection” fee, interest or other amount to the member liability until the member has had a reasonable opportunity (i.e., a minimum of 30 days) to pay.

Inform your patients in advance of your billing practices for the collection of member liability and of any fees or interest that you charge when member liabilities are not paid in a timely manner. Copayment amounts are indicated on the member’s ID card. You may contact our Centralized Service Center for patient coinsurance liability and, if applicable, deductible amounts.

CONFIDENTIALITY OF MEDICAL RECORDS AND PERSONAL INFORMATION

Hospitals are responsible for complying with all applicable state and federal laws and regulations regarding confidentiality of medical records and individually identifiable health information, including, without limitation, the privacy requirements of HIPAA (the federal Health Insurance Portability and Accountability Act of 1996, Pub. L.

104-19, and any regulations promulgated thereunder) no later than the effective date of those state and federal laws.

MEDICAL RECORDS REQUEST BY PATIENTS

Members have the right to request and receive a copy of their medical records and request that the

records be amended or corrected. We reprint, on the following pages, an excerpt of the actual regulation of the State of New Jersey Board of Medical Examiners on the preparation and release of information if requested by the patient or an authorized representative.

From the State Board of Medical Examiners Statutes and Regulations

(13:35-6.5) Preparation of patient records, computerized records, access to or release of information; confidentiality, transfer or disposal of records.

(a) The following terms shall have the following meanings unless the context in which they appear indicate otherwise:

Authorized representative means, but is not necessarily limited to, a person who has been designated by the patient or a court to exercise rights under this section. An authorized representative may be the patient’s attorney or an employee of an insurance carrier with whom the patient has a contract which provides that the carrier be given access to records to assess a claim for monetary benefits or reimbursement. If the patient is a minor, a parent or guardian who has custody (whether sole or joint) will be deemed to be an authorized representative, except where the condition being treated relates to pregnancy, sexually transmitted disease or substance abuse.

Examinee means a person who is the subject of professional examination where the purpose of that examination is unrelated to treatment and where a report of the examination is to be supplied to a third-party. Licensee means any person licensed or authorized to engage in a health care profession regulated by the Board of Medical Examiners. Patient means any person who is the recipient of a professional service rendered by a licensee for purposes of treatment or a consultation relating to treatment.

(b) Licensees shall prepare contemporaneous, permanent professional treatment records. Licensees shall also maintain records relating to billings made to patients and third-party carriers for professional services. All treatment records, bills and claim forms shall accurately reflect the treatment or services rendered. Treatment records shall be maintained for a period of seven years from the date of the most recent entry.

1. To the extent applicable, professional treatment records shall reflect:

i. The dates of all treatments;

ii. The patient complaint;

iii. The history;

iv. Findings on appropriate examination;

v. Progress notes;

vi. Any orders for tests or consultations and

the results thereof;

vii. Diagnosis or medical impression;

viii. Treatment ordered, including specific dosages, quantities and strengths of medications including refills if prescribed, administered or dispensed and recommended follow up;

ix. The identity of the treatment provider if the service is rendered in a setting in which more than one provider practices;

x. Documentation when, in the reasonable exercise of the physician’s judgment, the communication of test results is necessary and action thereon needs to be taken, but reasonable efforts made by the physician responsible for communication have been unsuccessful; and

xi. Documentation of the existence of any advance directive for health care for an adult or emancipated minor and associated pertinent information. Documented inquiry shall be made on the routine intake history form for a new patient who is a competent adult or emancipated minor. The treating doctor shall also make and document specific inquiry of or regarding a patient in appropriate circumstances, such as when providing treatment for a significant illness or where an emergency has occurred presenting imminent threat to life, or where surgery is anticipated with use of general anesthesia.

2. Corrections/additions to an existing record can be made, provided that each change is clearly identified as such, dated and initialed by the licensee.

