Policies, Procedures and General Guidelines
This section contains information about the policies, procedures and guidelines you are required to follow as a participating physician or other health care professional. Failure to comply with any of the following policies and procedures may constitute a breach of your Agreement(s).
All benefits are subject to contract limits and Horizon BCBSNJ's policies and procedures, including, but not limited to, prior authorization and utilization management requirements.
You are required to refer Horizon BCBSNJ patients and/or send Horizon BCBSNJ patient's testing samples to participating clinical laboratories. Failure to comply with this requirement may result in your termination from the Horizon BCBSNJ networks.
Horizon BCBSNJ's Managed Care laboratory network includes Quest Diagnostics in addition to Laboratory Corporation of America® (LabCorp®). LabCorp and Quest provide national in-network clinical laboratory services for your Horizon BCBSNJ managed care patients (i.e., members enrolled in Horizon HMO, Horizon EPO, OMNIA Health Plans, Horizon Direct Access, Horizon POS or Horizon Medicare Advantage plans¹).
You may refer members enrolled in Horizon PPO and Indemnity plans (and/or send their testing samples to LabCorp, Quest Diagnostics and/or BioReference Laboratories, Inc., or to one of our other participating clinical laboratories or hospital outpatient laboratories at network hospitals).
As a reminder, our networks include a number of participating laboratories that can provide a variety of specialized laboratory services. To view a full listing of our participating clinical laboratories, visit HorizonBlue.com/doctorfinder and:
- Select Other Healthcare Services from the Browse by Category menu.
- The select Laboratory – Patient Centers or Laboratory – Physician Access Only.
You may refer a Horizon BCBSNJ patient who has out-of-network benefits (or send his or her testing sample) to a nonparticipating clinical laboratory, if that patient chooses to use his or her out-of-network benefits and you follow the guidelines in our Out-of-Network Referral Policy.
Pathology services provided in a hospital setting to members enrolled in Horizon BCBSNJ managed care plans by a practice that participates in the Horizon Managed Care Network are allowed as an exception to the above-described network use requirements.
You must agree that in-network laboratories are authorized to release the results of all laboratory tests performed for Horizon BCBSNJ members to Horizon BCBSNJ.
Note: Certain self-insured employer groups for whom we administer health care benefits have established special benefit arrangements that allow their enrolled members to use the nonparticipating clinical laboratory affiliated with each employer group as exceptions to the guidelines of our Out-of-Network Consent Policy. These special benefit arrangements apply ONLY to members/ dependents enrolled in these employer group plans.
BioReference Laboratories Contact Information
For questions or service, or for specimen pickup, call BioReference Laboratories at 1-800-229-5227.
Quest Diagnostics Contact Information
For questions or service call Quest at 1-866-MYQUEST (697-8378).
LabCorp Contact Information
ELIGIBLE LABORATORY PROCEDURES
As a participating physician, you will only be reimbursed for performing certain laboratory services in your office.
You will not be reimbursed for, and may not collect charges from your patients for laboratory services performed in your office that are not included on the list below.
This list, organized by specialty, indicates the laboratory service procedure codes for which you will be reimbursed (in accordance with your specialty affiliation).
|Genetic Testing and Reproductive Health Solutions||81420|
|Hematologist/Oncologist||85025, 85027, 85032, 85041, 85044, 85045, 85046, 85048, 85097|
|Infectious Disease||87205, 87220, 87210|
|Nephrologist||81000, 81001, 81002, 81003|
|Ob/Gyn||87220, 87210, 81025, 81000, 81001, 81002, 81003|
|Reproductive Endocrinologist||89300, 89310, 89320, 89329, 84144, 89330, 83002, 82670, 83001, 84702|
|Rheumatologist||85025, 85027, 85651, 85652, 83872, 89060|
|Urologist||81000, 81001, 81002, 81003, 87086, 87088, 89300, 89320|
IN-OFFICE RADIOLOGY SERVICES
As a participating physician, you will only be reimbursed for performing certain diagnostic-related radiology/imaging tests in your office.
Participating PCPs, specialists and other health care professionals will be reimbursed for only those exams that they are privileged to perform in an office setting.
A complete list of the radiology/imaging procedures that may be performed by certain specialties in an office setting is available on HorizonBlue.com/radiologyimaging.
For all other radiology services, please refer your Horizon BCBSNJ patients to a participating radiology center. You can find the names and locations of all participating radiology centers through our Online Doctor & Hospital Finder.
For Advanced Imaging Services, you must call eviCore healthcare for scheduling all prior authorization or medical necessity review at 1-866-496-6200.
As a participating physician or other health care professional, you should write prescriptions for prescription drugs listed as Preferred on the formulary prescription drug list for those Horizon BCBSNJ members who have prescription drug coverage, unless it would not be medically appropriate to do so.
The prescription Drug List includes at least one Preferred prescription drug within each drug category. The list was developed by the Pharmacy & Therapeutics Committee (P&T), which is comprised of New Jersey independent physicians and clinical pharmacists. The Horizon Prescription Drug List was developed through careful analysis of the medical literature on clinical effectiveness and secondarily based on cost effectiveness.
Review our formulary and other prescription drug lists.
Alternatively, e-prescribe technology allows physicians to review our drug formulary at the point of care, eliminating any uncertainties about which medications are preferred, require PA, or have other special requirements.
Our Medicare Advantage formularies can be found at
PHARMACY PRIOR AUTHORIZATION
Pharmacy Prior Authorization (PA) ensures appropriate utilization of certain drugs, promotes treatment protocols and generic drug utilization, actively manages prescription drugs with serious side effects and positively influences the process of managing prescription drug costs.
Prescription drugs that have medical utility for only a select group of patients require PA before coverage is approved. Specific guidelines, developed and approved by physicians and pharmacists, have to be met for certain drugs to be approved and covered under our prescription drug benefit plans. The P&T Committee establishes PA criteria after evaluating medical literature, physician opinion, and the U.S. Food and Drug Administration (FDA)-approved labeling information.
View the current list of prescription drugs requiring PA.
Our PA program also helps us ensure that generic drugs are prescribed rather than brand name drugs, when medically appropriate.
You will need to submit a request for PA review (for certain prescriptions written for those Horizon BCBSNJ members whose benefit plans require PA for prescription drugs) when you prescribe:
- A brand name drug when a direct generic equivalent is available.
- A non-Preferred brand.
To minimize the number of PA requests you receive, please ensure that, whenever medically appropriate, your Horizon BCBSNJ patients are prescribed generic or Preferred brand drugs.
