Service

This section includes information about:

Updates on the Interactive Voice Response (IVR) System.
How to access information online through NaviNet^®..
A listing of the frequently used addresses, phone numbers and fax numbers.

We’ve also included information about how to access online training courses on Horizon BCBSNJ administrative policies and procedures, and the products and members you serve. Your satisfaction is important to us. We understand that as a health care facility, you may have questions or need information about patients’ health care plans outside of our regular business hours. We strive to have systems and processes in place that allow you to contact us in ways that are efficient, flexible and compatible with your needs.

INTERACTIVE VOICE RESPONSE (IVR) SYSTEM
The IVR system expands your options for contacting us, allowing you to obtain the information you need in a more convenient manner. You can access information 24 hours a day, generally including weekends and holidays, and get instant answers to many questions previously handled only by our service representatives.

Not only is the system available when you are, it’s also user-friendly. Our natural speech recognition technology gives you the option of speaking your request in a natural manner, much like you would when speaking with a service representative. You can access the easy-to-use IVR system by calling 1-888-666-2535 and exploring all the information and services that it has to offer.

IVR Tips
Use your natural voice or the touchtone keypad alone to enter the patient’s ID number or navigate through the call.

Speak clearly in your natural tone.
If accessing the IVR from a noisy environment, mute your phone and use the keypad to enter your responses.
Say numbers one digit at a time.
When speaking numbers, say Zero rather than O.
You may return to the main menu at any time by saying Main Menu. You may also say Repeat or Help.
You don’t have to listen to all the options. Go directly to the option you want by using the following voice prompts. Just say...
– Claims to check claim status or payment.

– Eligibility and Benefits to verify that a patient is enrolled under a Horizon BCBSNJ plan or to check their benefits (FEP® benefits and eligibility are separate menu options.)

– Authorizations to request an authorization, check the status of an authorization or find out if an authorization is required.

– Duplicate Vouchers to request a copy of a voucher by date or by patient. Hospital Services Representatives are available to help you and provide information that you may not be able to access through our IVR system. Call 1-888-666-2535, Monday through Friday, between 8 a.m. to 5 p.m., ET.

NAVINET^®
All participating facilities are required to register for NaviNet within 30 days of your effective date of participation. Through NaviNet, a multi-payer web portal, your facility has access to the important Horizon BCBSNJ information (eligibility, benefits, claims status, online explanations of payments, submit and check status of UM authorization requests, etc.) that you need to conduct business with us on a day-to-day basis. By using NaviNet, your facility will have access to Horizon BCBSNJ information, as well as the online information of many other New Jersey health plans.

To learn more about NaviNet, please visit NaviNet.net.
To access a NaviNet Information Demo, select Provider Reference Materials and mouse over Resources.
Select Training, then Education.
Select NaviNet Information Demo.

Billing Company Access to NaviNet
If you employ the services of a billing company, we want to remind you that you can help increase their effectiveness and efficiency by encouraging them to register and use NaviNet to carry out their day-to-day responsibilities on your behalf. To register for NaviNet, the billing company should:

Visit NaviNet.net and click Sign Up.
Follow the instructions and complete the online NaviNet New Registration Request Application using your company’s tax ID number. Ensure that Yes is selected in response to the question: Is your office a billing agency? Upon submission of the NaviNet New Registration Request Application, a NaviNet enrollment specialist emails an authorization form and instructions to the billing company contact.
Complete the authorization form. The billing company will need to obtain a signature from your office to grant them access to the information on your behalf.
Fax the completed and signed authorization forms to NaviNet to the fax number provided.

NaviNet processes the enrollment request and emails NaviNet login credentials to the billing company contact. If your billing company is registered for NaviNet and does not have access to your information, ask them to forward a copy of the authorization form (see step 3 listed above) they originally received from NaviNet for you to sign. For help registering, call NaviNet Customer Care at 1-888-482-8057.

NaviNet Online Capabilities
We continue to improve and expand upon the online capabilities available to you to provide a more efficient and productive experience. Below are some of the online capabilities you can access through NaviNet:

Answers to Frequently Asked Questions
Claim Inquiry (local and out-of-state members); Explanation of Payment (EOP)
Claim Submission (CMS 1500 and UB04)
Clear Claim Connection
Demographic Updates
EFT Registration
Eligibility and Benefits Inquiry
Horizon Healthcare Innovations
Payment Status Inquiry
Physical and Occupational Therapy Authorization
Provider Data Maintenance, which includes updating demographics and online credentialing
Provider Reference Materials
Referral/Authorization Inquiry
Referral Submission.
Statement of Payment Inquiry.

New features and improvement made to our Online Services options accessed through NaviNet will be communicated in Blue Review.

FREQUENTLY ASKED QUESTIONS
Horizon BCBSNJ makes answers to questions you might have about your Horizon BCBSNJ patients’ eligibility, benefits, claims and more available to registered NaviNet^®users. To view the Frequently Asked Questions (FAQs) section on NaviNet simply:
• Sign in to NaviNet.net.
• Click Help.
• Select Horizon BCBSNJ within the vMy Health Plans dropdown menu.

