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Provider Responsibilities

The Role of the Primary Care Physician

The Primary Care Physician (PCP) coordinates care received by the managed care member in the primary care setting, as well as from specialty care physicians, other health care professionals and facilities. Internists, general physicians, family physicians and pediatricians are all credentialed as PCPs. Certain managed care plans require that members select a PCP. Other managed care plans encourage, but do not require a PCP selection.

Members should see their PCP for the appropriate referral for specialty care services. PCPs also have a role in the development of certain policies and procedures. Through participation in our Quality Improvement and other committees, physicians provide valuable feedback to develop medical policies and protocols.

Primary Care Physician (PCP)

A duly licensed family physician, general health care professional, internist or pediatrician who has entered into an Agreement with us to be in the Horizon Managed Care Network and who has been selected by a member enrolled in a Horizon BCBSNJ managed care plan that requires the selection of a PCP or offers the option to select a PCP.

A PCP is responsible for coordinating all aspects of medical care for those members who have selected him or her as the member’s PCP. These responsibilities include personally providing medical care or referring members to the appropriate source for medical care, whether that source is a specialist, other health care professional or facility. In addition, other specialists or health care professionals with appropriate qualifications may serve as a member’s PCP where Horizon BCBSNJ so agrees.

The Role of the Participating Specialist

Participating specialists work in partnership with the PCP to provide appropriate, quality and cost-effective medical care to our members. PCPs/primary physicians refer members for specialty care services as a part of the treatment plan. Participating specialists play a critical role by providing efficient care within their area of expertise and within the scope of the member’s treatment plan. Participating specialists also participate in Horizon BCBSNJ’s Quality Improvement, Utilization Management and Credentialing Committees, where they are actively involved in the formation of policies and procedures, as well as peer-review activities.

The Blue Cross and Blue Shield Association has mandated that BCBS Plans identify a provider’s credentialed specialty by taxonomy code. You can view the taxonomy codes that identify specialties by visiting the National Uniform Claim Committee website, nucc.org.

To search for taxonomy codes:

• Click Code Sets.

• Select Provider Taxonomy.

• Select Code Lookup.

Example #1: Internal Medicine taxonomy code is Internal Medicine - 207R00000X

Example #2: Cardiology taxonomy code is Internal Medicine, Cardiovascular Disease - 207RC0000X

Example #3: Acute Care Hospital taxonomy code is Hospitals, General Acute Care Hospital - 282N00000X

Example #4: Home Health Agency taxonomy code is Agencies, Home Health - 251E00000X

Horizon BCBSNJ will collect taxonomy code(s) and their description(s) for each credentialed provider in our network(s) when available. Horizon BCBSNJ reserves the right not to credential specific taxonomy code specialties.

You may list your taxonomy code in your CAQH application specialty section and/or in the Centers for

Medicaid & Medicare Services National Plan and Provider Enumeration System (NPPES) NPI registry at

https://npiregistry.cms.hhs.gov.

Every rendering practitioner should have a valid NPI number type 1 and every billing provider (facility, ancillary provider, group practice) should have a valid NPI number type 2.

COMMUNICATION IN THE HEALTH CARE PROCESS

To help ensure the success of the health care treatment plan, it is essential for all parties to share information. The PCP usually begins the process by completing a referral to a participating specialist, including the reason the member is being referred. Upon seeing the patient, it is the responsibility of the participating specialist to share his or her findings and treatment plan with the PCP.

Although it is expected that the participating specialist will communicate his or her findings and treatment plan to the PCP/primary physician, requests for authorization of diagnostic procedures and/or hospitalizations may be made directly by the participating specialist to Horizon BCBSNJ.

This dynamic exchange of information enhances access to as well as the quality and effectiveness of the managed care delivery system.

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 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. This brochure is available at www.state.nj.us/health.

Registered NaviNet users may review our Medical Record Documentation Standards. Log into to NaviNet.net. Select Provider Reference Materials, then:

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

LICENSE, CERTIFICATION OR REGISTRATION

To maintain your contracting status with us, you are required to maintain a current, unrestricted, valid license, certification or registration to practice as a health care professional in New Jersey, or the contiguous states of New York, Pennsylvania or Delaware when your practice is outside the state of New Jersey. Horizon BCBSNJ does not oblige providers to violate state licensure regulations.

OUT-OF-STATE BCBS PLANS

Responsibilities and obligations under your Agreement are also applicable to customers and individuals who have health insurance underwritten or administered by out-of-state Blue Cross and/or Blue Shield Plans licensed by the Blue Cross and Blue Shield Association.

MEDICARE PARTICIPATION

Physicians or health care professionals who have opted out of (or have been excluded from) Medicare may not participate in our Horizon Managed Care Network. Participating physicians or health care professionals who opt out of (or become excluded from) Medicare will be terminated from the Horizon Managed Care Network.

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.

MEDICAL RECORDS

You agree that Horizon BCBSNJ and its affiliates and designees have the right, subject to reasonable advance notice, to review any and all documents, books and records, including but not limited to medical records, maintained by you in connection with services you provided under your Agreement.

According to your Agreement, upon Horizon BCBSNJ’s request, you agree to provide copies of these materials, in the manner and within the time frame set forth in that request.

Horizon BCBSNJ does not provide reimbursement for the reproduction of medical records, to cover postage and/or for any other miscellaneous costs associated with retrieval of a member’s medical record.

MEDICAL RECORDS FOR QUALITY-OF-CARE COMPLAINTS

Horizon BCBSNJ is required to investigate member complaints, including those that allege inadequate care that was received from a participating physician, other health care professional or facility.

Complaints that include potential medical quality-of-care issues will be referred to our Quality Case Review Committee – comprised of Horizon BCBSNJ medical directors and participating physicians – for further review.