We encourage prescribers to use our online drug authorization process to submit a PA request. The drug authorization process is free and easy to use. Simply register at NaviNet.net/HorizonPA. The Drug Authorization tool can be found by accessing the Horizon BCBSNJ page within the My Health Plans menu. Then select Drug Authorizations.
PRESCRIPTION DRUG DISPENSING LIMITATIONS
Certain prescription drugs have specific dispensing limitations for quantity, age, gender and maximum dose. To arrive at these quantity or safety limits, Horizon BCBSNJ follows recommendations by the FDA, coupled with our analysis of prescription drug dispensing trends and standard clinical guidelines. These dispensing limitations are drug-specific and are designed to provide a safe and effective amount of prescription drug to the member.
MEDICATION THERAPY MANAGEMENT PROGRAM
As part of our commitment to provide physicians with important information to support appropriate drug therapy, we offer our Medication Therapy Management (MTM) program.
Through the MTM program, we identify patients enrolled in our Medicare Advantage with Prescription Drug and Medicare Part D plans who may be at risk for medical or drug adverse events. We then work with you and your patients to reduce that risk.
The MTM program encourages these members to use prescription drugs according to national clinical guidelines and to take their prescription drugs appropriately and in accordance with their physicians' instructions.
MTM Participant Identification
Members are identified for participation in the MTM program from prescription claims history as outlined by CMS. Eligible members who meet all three of the following criteria are automatically enrolled* in the program. Members:
- Must have two or more chronic diseases.
- Must take five or more covered Medicare Part D drugs per month.
- Must incur at least $3,000 annually or at least $750 per quarter in covered Medicare Part D drug expenses.
The MTM program includes regular communications to members and physicians. Members may opt-out of the program at any time by calling the Member Services number on the back of their ID card.
MTM Program Activities
Horizon Healthcare of New Jersey, Inc. pharmacists conduct routine medication profile reviews. When a medication concern (is treating the same condition; excessive dosing of medications; drug-to-drug interactions), the pharmacist will contact your office.
Depending on the medication concern identified, the pharmacist may also contact the member to address the issue.
- Each member who participates in the MTM program will be offered an annual Comprehensive Medical Review (CMR) by a pharmacist via mail and/or phone. The CMR assesses medication therapies and helps to optimize patient outcomes by reviewing all medications being taken by the member, including prescription drugs, over-the-counter medications, herbal therapies and dietary supplements. A written summary of the CMR discussion will be provided to the member and may be sent to his/her physician(s) for review as needed.
- All Medicare Advantage with Prescription Drug coverage and Medicare Part D members enrolled with us will also receive a quarterly newsletter, Healthy Horizons. This newsletter provides information and resources to help members maximize their health. It includes updates on the latest prescription drug treatments, reminders about the importance of taking prescription drugs appropriately and lifestyle tips to help individuals with certain medical conditions better manage their health.
The success of the MTM program is measured through the acceptance of the recommended interventions, as well as by clinical outcomes such as reductions in hospitalization or Emergency Room visits, or reduced number of physician encounters. The MTM program complements and coordinates with the Chronic Care Program in which your patients may already be enrolled.
For additional information, contact your Network Specialist.
The Horizon BCBSNJ Specialty Pharmaceutical Program can help you obtain office-based and administered specialty medications from a contracted specialty pharmacy provider that will directly supply your office, at your convenience.
When you participate in this voluntary program, you'll obtain specialty pharmaceuticals directly from a specialty pharmacy. Under this program, your office should not submit claims for specialty medications when obtained from our specialty pharmacy providers. These selected providers will bill Horizon BCBSNJ directly for the cost of the medication.
To access information about the Specialty Pharmaceutical Program for therapies, or for information about the Specialty Pharmacy Program for self-administered therapies obtained by members through their pharmacy benefit, visit HorizonBlue.com/specialtyrx.
Specialty pharmacy claims for office-based therapies must be sent to the Blue Plan in the service area where the ordering physician is located. The claim will process according to the pharmacy's relationship with that Blue Plan.
For example, if the ordering physician is located in New Jersey, send the claim to Horizon BCBSNJ and the claim will process according to the pharmacy's participating status with Horizon BCBSNJ.
However, if the ordering physician is located in Pennsylvania, the claim must be sent to the Blue Plan in Pennsylvania and will process according to the pharmacy's contractual relationship with the Pennsylvania Blue Plan and consistent with the member's Home Plan benefits.
MEDICAL NECESSITY DETERMINATIONS FOR INJECTABLE MEDICATIONS
To help ensure that our members receive the appropriate and medically necessary care regarding the use of certain intravenous immunoglobulin (IVIG), oncology and rheumatoid arthritis injectable medications, Horizon BCBSNJ instituted a Medical Injectables Program (MIP) in collaboration with Magellan Rx Management, a specialty pharmaceutical management company.
Physicians must obtain a Medical Necessity and Appropriateness Review (MNAR) prior to administering certain injectable medications to avoid a delay or denial of claims pending receipt of information needed to determine medical necessity. As a participating physician, you may not balance bill the member for denied or pended claims that result from your noncompliance with our MIP.
HOME INFUSION MEDICAL INJECTABLE DRUGS
Magellan Rx Management and CareCentrix will have shared responsibilities for home infusion medical injectable drugs when performed by participating Horizon Care@Home ancillary services providers.
INJECTABLE MEDICATION FEE INFORMATION
Injectable Medication Fee Schedule information is available online. Registered NaviNet users should:
- Log on to NaviNet.net and select Horizon BCBSNJ from the My Health Plans menu.
- Mouse over Claim Management and select Fee Schedule Inquiry.
- On the Fee Schedule Inquiry page, select your Billing (Tax) ID number, County and Specialty.
- Enter the specific CPT and/or HCPCS codes for that specialty and view our allowances for those specific services.
Horizon BCBSNJ updates our Injectable Medication Fee Schedule information on a quarterly basis.
Revised information will be available on HorizonBlue.com/mip following the implementation of each quarterly update.
BEHAVIORAL HEALTH CARE
You may call the Horizon Behavioral Health team directly at 1-800-626-2212 for questions regarding behavioral health (mental health and substance use disorder) care.
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 HEARx Centers.
Horizon BCBSNJ works with HearUSA and their HEARx 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.
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. 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.
- Please note that benefits for audiology and hearing aids for members enrolled in other Horizon BCBSNJ managed care plans may vary. Please 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 HEARx Center. Visit HorizonBlue.com/doctorfinder and:
- Click Medical.
- Choose the member's plan.
- Click Browse by Category, select Other Healthcare Services and click Audiology.
Most members are eligible for one routine eye examination per year with a participating optometrist or ophthalmologist. These services do not require a referral from a PCP for those managed care plans that require referrals.