Our online FAQs are organized so you can quickly find information about these topics and more:
• Claims & Payments – View the status of a claim or payment, including how to enroll in Electronic Funds Transfer (EFT).
• Eligibility & Benefits – Look up which services are covered benefits for a specific Horizon BCBSNJ patient.
• Provider Resources – Check which plans you participate in and update your demographic information.
• Referrals & Authorizations – Access Horizon BCBSNJ’s Medical Policies or prior authorization process.
• Office & Provider Management – Access reports, including capitation and panel reports.
Check out our online FAQs often, as we will continue to add more answers to frequently asked questions.

CLEAR CLAIM CONNECTION
To help you navigate the health care system, Horizon BCBSNJ offers the Change Healthcare Clear Claim ConnectionTM, a web-based code editing disclosure solution. Clear Claim Connection is designed to help ensure our claim reimbursement policies, related rules, clinical edit clarifications and clinical sourcing information are easily accessible and transparent for our participating doctors and other health care professionals. Clear Claim Connection displays Horizon BCBSNJ’s code auditing rules for various code combinations and the corresponding clinical rationale.

To access Clear Claim Connection, log on to NaviNet.net, select Horizon BCBSNJ from the My Health Plans menu:

• Mouse over Claim Management and select Clear Claim Connection.
• Within Clear Claim Connection, enter the required data to obtain the appropriate code auditing results. Clear Claim Connection will provide you with the ability to identify Horizon BCBSNJ’s code auditing rules.

Note: This auditing reference tool will provide results that reflect the reimbursement policies on the current date, not necessarily the service date. Displayed results are not a guarantee of how your actual claim will be processed. Claim reimbursement is subject to member eligibility and all member and group benefit limitations, conditions and exclusions.

ELIGIBILITY AND BENEFITS INQUIRY
The Eligibility and Benefits Inquiry transaction allows you to access eligibility and benefits information for active Horizon BCBSNJ members. The Eligibility & Benefits Detail screen displays:
• Current Primary Care Provider Information (if applicable)
• Plan information
• Patient’s Gender and Date of Birth
• Patient’s relationship to Subscriber
• Group Information (if applicable)
• Service Type information section
• Benefit Accumulation
• Prior Authorization Indicator
• Status (identifies subsidized members who are delinquent on their premium payment)

Service Type Information Section
The Service Type Information section displays various service type product information for the patient.

Benefit Accumulation
Making arrangements to collect amounts that will be applied to a member’s deductible requires that you validate the amount applied to the members’ deductible to date. To view the deductible amount a member has satisfied to date within Eligibility & Benefits Inquiry
. • Enter the requested Subscriber Information and click Search. Note: In rare cases, you may see a listing of dependents in instances when multiple matches are found.
• From the list of dependents that displays, double click the member in question.,
• The annual deductible amount as well as the amount remaining to be satisfied will be displayed in the Health Benefit Plan Coverage section.

Remember 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.

HORIZONBLUE.COM
Horizon BCBSNJ makes most of our administrative information and important forms available online so that you have access to what you need when you need it. Our website provides the tools and resources you need to do business with us, including the ability to:
• View and print the most commonly used forms.
• Review the Claims Information Quick Reference Guide that highlights service phone numbers, claims and inquiry addresses and appeals/predetermination information for specific prefixes and suffixes.

Online Forms
Horizon BCBSNJ makes most of our forms available by visiting HorizonBlue.com/providers and selecting the forms tab. Commonly used forms include:

Inquiry Request and Adjustment Form (579)
- Our Inquiry Request and Adjustment Form replaces the Institutional Provider Adjustment/Inquiry Request (579) and the Physician/Health Care
Professional Inquiry Request (5348) forms. Use this form to:
– Request claim adjustments.

– Inquire about claim status.

– Help reconcile/recapture funds in overpayment situations.

– Submit additional information.
BlueCard Claims Appeal Form (5373)

With the Inquiry Request and Adjustment Form you can complete the required fields online and then print the form for submission. This method allows us to quickly and accurately process your forms. Or, if you prefer, you can print a blank form and type or handwrite your content. Mail the completed form along with all supporting documentation (e.g., the corrected CMS 1500 or UB-04 claim form, a Medicare or other carrier Explanation of Benefits (EOB), etc.) to:
Hospital and institutional physician inquiries:
Horizon BCBSNJ
PO Box 1770
Newark, NJ 07101-1770

Federal Employee Program (FEP) inquiries:
Horizon BCBSNJ
PO Box 656
Newark, NJ 07101-0656

BlueCard® inquiries:
Horizon BCBSNJ
PO Box 1301
Neptune, NJ 07754-1301

If our claim investigation results in a change to the claim reimbursement amount, Horizon BCBSNJ will send an Explanation of Payment (EOP) to the billing address we have on file. If the claim adjustment does not result in a change in the claim reimbursement amount, we will respond by letter to the name and address provided to us on the 579 form.

