Utilization Management

Utilization Management Program

Horizon BCBSNJ’s Utilization Management Program is based on the premise that quality medical care is the single most important element in delivering cost-effective care. It is a coordinated and comprehensive program designed to achieve medically appropriate and cost-effective delivery of health care services to members within the parameters of the benefits available under each member’s benefit contract.

While there is recognition that there is a wide variation of appropriate medical practice, Utilization Management activities are intended to identify optimal modes of practice and, when possible, to help ensure physicians manage care in a medically appropriate and cost-effective manner. We know that underutilization of appropriate services can be as dangerous to our member’s health status and our medical costs as overutilization. Horizon BCBSNJ adheres to the following principles in the conduct of our Utilization Management Program:

• Bases Utilization Management decisions on necessity and appropriateness of care and service within the parameters of the member’s benefit package.
• Does not compensate those responsible for making Utilization Management decisions in a manner that encourages them to deny coverage for medically necessary and appropriate covered services.
• Does not offer our employees or delegates performing Utilization Management reviews incentives to encourage denials of coverage or service and does not provide financial incentives to physicians and other health care professionals to withhold covered health care services that are medically necessary and appropriate.
• Emphasizes the provision of medically necessary and cost-effective delivery of health care services to members and encourages the reporting, investigation and elimination of underutilization.

Horizon BCBSNJ’s Utilization Management Program functions under the HCAPPA definition in much the same way as it has previously (when applicable). Our medical policies and criteria used to help us reach decisions about medical necessity for coverage purposes have been revised for compliance with HCAPPA’s definition standard.

As required by HCAPPA, policies and criteria, information about the processing and reimbursement of claims, and MCG clinical guidelines are available.

MCG Health’s Care Guidelines (MCG) is used to make behavioral health care coverage determinations for members enrolled in all Horizon BCBSNJ plans.

Horizon BCBSNJ uses American Society of Addiction Medicine (ASAM) criteria when making coverage determinations for services related Substance Use Disorders.

Horizon BCBSNJ will provide the clinical rationale for the determination(s) in the adverse determination letter. In addition, the MCG Care Guidelines used in making the specific determination are available free of charge upon request.

MEDICAL NECESSITY/MEDICALLY NECESSARY
The HCAPPA has established a new definition of medical necessity and medically necessary. The definition describes a number of factors used to determine medical necessity, including the prudent clinical judgment as exercised by a health care professional for the purpose of evaluating, diagnosing or treating an illness, injury or disease; and that the service “is in accordance with generally accepted standards of medical practice; clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the covered person’s illness, injury or disease; not primarily for the convenience of the covered person or the health care provider; and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that covered person’s illness, injury or disease.”

The HCAPPA definition does not change the way Horizon BCBSNJ’s Utilization Management Program functions. Our medical policies and UM criteria are used to help us make decisions about medical necessity for coverage purposes. They have been revised for compliance with HCAPPA’s definition standard.

MEDICAL POLICIES
Horizon BCBSNJ’s Medical Policies provide general information applicable to the administration of health benefits that Horizon BCBSNJ insures or administers.

Horizon BCBSNJ’s Medical Policy Committee develops the policies to be consistent with generally accepted standards of medical practice. The policies reflect Horizon BCBSNJ’s view of covered health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/investigational in nature.

The Medical Policies also consider:

• Whether, and to what degree, covered health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed.
• When relevant, whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider.
• Whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease.

Medical policies can be highly technical and are designed for use by Horizon BCBSNJ’s professional staff in making coverage determinations. Members referring to a Horizon BCBSNJ Medical Policy should discuss the policy with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.

Services, supplies and procedures that may not require prior authorization must still meet criteria for medical necessity as defined in Horizon BCBSNJ’s medical policies. Review our medical policies to determine if there is a medical policy for proposed services, supplies or procedures. It is important to note that Horizon BCBSNJ’s Medical Policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage or guarantee of reimbursement.

Online Access
Hospital staff may access Horizon BCBSNJ’s medical policies at HorizonBlue.com/medicalpolicy.

REQUESTING AUTHORIZATION
You must contact Horizon BCBSNJ before rendering services to our members who require prior authorization. Horizon BCBSNJ accepts requests for authorization for coverage of services from members and/or from providers acting on behalf of the member. This includes but is not limited to the attending/ordering physician or provider that is requesting the authorization as the member/claimant's authorized representative.