PCP referrals for those plans that require referrals must be obtained for any follow-up treatment for problems detected during an annual exam. Follow-up treatment or visits for eye disorders must be managed and referred by the PCP.
The routine vision examination covered for children through age 17 years is a vision screening by a pediatrician only. Coverage for refractive services (92015) varies from plan to plan. Call Physician Services at 1-800-624-1110 to verify coverage.
New Jersey health plans must provide coverage of mammograms at specified intervals for women based on age and/or medical necessity. Existing coverage for female members includes:
- One baseline mammogram examination for women who are at least 35 years of age.
- A mammogram examination every year for women age 40 and over.
- A mammogram examination at ages and intervals deemed medically necessary by a woman's doctor in the case of a woman who is under 40 years of age and has a family history of breast cancer or other breast cancer risk factors.
Expanded coverage for female members now includes:
- An ultrasound evaluation, a magnetic resonance imaging (MRI) scan, a three-dimensional (3D) mammography and other additional testing of an entire breast or breasts, after a baseline mammogram examination, if:
- The mammogram demonstrates extremely dense breast tissue;
- The mammogram is abnormal within any degree of breast density including not dense, moderately dense, heterogeneously dense or extremely dense breast tissue; or if
- The patient has additional risk factors for breast cancer, including but not limited to, family history of breast cancer, prior personal history of breast cancer, positive genetic testing, extremely dense breast tissue based on the Breast Imaging
Reporting and Data System established by the American College of Radiology or other indications as determined by the patient's doctor.
Note: The coverage required for an ultrasound evaluation, MRI scan, 3D mammography or other additional testing may be subject to utilization review, including periodic review of the medical necessity of the additional screening and diagnostic testing.
Expanded coverage may not be available to members enrolled in Administrative Services Only (ASO) health insurance plans that have opted not to adopt the New Jersey breast cancer screening mandate.
Female members can go directly to a participating Ob/Gyn for treatment of routine gynecological and obstetrical conditions without a referral from their PCP. However, prior authorization is still required for certain services.
Routine gynecological and obstetrical conditions do not include infertility-related services. Members who have infertility benefits must access those benefits in accordance with their contracts.
Participating obstetricians may directly provide or refer* members to participating physicians and other health care professionals for the following services when these services are medically necessary (and authorized as appropriate):
- Home uterine monitoring.
- Elective hysterectomies.
- Fetal non-stress tests (authorization required after the first three).
- Terbutaline pump.
- All pregnancy ultrasounds (Medical Necessity Determination after the first two).
Certain professional services and all hospital activity needed during the pregnancy (except outpatient radiology and same-day surgeries) must receive prior authorization.
* The Ob/Gyn may not refer to another specialist if the subsequent visit is not Ob-related.
Physicians and other health care professionals must notify Horizon BCBSNJ and obtain approval for certain infertility treatments. This applies to Horizon HMO, Horizon POS and Horizon Direct Access plans. It is your responsibility to obtain this approval where required.
For additional information, call Physician Services at 1-800-624-1110.
OUT-OF-NETWORK REFERRAL POLICY AND PROCEDURE
Horizon BCBSNJ's Out-of-Network Referral Policy* encourages our members to use participating physicians, other health care professionals and facilities, and helps ensure that our members fully understand the increased out-of-pocket expense they will incur for out-of-network care.
* The Out-of-Network Referral Policy does not apply to members enrolled in plans that do not include out-of-network benefits [e.g., Horizon HMO, Horizon EPO, OMNIA Health Plans, Horizon Medicare Blue Value (HMO) etc.].
Our Out-of-Network Referral Policy applies to referrals made to any nonparticipating physician, other health care professional or facility (including clinical laboratories and ambulatory surgery centers). All physicians and other health care professionals who participate in our managed care and/or PPO networks are required to adhere to our Out-of-Network Referral Policy.
Horizon BCBSNJ expects participating physicians and other health care professionals to ensure that, whenever possible, their Horizon BCBSNJ patients and patients enrolled through other Blue Cross and/or Blue Shield Plans are referred to participating physicians, other health care professionals or facilities unless the member wishes to use his or her out-of-network benefits and understands that higher out-of-pocket expenses will be incurred.
Participating physicians and other health care professionals should contact us for authorization if they believe that the necessary expertise does not exist within our network or that there is no available participating physician, other health care professional or facility to provide services to the member. If Horizon BCBSNJ agrees that a participating physician, other health care professional or facility is not available, the member's in-network coverage will apply to the out-of-network referral.
Prior to referring a Horizon BCBSNJ member for out-of-network services, participating physicians and other health care professionals are required to do the following:
- Advise the member of the nonparticipating status of the physician, other health care professional or facility, the out-of-network benefit level that will apply to those services and the member's responsibility for increased out-of-pocket expenses (including deductible, coinsurance and any amount that exceeds the plan's allowance).
- Advise the member of a participating physician, other health care professional or facility that could provide the same services, unless one does not exist within our network.
- Advise of any financial interest in, or compensation made by, the nonparticipating physician, other health care professional or facility.
- Complete an Out-of-Network Consent Form (2180), signed and dated by the member, and retain that document as part of the patient's medical record. In the event of an audit, this form must be provided within 10 business days.
Note: You must obtain the appropriate approval from Horizon BCBSNJ for those services that require prior authorization.
To access our Out-of-Network Referral Policy, registered NaviNet users should log on to NaviNet.net, select Horizon BCBSNJ from the My Health Plans menu, and:
- Mouse over References and Resources and click Provider Reference Materials.
- Mouse over Policies & Procedures.
- Select Policies, then Administrative Policies.
- Select Out-of-Network Referral Policy.
To access our Out-of-Network Consent Form, visit HorizonBlue.com/consent.
Contact your Network Specialist if you have questions.
When out-of-network claims are received, the participating ordering and/or rendering physician or other health care professional is contacted via letter and asked to provide us with a copy of the member's signed Out-of-Network Consent Form (2180). Specialists are not to balance bill members for any administrative charges related to the Out-of-Network Consent Form (2180).
If a signed form is not provided within 10 business days or if a participating physician otherwise fails to abide by our policy, he or she may be subject to loss or restriction of network participation and/or termination.
Horizon BCBSNJ reserves the right to audit a participating physician and other health care professionals medical records pertaining to, but not limited to, the member's signed Out-of-Network Consent Form (2180) as well as claims to out-of-network facilities.
If you require an assistant surgeon to participate in surgical services rendered to a Horizon BCBSNJ member, please verify that the assistant surgeon participates in the appropriate Horizon BCBSNJ network/plan according to that member's benefits.