BlueCard Claims Appeal Form (5373)
You can submit claim appeals as part of the Claim Status Inquiry transaction using this form. You will also need to submit all applicable documents, including:
–The relevant CMS 1500(s) or UB-04 claim forms.
– The relevant EOB or remittance advice information previously requested but not yet submitted, if available.
– Pertinent correspondence related to the appeal.
– A description of pertinent, unwritten communications related to this appeal.
– Relevant sections of the National Correct Coding Initiative (NCCI) or other coding support you relied upon, if the appeal concerns the disposition of billing codes.
– Other documents you believe support your position in this appeal including medical records/notes.

Hospital Fax Inquiry Form
If you have five or more inquiries for any of our Horizon HMO, Horizon POS, Horizon Direct Access, NJ DIRECT, NJ PLUS or Medicare Advantage members, you may use this form to fax your inquiries to 1-866-213-8812.

Federal Employee Program (FEP) Provider Fax Inquiry Form
If you have five or more inquiries for Federal Employee Program members, you may use this form to fax your inquiries to 1-973-274-4071.

ONLINE EDUCATION RESOURCES
We offer an online educational resource where information, job aids and training materials are available to you anytime. We have created an easy-to-use training and education page that will be your starting point to access a variety of information you need to know to conduct business with us. This webpage includes:
• A collection of online demos and webinars.
• Horizon BCBSNJ product knowledge courses and assessments.
• Online user guides, including facility manuals and information on the BlueCard^®program.
• A section for quick and concise updates and highlights on new features.
• A section for frequently asked questions and answers.
• Central, organized and easily accessed locations for:

– Newsletters and other communication

– Horizon BCBSNJ forms

– Policies and Agreements

To access this page:
• Log in to NaviNet.net and select Horizon BCBSNJ from the My Health Plans menu.
• Select Provider Reference Materials.

ONLINE DOCTOR & HOSPITAL FINDER
Visit HorizonBlue.com/doctorfinder and use our Online Doctor & Hospital Finder to locate participating physicians/other health care professionals, hospitals, laboratories and other health care services providers. Within the provider profile information of our Online Doctor & Hospital Finder you can review:
• Plans providers participate with
• OMNIA Tier Status
• Location address
• Phone number
• Specialty information
• Physician hospital affiliations
• And more

We also provide a value-added feature offering street maps and detailed directions to offices/facilities.

ELECTRONIC DATA INTERCHANGE (EDI)
Our EDI Service Desk supports all of the most common EDI transactions. All of our transactions are based on the nationally accepted ANSI (American National Standard Institute) format. Some of the transactions are set as a real-time process, providing responses within seconds, while others run in a batch format.

Transactions we handle include:
• Hospital (837)
• Claim Payment Advice (835)
• Notice of Admissions (278)

Benefits of EDI include:
• Faster exchange of information
• Improved accuracy
• Reduced postage cost
• Reduced administrative cost
• Elimination of paper documents
• Timely postings
• Reduced handling
• Reduced payment cycle
• Tracking capabilities
• More efficient means of conducting business
• Minimize possibility of lost or misrouted

If you have questions about EDI transactions, or for more information, contact the EDI Service Desk at 1-888-334-9242, via email at HorizonEDI@HorizonBlue.com.

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

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.

STANDARDS FOR ELECTRONIC TRANSACTIONS

HorizonNet 2000
HorizonNet 2000 (HNET) has been identified as an impacted software application in accordance with Health Insurance Portability and Accountability Act of 1996 (HIPAA) Version 5010 regulations. After a detailed impact analysis and consideration of several remediation options, Horizon BCBSNJ will only update HNET 2000’s Notice of Admission – Request for Authorization transactions. We reached this decision after considering several factors including development resources, costs and the fact that HNET 2000’s transactions are available to you through other platforms (our Online Services and various software vendors).

If you have general questions about HNET 2000 or want a copy of Horizon BCBSNJ’s approved Trading Partners list, call our EDI Service Desk at 1-888-334-9242, Monday through Friday, between 7 a.m. and 6 p.m., ET.

If you have specific questions about HNET 2000 remediation, email your inquiry to HIPAA@HorizonBlue.com.

CENTRALIZED SERVICE CENTER PHONE UNIT
Horizon BCBSNJ’s Centralized Service Center (CSC) Phone Unit is staffed by a dedicated team of representatives who are focused on serving the needs of our participating hospitals. Call our staff at 1-888-666-2535, Monday through Friday, between 8 a.m. and 5 p.m., ET, for information on:
• Detailed patient benefits, including deductibles and maximums.
• Eligibility information for a Horizon BCBSNJ plan.
• Help with payment clarification from your Explanation of Payment (EOP).
• Detailed claim and payment status.
• Inquiry status, including written correspondence and service request updates.
• Status of an appeal. CSC representatives will supply a service request (SR) number to the hospital if further research or an adjustment is required. Please allow at least 30 days for resolution and/or determination before calling for status.

If an adjustment is required, the hospital will receive an Explanation of Payment (EOP) with reimbursement information. If no adjustment is required, the hospital will receive either a letter or a phone call indicating the determination of the investigation.

Claims and/or reimbursement status, as well as benefit information, including referrals/ authorizations, can be accessed through NaviNet.net.

Horizon BCBSNJ Contact Information

Frequently used phone numbers, websites and addresses.