Benefits will always dictate coverage; some services are subject to individual benefit limitations. The individual protocols and criteria that Horizon BCBSNJ uses to render utilization management decisions are available upon request.

Authorizations older than six months, in accordance with industry standards, will not be honored by Horizon BCBSNJ and will require a new review of the current clinical circumstances.

SERVICES REQUIRING PRIOR AUTHORIZATION
Providers must contact Horizon BCBSNJ before rendering services or providing supplies to our members who require prior authorization. Please use our Prior Authorization Procedure Search Tool to determine if services require prior authorization for your Horizon BCBSNJ patients.

Our Prior Authorization Procedure Search Tool allows you to enter a CPT or HCPCS code and select a place of service (e.g., inpatient, outpatient, office, home) to determine if the particular service provided in the selected service setting requires a prior authorization.

This tool can also be accessed on NaviNet by selecting Horizon BCBSNJ from My Health Plans menu, or by visiting HorizonBlue.com/providers and:

• Clicking Policies & Procedures
• Clicking Utilization Management
• Clicking Services Requiring Prior Authorization

Our Prior Authorization Procedure Search Tool presently will only display results for insured Horizon BCBSNJ plans. Prior authorization information for members enrolled in self-insured, Administrative Services Only (ASO) plans, Medicare or Medicaid products cannot be accessed through this tool. The information provided by this tool is not intended to replace or modify the terms, conditions limitations and exclusions contained within health benefit plans issued or administered by Horizon BCBSNJ. In the event a conflict between the information contained on the tool and member plan documents, member plan documents shall prevail.

This application is intended for informational purposes only. The results provided by this tool are not a guarantee of payment. Claim processing is subject to member eligibility and all member and group benefit limitations, conditions and exclusions.

HORIZON CARE@HOME PROGRAM SERVICES
Horizon BCBSNJ is committed to providing our members with access to high-quality home health care services. As part of that commitment, Horizon BCBSNJ collaborates with CareCentrix1, a home health benefits management company, to administer certain services for the Horizon Care@Home program. CareCentrix credentials, manages and maintains the Horizon Care@Home network of ancillary services providers, arranges for delivery and conducts the utilization management for these services:

• Durable medical equipment (including medical foods [enteral], and diabetic and other medical supplies)
• Orthotics and prosthetics
• Home infusion therapy services, including hemophilia

Traditional home health (including in-home nursing services, physical therapy, occupational therapy and speech therapy) is managed by Horizon BCBSNJ.

¹ Horizon BCBSNJ contracts with CareCentrix, Inc., a Delaware corporation and its subsidiary, CareCentrix of New Jersey, Inc., a New Jersey Corporation licensed by the NJ Department of Banking and Insurance as an Organized Delivery System to administer certain services for the Horizon Care@Home program.

Prior Authorization/Pre-Service Registration
CareCentrix is responsible for ensuring certain Horizon Care@Home services are medically necessary and appropriate through its utilization management activities, including:

• Durable medical equipment (including medical foods [enteral], and diabetic and other medical supplies)
• Orthotics and prosthetics
• Home infusion therapy
• Diabetic and other medical supplies

For home health services (including in-home nursing services, physical therapy, occupational therapy and speech therapy), you must obtain prior authorization using Horizon BCBSNJ’s online Utilization Management Request Tool via NaviNet.

Referring/Ordering Providers
Physicians, other health care professionals, hospital discharge planners and case managers may initiate a prior authorization/pre-service registration by calling CareCentrix at 1-855-243-3321 between 8 a.m. and 6 p.m. (ET) for:

• Durable Medical Equipment (including medical foods [enteral] and diabetic and othermedical supplies)
• Orthotics and prosthetics
• Home infusion therapy
• Diabetic and other medical supplies

You may also call CareCentrix at 1-855-243-3321 tofind a Horizon Care@Home participating ancillary services provider.

For home health services (including in-home nursing services, physical therapy, occupational therapy and speech therapy), you must obtain prior authorization using Horizon BCBSNJ's online Utilization Management Request Tool via NaviNet. As part of the review of a request for home care services to be provided, Horizon BCBSNJ or CareCentrix may contact your office for information required to conduct/complete their review.