If you are planning to use a nonparticipating assistant surgeon (for a member who has and wishes to use his/her out-of-network benefits), you must first:
- Advise the member of the nonparticipating status of the assistant surgeon, the out-of-network benefit level that will apply to those services and the member's responsibility for increased out-of-pocket expenses.
- Complete an Out-of-Network Consent Form (2180) (signed and dated by the member) and retain that document as part of the patient's medical record. In the event of an audit, this form must be provided within 10 business days.
All participating physicians and health care professionals are required to follow our Out-of-Network Consent Policy to help ensure that members fully understand the increased out-of-pocket expense they will incur for out-of-network care.
You must obtain the appropriate approval from Horizon BCBSNJ for services that require prior authorization.
REIMBURSEMENT FOR ASSISTANTS AT SURGERY SERVICES
We do not reimburse for assistants at surgery in surgical procedures if use of an assistant at surgery is not established as medically necessary and appropriate for that procedure.
To avoid misunderstandings regarding reimbursement of assistants at surgery, we encourage you to check on reimbursable procedures in advance by reviewing our medical policy for Assistants at Surgery. Review the information in our Medical Policy Manual at HorizonBlue.com/medicalpolicy.
You are responsible for ensuring that assistants at surgery (where medically necessary) are participating. If a nonparticipating assistant at surgery is used, unless Horizon BCBSNJ has authorized the use of that nonparticipating assistant at surgery, then Horizon BCBSNJ will consider you responsible for the difference between the participating and nonparticipating rates and for ensuring that the member is not balanced billed over and above our allowed amount.
HOSPITAL AND OTHER INPATIENT CARE
To maximize their benefits, members should use 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, members can be referred to a nonparticipating facility if their need for medical treatment cannot be accommodated through our Horizon Hospital 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.
You must obtain authorization for all elective inpatient stays. An authorization number must be given to the member to present to the facility upon admission. Facility authorizations cover all inpatient services, including preadmission testing, anesthesia, laboratory, pharmacy and other specialty services related to the admission.
In emergency situations, you must notify us at 1-800-664-BLUE (2583).
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. 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.
Transferring members to network hospitals help us to ensure that our members are not exposed to the high out-of-pocket expense associated with out-of-network care. It also allows participating physicians, familiar with the patient, to be involved in their care while in the hospital.
If one of your patients is admitted to a nonparticipating hospital, contact us immediately. 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 primary physician and encourage regular contact between the primary physician and the attending physician.
If the member is ready for transfer, the CRNC will:
- Provide the primary physician 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 primary physician 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 primary physician will not be the attending physician).
Note: If the patient is not stable for transfer, the primary physician and/or the attending physician must advise the CRNC of the medical necessity for the transfer not to occur.
REFERRING TO NONPARTICIPATING PHYSICIANS AND OTHER HEALTH CARE PROFESSIONALS
On rare occasions, you may need to refer a patient to a nonparticipating physician. Doing so requires authorization for members enrolled in Horizon plans with no out-of-network benefits and for members enrolled in Horizon POS plans, if benefits are to be accessed on an in-network basis. These requests are handled on an individual basis and require medical review.
Access our Online Doctor & Hospital Finder for information about the participation status of specific physicians or other health care professionals.
COPAYMENTS AND ALLOWED AMOUNTS
Copayment amounts vary from plan to plan. It is possible that a member's copayment may be greater than our allowance for the services provided.
You are permitted to collect the copayment indicated on the member's ID card at the time of service, but if our allowed amount for the service you provided (indicated on your EOP) is less than the copayment amount collected, you may need to refund the difference to the member.
Participating physicians and other health care professionals may collect applicable office visit copayments at the time of service.
However, in certain situations, the office visit copayment listed on a Horizon BCBSNJ member ID card should not be collected at the time of service.
When a Patient Does Not See a Health Care Professional
When a patient enters the office but does not see a physician, specialty care physician or other health care professional, the copayment should not be collected. Examples of these visits include, but are not limited to, allergy injections, blood pressure and weight checks.
Patients Enrolled in Consumer-Directed Healthcare (CDH) High-deductible Plans
High-deductible health insurance plans offered in conjunction with a Health Savings Account (HSA) are required to apply all services, excluding preventive care services, toward the plan's deductible. The high-deductible health insurance plans we offer to employer groups for use in conjunction with Health Reimbursement Arrangements (HRAs) follow this same plan design.
Office visit copayments for members enrolled in CDH plans only apply after a patient's deductible has been satisfied.
Please submit your claims and wait until you receive our Explanation of Payment (EOP) and CDH EOP (for those members enrolled in HRA plans) before billing the member for any amount, including office visit copayments.
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.
Patients Enrolled in Plans Without Copayments
Some Horizon BCBSNJ plans do not include a member copayment. If the member ID card does not indicate a copayment, please do not collect any amount from the patient at the time of service.
COPAYMENTS AND PREVENTIVE CARE SERVICES
As mandated by the ACA, most health insurance plans allow members to receive preventive care services without copayments or other cost sharing. This means that preventive services, including screenings, checkups and counseling, are covered with no out-of-pocket costs if the member sees an in-network health care professional and receives only preventive care services during the visit. Please do not collect preventive care copayments from your Horizon BCBSNJ patients.
However, based upon the services that are provided during the course of a scheduled preventive visit, it may be appropriate for you to collect a nonpreventive copayment from a Horizon BCBSNJ member. We encourage you, in such circumstances, to discuss with your patients the nonpreventive treatment/services that they received.
Note: The ACA allows group health plans offering custom benefits to opt to retain a copayment for preventive care services.
For more information about preventive services, visit HealthCare.gov.
MAKING ARRANGEMENTS FOR THE PAYMENT OF DEDUCTIBLE LIABILITY AT THE TIME OF SERVICE
Although we prefer that participating practices submit claims and wait for our Explanation of Payment (EOP) prior to collecting any member liability amounts other than copayments, we understand the challenges that participating practices are facing in regard to the collection of amounts that are applied toward deductibles.
Participating practices are no longer prohibited from making arrangements with members for the payment of amounts that will be applied toward deductibles.
Participating practices may choose to establish a “time-of-service” payment arrangement policy for the collection of amounts that will be applied to member deductibles.
Participating practices may NOT seek amounts that will be applied to member deductibles at the time of service from:
- Members enrolled in Horizon Medicare Advantage plans.
- Members enrolled in high-deductible health insurance plans that work in conjunction with an employer-sponsored Health Reimbursement Arrangement (HRA).
Participating practices may NOT seek any projected coinsurance amounts at the time of service from members. Participating practices are required to submit claims and wait for our Explanation of Payment (EOP) prior to collecting coinsurance amounts.