3. A patient record may be prepared and maintained on a personal or other computer only when it meets the following criteria:

i. The patient record shall contain at least two forms of identification, for example, name and record number or any other specific identifying information;

ii. An entry in the patient record shall be made by the physician contemporaneously with the medical service and shall contain the date of service, date of entry and, full printed name of the treatment provider. The physician shall finalize or sign the entry by means of a confidential personal code (CPC) and include date of the signing;

iii. Alternatively, the physician may dictate a dated entry for later transcription. The transcription shall be dated and identified as preliminary until reviewed, finalized and dated by the responsible physician as provided in (b)3ii above;

iv. The system shall contain an internal permanently activated date and time recordation for all entries, and shall automatically prepare a back-up copy of the file;

v. The system shall be designed in such a manner that, after signing by means of the CPC, the existing entry cannot be changed in any manner. Notwithstanding the permanent status of a prior entry, a new entry may be made at any time and may indicate correction to a prior entry;

vi. Where more than one licensee is authorized to make entries into the computer file of any professional treatment record, the physician responsible for the medical practice shall assure that each such person obtains a CPC and uses the file program in the same manner;

vii. A copy of each day’s entry, identified as preliminary or final as applicable, shall be made available promptly:

(1) To a physician responsible for the patient’s care;

(2) To a representative of the Board of Medical Examiners, the Attorney General or the Division of Consumer Affairs as soon as practicable and no later than 10 days after notice; and

(3) To a patient as authorized by this rule within 30 days of request (or promptly in the event of

emergency); and

viii. A licensee wishing to continue a system of computerized patient records, which system does not meet the requirements of (b)3i through vii above, shall promptly initiate arrangements for modification of the system which must be completed by October 19, 1993. In the interim, the licensee shall assure that, on the date of the first treatment of each patient treated subsequent to October 19, 1992, the computer entry for that first visit shall be accompanied by a hard copy printout of the entire computer-recorded treatment record. The printout shall be dated and initialed by the attending licensee. Thereafter, a hard copy shall be prepared for each subsequent visit, continuing to the date of the changeover of computer program, with each page initialed by the treating licensee. The initial printout and the subsequent hard copies shall be retained as a permanent part of the patient record. (c) Licensees shall provide access to professional treatment records to a patient or an authorized representative in accordance with the following:

1. No later than 30 days from receipt of a request from a patient or an authorized representative, the licensee shall provide a copy of the professional treatment record, and/or billing records as may be requested. The record shall include all pertinent objective data including test results and x-ray results, as applicable, and subjective information.

2. Unless otherwise required by law, a licensee may elect to provide a summary of the record in lieu of providing a photocopy of the actual record, so long as that summary adequately reflects the patient’s history and treatment. A licensee may charge a reasonable fee for the preparation of a summary which has been provided in lieu of the actual record, which shall not exceed the cost allowed by (c)4 below for that specific record.

3. If, in the exercise of professional judgment, a licensee has reason to believe that the patient’s mental or physical condition will be adversely affected upon being made aware of the subjective information contained in the professional treatment record or a summary thereof, with an accompanying notice setting forth the reasons for the original refusal, shall nevertheless be provided upon request and directly to:

i. The patient’s attorney;

ii. Another licensed health care professional;

iii. The patient’s health insurance carrier through an employee thereof; or

iv. A governmental reimbursement program or an agent thereof, with responsibility to review utilization and/or quality of care.

4. Licensees may require a record request to be in writing and may charge a fee for:

i. The reproduction of records, which shall be no greater than $1 per page or $100 for the entire record, whichever is less. (If the record requested is less than 10 pages, the licensee may charge up to $10 to cover postage and the miscellaneous costs associated with retrieval of the record.) If the licensee is electing to provide a summary in lieu of the actual record, the charge for the summary shall not exceed the cost that would be charged for the

actual record; and/or

ii. The reproduction of X-rays or any material within a patient record which cannot be routinely copied or duplicated on a commercial photocopy machine, which shall be no more than the actual cost of the duplication of the materials, or the fee charged to the licensee for duplication, plus an administrative fee of the lesser of $10 or 10 percent of the cost of reproduction to compensate for office personnel time spent retrieving or reproducing the materials and overhead costs.

5. Licensees shall not charge a patient for a copy of the patient’s record when:

i. The licensee has affirmatively terminated a patient from practice in accordance with the requirements of N.J.A.C. 13:35-6.22; or

ii. The licensee leaves a practice that he or she was formerly a member of, or associated with, and the patient requests that his or her medical care continue to be provided by that licensee.

6. If the patient or a subsequent treating health care professional is unable to read the treatment record, either because it is illegible or prepared in a language other than English, the licensee shall provide a transcription at no cost to the patient.