Members with BlueCard Coverage
As a reminder, you have the ability through NaviNet to access the online prior authorization tools of other Blue Plans to review/initiate prior authorizations online for BlueCard members. Members with BlueCard coverage who are enrolled through another Blue Cross and/or Blue Shield Plan and are receiving care in New Jersey would access in-network home care services through a participating Horizon Care@Home provider; however, prior authorization requirements may vary based on the member’s benefits. Simply log in to NaviNet.net and:

• Mouse over Referrals and Authorization.
• Select Pre-Service Review for Out-of-Area Members.
• Home infusion therapy
• Diabetic and other medical supplies

After entering the member’s alpha prefix, you’ll be routed to the member’s Home Plan. You can then follow the prompts to review a member’s pre-service authorization requirements as well as submit a prior authorization request, if necessary.

Find A Provider
Participating Horizon Care@Home providers may be located by visiting our Online Doctor & Hospital Finder. Select Other Healthcare Services from the What are you looking for? dropdown menu. Choose one of the services from the Service Type dropdown menu, select a plan and click Search.

Online listings of Horizon Care@Home providers who provide home health services, including in-home nursing services, physical therapy, occupational therapy and speech therapy, will include the provider’s physical address and phone number. If you provide these services and are interested in participating in the Horizon Care@Home program, please call 1-800-624-1110. Online listings of Horizon Care@Home providers who provide services for Durable Medical Equipment (DME), (including medical foods (enteral), and diabetic and other medical supplies); orthotics and prosthetics (O&P) and home infusion therapy (HIT) services, including hemophilia, include the provider’s actual physical address, but display CareCentrix’s phone number, 1-855-243-3321.

If you provide these services and are interested in participating in the Horizon Care@Home program, call CareCentrix at 1-855-243-3324 for information between 8 a.m. to 6 p.m., ET.

About Nonparticipating
Home Health Care Service Providers
We remind participating physicians and other health care professionals that you are required to adhere to our Out-of-Network Referral Policy. This policy requires that you, whenever possible, refer Horizon BCBSNJ members to participating providers (including participating ancillary services providers) unless the member has, and wishes to use, his or her out-of-network benefits, understands that a much greater member financial liability may be involved and signs a completed copy of our Out-of-Network Consent Form. Participating physicians and other health care professionals who do not comply with our Out-of-Network Referral Policy will be at risk of an audit regarding their compliance with Horizon BCBSNJ policies and procedures.

To access our Out-of-Network Referral Policy, registered NaviNet users affiliated with participating practices should log on to NaviNet.net, select Horizon BCBSNJ within the My Health Plans menu and:

• Select Provider Reference Materials.
• Mouse over Policies & Procedures.
• Select Policies, then Administrative Policies.
• Select Out-of-Network Referral Policy.

Please note that prior authorization requirements still apply (for home health care services that require prior authorization) to services provided by a home health care provider that is not participating in the Horizon Care@Home program.

HOME INFUSION THERAPY
Magellan Rx Management and CareCentrix will have shared responsibilities for certain medical injectable drugs subject to the Horizon BCBSNJ Medical Injectables Program depending upon where they will be administered, as follows:

• For medical injectable drugs that are to be administered in the patient’s home by a participating Horizon Care@Home ancillary service provider, please initiate a pre-service registration with CareCentrix.
• For medical injectable drugs that are to be administered at a freestanding or hospital-based dialysis center, in an outpatient facility or in a doctor’s office, please continue to contact Magellan Rx Management to initiate a medical necessity and appropriateness review. For more information, visit HorizonBlue.com/hcah.

OBTAINING AUTHORIZATION
Hospitals can obtain online authorizations easily an securely for most services using our online Utilization Management Request Tool via NaviNet. To access this tool, log on to NaviNet.net, select Horizon BCBSNJ within the My Health Plans menu and:

• Under Workflows for this Plan, mouse over Referrals and Authorizations.
• Click Utilization Management Requests.

Using our online Utilization Management Request Tool, providers can submit authorization, predetermination and specialty pharmacy requests securely over the internet using a data entry for that captures pertinent client-defined data. It allows for early identification of case and disease management candidates, focusing on better health outcomes and lower costs. The turnaround time for nonurgent prior authorization requests is up to 14 calendar days of receipt. The turnaround time for urgent prior authorization requests is within 72 hours of receipt. For questions, call the Utilization Management Department at 1-800-664-BLUE (2583).