Guidelines for Practices
Participating practices that choose to implement a “time-of-service” collection policy must comply with the following guidelines:
- In no case shall treatment be refused to a Horizon BCBSNJ member if he or she is not able to pay a requested amount at the time of service.
- Practices may make arrangements for the payment of an amount that is determined to be accurate with reasonable certainty based on:
- Our allowance for the service(s) provided.
- Your validation of the members' estimated deductible liability.
Please keep in mind that the deductible information displayed on NaviNet is based on finalized claims as of the date that NaviNet is accessed. Claims that are processed or adjusted following your review of this information and prior to the processing of claims to be submitted might alter the patient's true deductible liability.
- Practices should work with members to establish fair and appropriate payment plan options and to take certain circumstances into consideration when establishing those payment arrangements (for example, members who may visit multiple doctors and/or health care professionals on a single day, or members who may bring multiple dependents for services on the same day).
- In the event that an amount collected by a participating practice needs to be refunded to a member, we expect that refund to occur no later than 30 days after a member overpayment is identified.
Non-Waiver of Member Liability
Participating physicians, other health care professionals and practices shall not waive any appropriately applied member liability (including copayments, coinsurance or deductible amounts, as well as other amounts associated with exclusions or limitations contained within a covered person's health benefit plan).
Physicians and other health care professionals should not recommend any treatment they feel is unacceptable.
You have sole responsibility for the quality and type of health care service you provide to your patients. You should refer patients to other physicians and health care professionals as medically appropriate and medically indicated.
You can communicate openly with a member about all appropriate diagnostic testing and treatment options, including alternative medications, regardless of benefit coverage limitation.
CREDENTIALING AND RECREDENTIALING OBLIGATIONS
You are required to comply with the standards of participation identified in the Horizon BCBSNJ's Credentialing and Recredentialing Policy for Participating Physicians and Health Care Professionals.
We strongly encourage you to review this policy at HorizonBlue.com/credentials.
Participating physicians and other health care professionals are required to report any changes in their credentialing information, including, for example, any disciplinary action by the applicable licensing authority, any criminal conviction and the pendency of any investigation for matters related to their professional practice.
Physicians and other health care professionals who fail, at any time, to meet any of the standards, as determined by our Credentialing Committee, are subject to loss or restriction of network participation and termination of their Agreement.
Participating physicians and other health care professionals are subject to loss or restriction of network participation and termination of their contract if (among other circumstances):
- They are subject to disciplinary action, including, but not limited to, voluntarily and involuntarily submission to censure, reprimand, nonroutine supervision, nonroutine admissions review, monitoring or remedial education or training;
- Their license, accreditation or certification is restricted, conditioned, reclassified, suspended or revoked, whether active or stayed, and whether by the applicable authority, or any federal or state agency, or any hospital, managed care organization or similar entity;
- They are the subject of an investigation for matters related to their professional practice; or
- They are convicted of a criminal offense.
CREDENTIALING DOCTORS AND OTHER HEALTH CARE PROFESSIONALS
To access information we require to add doctors or other health care professionals to an existing practice visit HorizonBlue.com/whyjoin.
This page includes our Requirements for Physicians and our Requirements for Other Health Care Professionals. These documents provide instructions and access to all the necessary forms and information we require to complete initial credentialing of a doctor or other health care professional in either our Horizon Managed Care Network or our Horizon PPO Network.
Horizon BCBSNJ does not credential doctors or other health care professionals in more than one specialty.
As required by New Jersey state guidelines and accreditation bodies, all health care professionals must be recredentialed every 36 months. Our recredentialing process begins approximately six months prior to the recredentialing date.
Physicians and other health care professionals who fail to provide the necessary information in a timely manner are subject to termination of their Agreement(s).
Standards for participation may be reviewed online in our Horizon BCBSNJ Credentialing and Recredentialing Policy for Participating Physicians and Health Care Professionals.
We work with andros, to help us carry out our recredentialing process, broadly outlined as follows:
- Six months prior to your recredentialing due date, Androsbegins the recredentialing process by searching for current information on the Council for Affordable Quality Healthcare's (CAQH) online data-collection service ProView™. If your information is up to date on ProView, the recredentialing process will continue.
- If information is either not on CAQH ProView, or not updated on CAQH ProView, andros will reach out to you by phone, fax and mail to request that you provide updated and/or missing information.
- If andros does not receive a response, andros will email, fax or mail three requests to your office. You will receive the first notification 90 days before the recredentialing cycle ends, the second notification 60 days before the recredentialing cycle ends The final notification 30 days before the recredentialing cycle ends.
- If andros does not receive a response from these attempts by the 5th business day of the month you are due to be recredentialed, you will be terminated from Horizon BCBSNJ's networks at the end of that month. No additional requests will be sent and no information will be accepted after the first of that month.
If you have questions, call Andros at 1-866-688-8881 x2.
There are two ways to carry out your recredentialing responsibilities with Horizon:
- CAQH ProView.
- New Jersey Universal Recredentialing Application Form.
We encourage you to use ProView to carry out your credentialing and recredentialing responsibilities with us.
Visit caqh.org and click CAQH ProView to access this valuable resource.
If you're already registered with CAQH:
- Review and/or update your information.
- Re-attest that your information is true, accurate and complete.
If you're not registered with CAQH:
- Visit ProView.caqh.org/pr to self-register with CAQH. Upon completion of the self-registration process, you will receive a CAQH welcome email with your unique CAQH Provider ID number.
- Visit caqh.org, mouse over CAQH Proview and select Log In.
- Complete an online application (ensure that you select Horizon BCBSNJ so that we can access your information) and then attest that the information provided is true, accurate and complete.
New Jersey Universal Recredentialing Application Form
If you are unable to use CAQH ProView, complete a copy of the NJ Physician Recredentialing Application Form available on the New Jersey Department of Banking and Insurance website at state.nj.us/dobi/formlist.
Print copy recredentialing information and required source documents may be submitted to andros.
Andros will provide a mailing address upon request.
To ensure that the recredentialing process runs smoothly for you, confirm that:
- Your CAQH Attestation has not expired.
- The Primary Credentialing Contact section represents the name, email address, fax number and phone number of the person andros will contact if additional information is required.
- All Disclosure questions are answered and explanations provided for negative responses.
- Malpractice Insurance and Hospital Admitting Privileges sections are current and completely filled out. These are the items most frequently expired or missing.
- All other information and required source documents are current and included (for example, your federal Drug Enforcement Agency [DEA] certificate, your Controlled Dangerous Substance [CDS] certificate, etc.).
- Information on the application matches the information on your source documents.