7. The licensee shall not refuse to provide a professional treatment record on the grounds that the patient owes the licensee an unpaid balance if the record is needed by another health care professional for the purpose of rendering care. (d) Licensees shall maintain the confidentiality of professional treatment records, except that:

1. The licensee shall release patient records as directed by a subpoena issued by the Board of Medical Examiners or the Office of the Attorney General, or by a demand for statement in writing under oath, pursuant to N.J.S.A. 45:1-18. Such records shall be originals, unless otherwise specified, and shall be unedited, with full patient names. To the extent that the record is illegible, the licensee, upon request, shall provide a typed transcription of the record. If the record is in a language other than English, the licensee shall also provide a translation. All X-ray films and reports maintained by the licensee, including those prepared by other health care professionals, shall also be provided.

2. The licensee shall release information as required by law or regulation, such as the reporting of communicable diseases or gunshot wounds or suspected child abuse, etc., or when the patient’s treatment is the subject of peer review.

3. The licensee, in the exercise of professional judgment and in the best interests of the patient (even absent the patient’s request), may release pertinent information about the patient’s treatment to another licensed health care professional who is providing or has been asked to provide treatment to the patient, or whose expertise may assist the licensee in his or her rendition of professional services. 4. The licensee, in the exercise of professional judgment, who has had a good faith belief that the patient because of a mental or physical condition may pose an imminent danger to himself or herself or to others, may release pertinent information to a law enforcement agency or other health care professional in order to minimize the threat of danger. Nothing in this paragraph, however, shall be construed to authorize the release of the content of a record containing identifying information about a person who has AIDS or an HIV infection, without patient consent, for any purpose other than those authorized by N.J.S.A. 26:5C-8.

If a licensee, without the consent of the patient, seeks to release information contained in an AIDS/HIV record to a law enforcement agency or other health care professional in order to minimize the threat of danger to others, an application to the court shall be made pursuant to N.J.S.A. 26:5C-5 et seq. (e) Where the patient has requested the release of a professional treatment record or a portion thereof to a specified individual or entity, in order to protect the confidentiality of the records, the licensee shall: 1. Secure and maintain a current written authorization, bearing the signature of the patient or an authorized representative; 2. Assure that the scope of the release is consistent with the request; and 3. Forward the records to the attention of the specific individual identified or mark the material Confidential. (f) Where a third-party or entity has requested examination, or an evaluation of an examinee, the licensee rendering those services shall prepare appropriate records and maintain their confidentiality, except to the extent provided by this section.

The licensee’s report to the third party relating to the examinee shall be made part of the record. The licensee shall: 1. Assure that the scope of the report is consistent with the request, to avoid the unnecessary disclosure of diagnoses or personal information which is not pertinent; 2. Forward the report to the individual entity making the request, in accordance with the terms of the examinee’s authorization; if no specific individual is identified, the report should be marked Confidential; and 3. Not provide the examinee with the report of an examination requested by a third party or entity unless the third party or entity consents to its release, except that should the examination disclose abnormalities or conditions not known to the examinee, the licensee shall advise the examinee to consult another health care professional for treatment.

(g) (Reserved) (h) If a licensee ceases to engage in practice or it is anticipated that he or she will remain out of practice for more than three months, the licensee or designee shall: 1. Establish a procedure by which patients can obtain a copy of the treatment records or acquiesce in the transfer of those records to another licensee or health care professional who is assuming responsibilities of the practice. However, a licensee shall not charge a patient, pursuant to (c)4 above, for a copy of the records, when the records will be used for purposes of continuing treatment or care. 2. Publish a notice of the cessation and the established procedure for the retrieval of records in a newspaper of general circulation in the geographic location of the licensee’s practice, at least once each month for the first three months after the cessation; and 3. Make reasonable efforts to directly notify any patient treated during the six months preceding the cessation, providing information concerning the established procedure for retrieval of records.

Note: The Medical Record fee does not apply to Horizon BCBSNJ’s request for medical records.

MEDICAL EMERGENCY

A medical emergency is a medical condition manifesting itself by acute symptoms of sufficient severity, including, but not limited to, severe pain, psychiatric disturbances and/or symptoms of substance abuse such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:

  • Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy.
  • Serious impairment to bodily functions.
  • Serious dysfunction of a bodily organ or part. With respect to a pregnant woman who is having contractions, an emergency exists where:
  • There is inadequate time to effect a safe transfer to another hospital before delivery.
  • The transfer may pose a threat to the health or safety of the woman or unborn child.

When a physician or other health care professional refers a member to the Emergency Room (ER), you must contact us within 48 hours. Members who use the ER for routine or non-emergent care may be responsible for all charges.

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. (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).

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.