If we receive a member complaint that includes a potential medical quality-of-care issue, your office may be asked to provide medical records and documentation to help the Committee investigate the complaint. You are required to respond to such requests under the terms and conditions of your participating Agreement(s) and your obligation to follow our policies and procedures.

  • Failure to comply with a request for medical records and/or additional documentation required to investigate a medical quality-of- care complaint is a very serious issue and may result in termination for cause from Horizon BCBSNJ’s networks.
  • Physicians and other health care professionals who do not respond to such requests in a timely manner will have a notation placed in their credentialing file for consideration at the time of recredentialing.
  • We will also advise impacted members of any failures to comply with requests for medical records and make these members aware of their right to file a complaint with the New Jersey State Board of Medical Examiners.

NOTIFICATIONS

You must notify us in writing if:

  • Your license, certification or registration to practice is restricted, suspended actively or stayed, or revoked for any reason.
  • Your certification(s) to prescribe medication is suspended actively or stayed, or revoked for any reason.
  • Your medical staff privileges at any hospital are voluntarily or involuntarily withdrawn, restricted temporarily or permanently, or suspended actively or stayed, or revoked for any reason.
  • You change your name or the name of your group practice.
  • Your tax ID number or address changes or you join or leave a group practice.
  • You fail to maintain required medical malpractice insurance.
  • You take a leave of absence or resign from the medical staff of any hospital.
  • You are indicted, convicted of, or plead guilty to a criminal offense, regardless of the nature of the offense.
  • You are subject to any disciplinary action (including, but not limited to, voluntarily or involuntarily being subject to censure, reprimand, nonroutine supervision or monitoring or remedial education or training) by any government program, licensing, professional registration or certification authority, or hospital privileging authority.

Please mail notifications to:

Horizon BCBSNJ

PO Box 420, PP-14C
Newark, NJ 07101-0420

Or

email: EnterprisePDM@HorizonBlue.com

REFERRING A PATIENT

Horizon BCBSNJ is proud of our comprehensive network of participating physicians, other health care professionals and facilities. We remind participating physicians, other health care professionals and facility staff in our Horizon Managed Care Network about the important role referrals play in helping to ensure that your patients receive the highest level of benefit coverage.

Referring physician responsibilities

  • All referrals for patients enrolled in managed care plansshould be created electronically through either through NaviNet.netor our IVR system by calling 1-800-624-1110.
  • Ob/Gyns may create Primary referrals for Ob/Gyn-related services only.
  • Participating specialists may create Refer-On referrals to radiology centers and ambulatory surgery centers.
  • All referrals for patients enrolled in managed care plans must be made to specialty care physicians, other health care professionals or facilities that participate in the Horizon Managed Care Network. Visit our Online Doctor & Hospital Finder at HorizonBlue.com/doctorfinder to confirm participation status.
  • We recommend that all referring physicians print a Referral Confirmation and:

Horizon Direct Access, NJ Direct, OMNIA Health Plan, Advantage EPO and Medicare Advantage members do not need referrals to visit physicians who participate in our Horizon Managed Care Network.

Referred to provider responsibility

  • Specialty care physicians, other health care professionals or facilities that participate in the Horizon Managed Care Network and to whom a Horizon BCBSNJ managed care member has been referred, must confirm that a referral was obtained by the referring physician prior to providing services.
  • Registered users of NaviNet may review and print a Referral Confirmation quickly and easily at any time.
  • You may request a fax copy of a Referral Confirmation or create a secondary referral through our IVR system by calling 1-800-624-1110.

To learn more about creating, submitting and reviewing referrals, as well as printing referral confirmations, registered NaviNet users may view a tutorial. Simply:

  • Log on to NaviNet.net.
  • Select Horizon BCBSNJ within the My Health Plans menu.
  • Select Provider Reference Materials and mouse over Resources.
  • Select Training, then Education.
  • Select NaviNet Information Demo.

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, mental or physical disability, medical condition, sexual orientation, gender identity, marital status, claims experience, medical or mental health history or status, pre-existing medical/health conditions, need for or receipt of health care services, evidence of insurability, geography, disability, genetic information, actuarial class, source of payment or any other unlawful purpose.

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

HEALTH CARE FRAUD AND ABUSE INVESTIGATION

Health care fraud, waste and abuse are national problems that affect us all.

Horizon BCBSNJ takes health care fraud, waste and abuse seriously. Each day, our Special Investigations works to uncover fraudulent activities and recover monies paid as a result of such activity.

Health care fraud, waste and abuse can take many forms, including:

  • Performing unnecessary health care services or procedures for the sole purpose of producing more billings and insurance payments
  • Falsifying a patient’s diagnosis to justify tests, surgeries or other procedures
  • Supplying durable medical equipment that patients do not need

Participating providers MUST comply with any requests for medical records that are related to fraud investigations.

If you suspect that a member, health care professional or employee of a health care facility is committing fraud, call our Special Investigations Anti-Fraud Hotline at 1-800-624-2048 or send documents and/or inquiries to:

Horizon-BCBSNJ Special Investigations
PO Box 200145

Newark, NJ 07102-0303

As a Medicare Advantage and Medicare Part D plan sponsor, we also work closely with the Centers for Medicare & Medicaid Services (CMS) to investigate and prosecute all instances of fraud, waste and abuse involving those lines of business. Our dedicated Medicare Advantage and Medicare Part D Fraud, Waste and Abuse Hotline is 1-888-889-2231. You may also send documents and/or inquiries to:

Horizon BCBSNJ Investigations Riverfront Plaza
PO Box 200145

Newark, NJ 07102-0303

All information is strictly confidential.