NETWORK PARTICIPATION AND MEDICARE PARTICIPATION
Horizon BCBSNJ's Credentialing Department reviews the Centers for Medicare & Medicaid Services (CMS) Opt Out List on a quarterly basis.
Horizon Managed Care Network
As stated in our Credentialing and Recredentialing Policy for Participating Physicians and Health Care Professionals, “Physicians and health care professionals who have opted out of Medicare may not participate in the Horizon Managed Care Network.” Physicians or health care professionals who have opted out of (or have been excluded from) Medicare will be terminated from the Horizon Managed Care Network.
Horizon PPO Network
Physicians or health care professionals who have opted out of Medicare may continue to participate in our Horizon PPO Network. However, these practitioners are not eligible to receive reimbursement for services rendered to patients enrolled in one of our Medicare Advantage plans that include out-of-network benefits¹(except for emergency or urgent care services).
Continued Horizon PPO Network participation of physicians or health care professionals who have been excluded from Medicare is contingent upon the decision of our Credentialing Committee
¹The Horizon BCBSNJ Medicare Advantage plans that offer out-of- network benefits are: Horizon Medicare Access Group (HMO- POS), Horizon Medicare Blue Access Group w/Rx (HMO POS), Horizon Medicare Blue (PPO), Horizon Medicare Blue Group (PPO) and Horizon Medicare Blue Group w/Rx (PPO).
PROVIDER DIRECTORY MANAGEMENT POLICY
It's critical that the provider file information we maintain and display is accurate and up-to-date as this information is used to populate our Doctor & Hospital Finder. Inaccurate or outdated information may result in a misrepresentation of your practice to patients and referring physicians or other health care professionals searching our Online Doctor & Hospital Finder.
Horizon BCBSNJ's Provider Directory Management administrative policy addresses situations in which we are unable to validate whether information included within our provider files is current and accurate.
Our Provider Directory Management administrative policy outlines the process Horizon BCBSNJ staff, Network Outreach team and business partners or CAQH acting on our behalf will take as they work to ensure that the information within our provider files is correct. This revised policy also outlines actions that will be taken in regard to provider directory inclusion and continued participation of practice location(s) and/or practitioners whose information we are unable to validate.
Based on the guidelines within our Provider Directory Management administrative policy:
Horizon BCBSNJ validates practitioner information every 90 days through outreach efforts conducted by our business partners or CAQH. These outreach efforts seek to validate that the information we have on file is accurate.
If the initial outreach efforts are not successful, Horizon BCBSNJ staff will conduct a secondary 90-day outreach effort to validate that the information we have on file is accurate. While this secondary outreach is conducted, the information pertaining to practitioners in question will be suppressed from appearing within our Online Doctor and Hospital Finder.
If, at the end of this second 90-day period, we are unable to validate that the information we have on file is accurate, the practice location(s) and/or practitioner in question will be terminated from all Horizon BCBSNJ networks.
Notification letters will be sent to advise of suppression or termination actions taken.
We encourage you to review our Provider Directory Management administrative policy online.
To access this information, registered NaviNet users may sign in to NaviNet.net, select Horizon BCBSNJ from the My Health Plans menu and:
- Mouse over References and Resources and click Provider Reference Materials.
- Mouse over Policies & Procedures and click Policies.
- Click Administrative Policies.
- Click Provider Directory Management.
PRODUCTS THAT UTILIZE TIERING AND/OR
A SUBSET OF AN EXISTING HORIZON BCBSNJ 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 utilize 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 utilize tiering and/or a subset of an existing Horizon BCBSNJ Network.
We strongly encourage all participating physicians and other health care professionals to review this policy by visiting HorizonBlue.com/adminpolicy and selecting Participation Status in Products that Utilize Tiering and/or a Subset of an Existing Horizon Network.
MEMBERS WITHOUT PROPER ID CARDS
If a member is unable to present an ID card at the time of service, there are several ways to verify eligibility:
- If you are a registered NaviNet user, you may check patient eligibility on NaviNet.net.
- Managed Care PCPs may verify the member's eligibility on the most recent Capitation Report or Membership Report. (If the member's name is not on these reports, call Physician Services at 1-800-624-1110).
- You may ask the member for a copy of his or her signed application or, for Medicare Advantage members, a copy of their confirmation of enrollment letter.
- Your patient may present a proof of coverage letter or virtual ID card, obtained by signing on HorizonBlue.com. Treat the proof of coverage letters and virtual ID cards as you would any other Horizon BCBSNJ ID card.
If the member's status is unclear after reasonable attempts to verify coverage, you have the option of billing the member for the visit. If the member is actively enrolled, we will ask that you reimburse the member.
ASKING A MEMBER TO SELECT ANOTHER PHYSICIAN
The patient/physician relationship is essential to the delivery of quality, coordinated health care. In rare instances, this relationship can become seriously eroded if, for example, a member does not comply with treatment regimens or is abusive to you or your staff.
In such situations, you may initiate a discussion with your patient, asking him or her to choose another physician.
If the member does not select a new physician, follow up with a letter to the member personally signed by you.
If the patient is enrolled in a managed care plan and you are the selected PCP, also mail a copy of this letter to us at the address below so we can contact the member and instruct him or her to select a new PCP.Horizon BCBSNJ
PO Box 820
Newark, NJ 07101-0820
Until a new PCP is selected, you are required to continue to serve in this capacity.
CLOSING YOUR PANEL
If you are a PCP and have achieved a panel size of at least 250 members (per physician) or find that you cannot manage additional patients, you may choose to close your panel.
According to your Agreement, you may close your panel after you provide Horizon with days advance written notice of your intention to close your panel to new patients.
Please send a written request to your Network Specialist and include:
- Your practice name and address.
- Your NPI and Tax ID number.
- A detailed explanation of your request.
Please allow 30 days from the date of your inquiry for confirmation of your request.
According to your Agreement, you may not close or limit your panel for Horizon BCBSNJ covered members if your panel remains open for other patients.
If you have closed your panel, you must continue to provide health care services to existing members in your practice. This includes existing patients who are newly enrolled members because their employer entered into an Agreement with us or who otherwise are newly enrolled with Horizon BCBSNJ. These requirements apply to insured plans and self-funded plans.
We will indicate in our Directory of Participating Physicians and Other Health Care Professionals and online Doctor & Hospital Finder that your panel is closed. If you close your panel, the directory will indicate your closed panel status in the next printing of the directory. In addition, our enrollment department will suspend further enrollment of new members into your panel.
If you decide to re-open your panel, you can do so seven days after Horizon BCBSNJ receives written notification from you.