URGENT CARE

Urgent care is defined as a non-life-threatening condition that requires care by a physician or health care professional within 24 hours. In situations requiring urgent care, members are instructed to contact their primary care physician, who can then assess the situation and coordinate the appropriate medical treatment.

If you recommend urgent treatment in your office and the member goes to a hospital ER instead, the resulting charges will be the member’s responsibility. Urgent Care Centers (UCCs) provide an alternative to the Emergency Room (ER) for an injury or illness that requires immediate care but is not life threatening. Treatment often costs considerably less than care in an ER and an average visit usually lasts less than one hour.

The UCCs in Horizon BCBSNJ’s network have extended and weekend hours. Treatment is available for wounds, sprains and other conditions that require attention within 24 hours, but do not pose a danger to a person’s life or long-term health.

All UCCs participating with Horizon BCBSNJ can perform essential medical services, diagnosis illness and treat emergent conditions. Routine office visits, including preventive care, sports physicals, routine obstetric services, occupational medicine and physical therapy are not covered at UCCS.

NEVER EVENTS GUIDELINES

The term “never events” is used to reference adverse events or errors in medical care that are clearly identifiable, preventable and present serious consequences to patients. Never events include hospital-acquired conditions and wrong surgeries. Horizon BCBSNJ follows the Centers for Medicare & Medicaid Services’ (CMS) reimbursement policy for never events, including certain conditions identified by the state of New Jersey.

Horizon BCBSNJ will not reimburse hospitals for any services related to wrong surgeries and may reduce reimbursements to hospitals for services to treat hospital-acquired conditions that were not present on admission. Members must be held harmless for any reimbursement for services related to never events, including hospital-acquired conditions and wrong surgeries.

Horizon BCBSNJ will conduct a clinical quality review of all claims with the identified never events and hospital-acquired conditions listed below. Any claim issues identified during our review will be presented to the hospital for further review, as appropriate. Hospital medical records may be requested to facilitate the review. Hospitals should include a Present on Admission (POA) indicator on all claims.

Never Events Subject to Review

Hospital-Acquired Conditions (HACs)

  • Pressure ulcers, stages III and IV
  • Catheter-associated urinary tract infections
  • Vascular catheter-associated infection
  • Surgical site infection, mediastinitis, following coronary artery bypass graft (CABG)
  • Air embolism
  • Blood incompatibility
  • Foreign object retained after surgery
  • Falls and trauma (fracture, dislocation, intracranial injury, crashing injury, burn, electric shock)
  • Surgical-site infections following certain orthopedic procedures
  • Surgical-site infections following bariatric surgery for obesity
  • Manifestations of poor glycemic control
  • Deep vein thrombosis and pulmonary embolism following certain orthopedic procedures

Wrong Surgeries:

  • Surgery performed on a wrong body part.
  • Surgery performed on a wrong patient.
  • Wrong surgical procedure performed.

Note: HACs were included on CMS’ list of never events as of October 1, 2008. Wrong surgeries were adopted by CMS on January 15, 2009.

ADVANCE DIRECTIVES

Advance directives allow patients to make sure their wishes are clearly known regarding the type of care a member would like to receive. They also allow the patient to appoint someone to make medical decisions for them if they are unable to speak for themselves.

Advance directives are legally recognized documents and are an important part of a member’s medical record. During an audit, Horizon BCBSNJ representatives look for documentation that the physician asked their patient if they either have an advance directive or would like to create one. When treating your Medicare Advantage patients, ask them if they have completed their advance directives.

  • If the patient responds that he or she has an advance directive, that documentation (along with an actual copy of the advance directive document itself) should be included as a prominent part of the medical record. Also advise your patients who have advance directives already in place that they should make their designated health care proxy and their family members aware of the advance directive.
  • If the patient responds that he or she has no desire to create an advance directive, that documentation should also be included as a prominent part of the medical record. There are three options available when patients are making an advance directive choice:
  • Proxy Directive – Proxy Directives, or durable power of attorney for health care, are used to designate a health care representative or health care proxy who is authorized to make medical decisions on the patient’s behalf, in the event he or she is unable to do so.
  • Instruction Directive – Instruction Directives, also known as living wills, specifically express in writing the patient’s desires or instructions for treatment and indicate treatments the patient is not willing to accept.
  • Combined Directive – A Combined Directive is a single document in which the patient names a proxy and documents specific treatment instructions used to guide treatment decisions. The state of New Jersey has advance directive forms available online; however, no particular form is required. For an advance directive to be legally recognized, it must be documented in writing and signed by the patient in front of two adult (age 18 years or older) witnesses or by a Notary Public. In addition, the patient should be encouraged to make his or her desires known, not only to his or her health care proxy and physician, but also to his or her family members.