TREATMENT OF FAMILY MEMBERS
Horizon BCBSNJ products typically exclude payment for services when the patient is a family member of the physician or other health care professional providing treatment.
Immediate relatives include:
- Spouse or domestic partner
- Children (natural, adopted or stepchildren)
- Parents (natural, step-parents or in-laws)
- Siblings (natural, stepbrother, stepsister or in-laws)
Do not submit claims to us for services provided to any of the above-referenced individuals.
Horizon BCBSNJ prohibits participating physicians and other health care professionals from requiring Horizon BCBSNJ members to pay retainer fees* (annually or with any other frequency) to become, or continue to be, a member of their panel/ practice, receive treatment, receive an enhanced level of service, and or receive particular types of personalized services.
To access our Retainer-Based Medicine policy, visit HorizonBlue.com/providers, and:
- Mouse over Policies & Procedures, select Policies, then select Administrative Policies.
- Select Retainer-Based Medicine.
Participating physicians or other health care professionals who fail to comply with our policy may be subject to loss or restriction of network participation and/or termination.
* Retainer fees do not include fees permitted under a member's health benefits plan, for example, applicable copayments, coinsurance and deductibles.
Physicians or other health care professionals who charge a retainer fee may continue to participate with Horizon BCBSNJ if they agree not to require Horizon BCBSNJ members to pay a retainer fee.
However, Horizon BCBSNJ will not display the listings of these physicians and/or other health care professionals in our online or printed provider directories.
NONSOLICITATION OF OUR CUSTOMERS
Horizon BCBSNJ provides information on our customers and health benefit plans (and administrative services arrangements) to enable physicians and other health care professionals to provide services to our members. This information is proprietary to Horizon BCBSNJ.
As a participating physician or other health care professional, you may not infringe on Horizon BCBSNJ's relationship with any of our customers, including groups or members, by (directly or indirectly) soliciting any customer, member or group to enroll in any other health benefits plan (or administrative services arrangement).
Nor may you use any information as to Horizon BCBSNJ's benefit plans (or administrative services arrangements) or customers for any competitive purpose or provide it to any person or entity for financial gain.
RESPONSIBILITY FOR THE USE OF PARTICIPATING TAX ID NUMBERS
Horizon BCBSNJ's billing policy prohibits the use of participating tax identification number (TINs) as outlined below.
Multiple TINs at a Single Practice Location Horizon BCBSNJ's billing policy prohibits a participating physician or other health care professional from using more than one participating tax identification number (TIN) to bill us for services provided at a single practice location.
Use of a Participating TIN by Nonparticipating Practitioners
Horizon BCBSNJ's billing policy prohibits the use of a participating tax identification number (TIN), including a group TIN, by a nonparticipating physician or other health care professional.
- If a nonparticipating physician or other health care professional joins your practice, you may not bill under the group TIN for services provided by this individual until he or she joins our network(s).
For information, visit HorizonBlue.com/whyjoin.
- If a physician or other health care professional within your practice leaves our network and becomes nonparticipating, that individual may no longer bill for services provided under your group TIN.
- If a nonparticipating physician or other health care professional bills for services provided under a participating TIN (including a group TIN), submitted services will be reimbursed at our participating allowance.
Horizon BCBSNJ will hold you, the group practice, responsible for the difference between our participating allowance and total billed charges and for ensuring that our member is not held responsible for any balance due (less any applicable deductible, coinsurance or copayment amounts).
- If a participating physician or health care professional joins or is linked to a nonparticipating group, our systems will consider that group TIN as participating.
All claims submitted under that group practice's TIN will be reimbursed at our participating allowance.
TERMINATING YOUR PARTICIPATION IN THE NETWORK
There are certain policies and procedures you must follow when your Agreement(s) (i.e., Horizon Healthcare of New Jersey, Inc. Agreement with Participating Physicians and Other Health Care Professionals and/or your Agreement with Participating Physicians and Other Health Care Professionals) are terminated. Following these policies and procedures will help to ensure that your patients continue to receive care by a participating physician or other health care professional.
You are also required to notify us if you are retiring or moving your practice out of the area pursuant to the termination provisions under your Agreement.
If you decide to terminate your Agreement(s), write a letter indicating your intention. The termination letter must be signed personally by the physician or other health care professional.
Termination letters should be submitted to:
Provider Data Management
3 Penn Plaza East, Mail Station PP-14C
Newark, NJ 07105-2200
Effective Date of Termination
Your effective date of termination (unless another date is agreed upon by you and Horizon BCBSNJ) will be:
- 90 days following the receipt of your termination letter from our Horizon Managed Care Network.
- 30 days following the receipt of your termination letter from our Horizon PPO Network.
These 90- and 30-day periods leading up to your effective date of termination do not run concurrently with our Continued Provision of Care periods (for more information please see the Continued Provision of Care section to the right).
Patients Undergoing a Course of Treatment
You are required to notify us of any Horizon BCBSNJ members undergoing a course of treatment. Please prepare a list of members and send it to your Network Specialist. We, in turn, notify those members who are receiving a course of treatment of your termination from the Horizon Managed Care Network or Horizon PPO Network prior to the effective date of your termination. Authorizations are established for any members who require continued care.
Our Request for Continuity of Practitioner Care for Medical Benefits form is available on HorizonBlue.com/cocmedicalform. It may be completed by a member or by your office on behalf of a member.
Continued Provision of Care
You must treat existing Horizon BCBSNJ managed care, PPO and Indemnity patients for up to four months beyond your effective date of termination if they are in the midst of an ongoing course of treatment (not including the 90- or 30-day period leading up to your effective date of termination).
An existing patient is defined as one to whom you provided care within the 12-month period immediately preceding the effective date of termination of your Agreement(s).
Additionally, members undergoing certain courses of treatment are granted longer periods of care as indicated below:
- Oncological treatment (up to one year).
- Post-operative follow-up care (up to six months).
- Pregnancy – up to the postpartum evaluation (up to six weeks after delivery).
- Psychiatric treatment (up to one year).
You are required to accept our reimbursement for services provided during these extended periods as payment in full, less any applicable copayments, coinsurance or deductible amounts. All benefits shall be subject to contract limits and Horizon BCBSNJ's policies and procedures, including, but not limited to, payment at Horizon BCBSNJ's fee schedule, prior authorization and utilization management requirements.
If you have questions, contact your Network Specialist.
Rescinding a Request to Terminate
If you decide to rescind a recently submitted termination request, contact your Network Specialist in writing within 30 days of the original termination letter.