For more information on advance directives, review the brochure Advance Directives for Health Care, published by the State of New Jersey Commission of Legal and Ethical Problems in the Delivery of Health Care at www.state.nj.us/health.

Registered NaviNet users may review our Medical Record Documentation Standards after logging to

NaviNet.net. Select Horizon BCBSNJ from the My Health Plans menu, and:

  • Select Provider Reference Materials.
  • Mouse over Policies & Procedures and select Policies, then Administrative Policies.
  • Select Medical Records Documentation Standards.

AUDIOLOGY AND HEARING AID BENEFITS

Audiology Distribution, LLC, doing business as HearUSA, works with Horizon BCBSNJ to administer hearing benefits and provide related products and services through their network of independently practicing audiologists, hearing care professionals and company-owned HearUSA Centers. Horizon BCBSNJ works with HearUSA and their HearUSA Centers to provide audiology services, hearing aids and discounts on certain services to our enrolled members. The following information outlines the role that HearUSA plays in various member benefits.

Note: The benefit information provided is not a guarantee of reimbursement. Claim reimbursement is subject to member eligibility, and all member and group benefit limitations, conditions and exclusions. Please confirm member audiology benefits and hearing aid benefit amounts before providing services.

Members enrolled in Horizon Medicare Advantage plans that include audiology/hearing benefits receive audiology/hearing aid benefits through HearUSA as follows:

  • In-network routine hearing services (including annual routine hearing exam, hearing aids that are medically necessary, hearing aid batteries, and/or the evaluation for fitting hearing aids) must be coordinated through HearUSA. Members must call HearUSA at 1-800-442-8231 to schedule all in-network routine hearing services.
  • Members enrolled in Horizon Medicare Advantage plans that do not include out-of-network benefits have no benefits for routine hearing services that are not coordinated through HearUSA.
  • Those members enrolled in Horizon Medicare Advantage plans that include out-of-network benefits who choose to use their out-of-network benefits (understanding that they will incur more cost sharing responsibility) may obtain an annual routine hearing exam from a non-HearUSA provider without first calling HearUSA. These members have no similar OON benefits for hearing aids that are medically necessary, hearing aid batteries, and/or the evaluation for fitting hearing aids. These services must be coordinated through HearUSA.

Members enrolled in Horizon Medicare Blue (PPO) or Horizon Medicare Blue Group (PPO) plans have no benefits for routine hearing exams and/or hearing aids.

Members enrolled in any other Horizon BCBSNJ managed care plan (Horizon HMO, Horizon Direct Access, Horizon EPO, Horizon POS, etc.) may receive audiology/hearing aid benefits through HearUSA as follows:

  • Though not required, these members may choose to use HearUSA or any other participating Horizon Managed Care Network audiologist on an in-network basis.
  • Note that benefits for audiology and hearing aids for members enrolled in other Horizon BCBSNJ managed care plans may vary. Confirm member benefits before providing services.
  • Members enrolled in any other Horizon BCBSNJ plan may receive audiology/hearing aid benefits through HearUSA as follows:
  • Any enrolled Horizon BCBSNJ member is entitled to receive a 15 percent discount on the cost of a hearing aid purchased from HearUSA. Use our Online Doctor & Hospital Finder to locate a HearUSA Center. Visit

HorizonBlue.com/doctorfinder and:

  • Select Other Healthcare Services in the What are you looking for? menu.
  • Choose the member’s plan.
  • Select Audiology within the Service Type menu.
  • Enter a ZIP Code or City, State, County.
  • Click Search.

PRODUCTS THAT USE TIERING AND/OR SUBSET OF AN EXISTING HORIZON NETWORK

Horizon BCBSNJ has revised our policy that outlines our process for selecting physicians and other health care professionals who will be included for participation in one or more of the products that use tiering and/or a subset of an existing Horizon BCBSNJ Network.

This policy applies to all physicians and health care professionals participating in the Horizon BCBSNJ Network for care rendered to members enrolled in one of the products that use tiering and/or a subset of an existing Horizon

BCBSNJ Network.

To access this administrative policy, visit HorizonBlue.com/adminpolicy and select Participation Status in Products that Utilize Tiering and/or a Subset of an Existing Horizon Network.