SPECIALTY MEDICAL SOCIETY RECOMMENDATIONS
Horizon BCBSNJ recognizes that from time to time, specialty societies will issue recommendations for new or updated technologies or treatments. To submit a new recommendation for consideration by Horizon BCBSNJ's Medical Policy Department, provide the following information:
- A detailed description of the technology or treatment and the recommendation on the specialty society's letterhead.
- A list of the references and/or case studies used to determine the recommendation.
- The contact information for a representative of the specialty society who can respond to questions related to this recommendation.
Submit information as soon as possible to:Horizon BCBSNJ
Medical Policy Department
3 Penn Plaza East
Newark, NJ 07105-2200
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 use disorder 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 you refer a member to the Emergency Room (ER), you must contact us within 48 hours.
Members who use the ER for routine care may be responsible for all charges except the medical emergency screening exam.
If emergency care is obtained with the assumption that the member's health is in serious danger, but it is later determined that it was not an emergency, the medical emergency screening exam would still be covered
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.
If you are a PCP, you agree to arrange for coverage for your managed care members by a qualified, licensed, insured and participating Horizon Managed Care Network physician any time you are not available.
The covering physician must comply with all Horizon BCBSNJ policies and procedures with respect to any health care services provided. Reimbursement to a physician covering for a fee-for-service PCP will be made directly to the covering physician. Capitated PCPs are responsible for all financial arrangements with their covering physicians.
Horizon Blue Cross Blue Shield of New Jersey has established access standards for our doctors and other health care professionals to help ensure that members receive the quality care they need when they need it. Access listings of access standards for PCPs, OB/GYNs and Specialist practitioners.
CONFIDENTIALITY OF MEDICAL RECORDS AND PERSONAL INFORMATION
Physicians and other health care professionals, as well as hospitals and other facilities, 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.
If the practitioner is a PCP and a member changes to a new PCP, the practitioner shall forward copies of the member's medical records, upon request, to the new PCP within 10 business days from receipt of request or prior to the next scheduled appointment with the new PCP, whichever is earlier.
Note: This addition is in supplement to the existing requirement that the practitioner may release information to another health care professional. However, this language also emphasizes and ensures patient care coordination in a timely manner.
MEDICAL RECORDS REQUESTS 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 use disorder.
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:
- The dates of all treatments;
- The patient complaint;
- The history;
iv. Findings on appropriate examination;
- Progress notes;
- Any orders for tests or consultations and the results thereof;
- Diagnosis or medical impression;
- Treatment ordered, including specific dosages, quantities and strengths of medications including refills if prescribed, administered or dispensed and recommended follow up;
- The identity of the treatment provider if the service is rendered in a setting in which more than one provider practices;
- 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.
- Corrections/additions to an existing record can be made, provided that each change is clearly identified as such, dated and initialed by the licensee.
- 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;
- A patient record may be prepared and maintained on a personal or other computer only when it meets The patient record shall contain at least two forms of identification, for example, name and record number or any other specific identifying information;
- 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;
- 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; the following criteria:
- 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;
- 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;
- 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;
- A copy of each day's entry, identified as preliminary or final as applicable, shall be made available promptly:
- To a physician responsible for the patient's care;
- 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
- To a patient as authorized by this rule within 30 days of request (or promptly in the event of emergency); and
- 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.]
- Licensees shall provide access to professional treatment records to a patient or an authorized representative in accordance with the following:
- 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.
- 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.
- 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:
- The patient's attorney;
- Another licensed health care professional;
- The patient's health insurance carrier through an employee thereof; or
- A governmental reimbursement program or an agent thereof, with responsibility to review utilization and/or quality of care.
- Licensees may require a record request to be in writing and may charge a fee for:
- 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
- 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.
- Licensees shall not charge a patient for a copy of the patient's record when:
- The licensee has affirmatively terminated a patient from practice in accordance with the requirements of N.J.A.C. 13:35- 6.22; or
- 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.
- 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.
- 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.
- Licensees shall maintain the confidentiality of professional treatment records, except that:
- 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.
- 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.
- 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.
- 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.
- 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:
- Secure and maintain a current written authorization, bearing the signature of the patient or an authorized representative;
- Assure that the scope of the release is consistent with the request; and
- Forward the records to the attention of the specific individual identified or mark the material Confidential.
- 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:
- 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;
- 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
- 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.
- 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:
- 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.
- 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
- 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.
CLINICAL PRACTICE GUIDELINES
Horizon BCBSNJ's clinical practice guidelines (CPGs) are available to all participating physicians and other health care professionals.
These guidelines were adopted from nationally known organizations such as the Advisory Committee on Immunization Practices, the American Academy of Pediatrics, the American Academy of Family Physicians, the American Psychiatric Association, the Agency for Health Care Policy and Research, the American Society of Addictive Medicine and the American Diabetes Association. They also include Healthcare Effectiveness Data and Information Set (HEDIS©) technical specifications.
Horizon BCBSNJ CPGs
Registered NaviNet users can view, print or download our CPGs. Simply:
- Visit NaviNet.net and log in by entering your User Name and Password.
- Select Horizon BCBSNJ within the My Health Plans menu.
- Mouse over References and Resources click Provider Reference Materials.
- Under Additional Information, click Clinical Practice Guidelines.
If you are not registered for NaviNet, visit NaviNet.net and click Sign up. Copies of our CPGs can also be mailed to you. Call 1-877-841-9629 or email your request to: QualityManagement_Coordinator@HorizonBlue.com.
GENERAL RISK ADJUSTMENT
Horizon BCBSNJ requires physicians to cooperate with us on the implementation of initiatives to support Medicare, Medicaid and the Affordable Care Act Commercial Risk Adjustment provisions. You will be held responsible for the following:
- You will allow physician and staff participation in periodic in-office training provided by us on key issues related to risk adjustment.
- You will capture member diagnoses with the highest level of specificity available.
- You will reach out to specific members, at our request, to schedule office visits. The criteria below only applies to Medicare and Commercial Risk Adjustment:
- You will review and use member diagnostic information provided by Horizon BCBSNJ to comprehensively evaluate all health conditions for a member under your care.
- You will work collaboratively with Horizon BCBS to review and use member diagnostic information to comprehensively evaluate all health conditions for a member under your care.
- For Medicaid: All pertinent risk adjustment diagnoses will be included on the claim submitted for payment even if you are capitated.
- Important: you will make available all requested medical records for chart reviews and comply with our chart review processes.
- You are required to submit any requested medical record within 10 days of request barring any hardship requests.
It is also important that your medical records reflect the following:
- All medical conditions that contributed to the office visit are documented and coded.
- All causational relationships of various comorbidities (e.g., if retinopathy is caused by diabetes) are documented.
- All historical conditions are appropriately coded with Z-codes.
- All medical charts are signed as required by CMS.