Note: Retroactive authorizations will not be granted. As a participating facility, it is your responsibility to make sure all authorization procedures are followed. If authorization is needed for services you are referring for or rendering and no authorization is obtained, claim reimbursement may be limited or denied, and if denied, the member may not be billed for the service.

ONLINE AUTHORIZATIONS FOR PT AND OT SERVICES
In most cases, Horizon BCBSNJ authorizes the initial 25 visits of outpatient physical therapy or occupational therapy (PT/OT) services upon receipt of an initial claim from a participating physical therapist or occupational therapist. Eligibility and benefits must be confirmed prior to providing the service. A prior authorization must be obtained in the following situations:

• Other PT or OT services have already been authorized in the current calendar year.

  - Review annual benefit limits.

• Diagnosis-related temporomandibular joint (TMJ) disorders.

  - Review for benefit and medical necessity.

• Treatment for work-related injuries.
• Patients under 19 years of age.

  - Review for medical necessity.

• More than 25 visits are required.
• All services from nonparticipating providers.

Prior authorizations can be requested using our online Physical and Occupational Therapy Authorization tool available on NaviNet.net. Remember that you still must check member eligibility and benefits by logging on to NaviNet.net prior to treating the patient.

Claims processing and reimbursement for services provided are subject to member eligibility and all member and group benefits, limitations and exclusions.

Note: The PT/OT tool is for the use of rendering physical therapy and occupational therapy providers only. This tool cannot be used to create referrals for physical therapy or occupational therapy services. Upon review of all routine, nonurgent requests, the Prior Authorization Department will send you a secure email as soon as possible, not to exceed 15 days from our receipt of all required clinical information for commercial plans (14 days for Medicare).

Urgent requests are determined as soon as possible, not to exceed 72 hours from receipt, based on the medical urgency of the case. If you receive a denial notification for a patient, you may discuss the determination with the physician who rendered the decision. The physician’s name and phone number will be on the denial notification.

PRIOR AUTHORIZATION PROCEDURE SEARCH TOOL
Our Prior Authorization Procedure Search tool allows you to enter a CPT® or HCPCS code and select a place of service (e.g., inpatient, outpatient, office, home) to determine if the particular service provided in the selected service setting requires a prior authorization.

The tool, as well as certain prior authorization lists for ASO member groups, is accessible on HorizonBlue.com/priorauthtool.

To determine if a patient is fully insured or part of an ASO member group, please refer to the back of the member’s ID card. Fully insured members’ cards will state: “Insured by Horizon Blue Cross Blue Shield of New Jersey.” ASO members’ cards will state: “Horizon Blue Cross Blue Shield of New Jersey provides administrative services only and does not assume financial risk for claims.”

NOTICE OF ADMISSION (NOA)
We require a Notice of Admission (NOA) to be submitted within 24 hours, anytime a Horizon BCBSNJ member is admitted on an inpatient basis. When Horizon BCBSNJ is a payer on the claim, submit the NOA to us. This is true for all Horizon BCBSNJ products, except Medigap. Submit the NOA electronically. For information on electronic options, please call our EDI Help Desk at 1-888-334-9242.

When your facility is able to submit the 278 Requisition/Authorization HIPAA transaction, we will require you to send an inpatient NOA electronically to Horizon BCBSNJ.

Failure to provide the required information will result in rejection of the NOA. Submit only one NOA per patient, per admission. Duplicate submission of the NOA is unnecessary and may delay appropriate claim processing. Our goal is to process NOA information received by 1 p.m. on the UM logs generated the next business day. Review the log to confirm our receipt and to obtain a case number. See sample logs at the end of this section.

BLUECARD MEMBERS:
PRECERTIFICATION/PRIOR AUTHORIZATION
Participating Horizon Hospital Network facilities are required to obtain prior authorization/precertification for inpatient facility services for BlueCard® members who are enrolled in an out-of-state Blue Cross and/or Blue Shield plan, but reside or are traveling within our local service area.

If prior authorization/precertification is required and not obtained for inpatient facility services, the facility is financially responsible and the member held harmless. Hospitals must also follow specified timeframes for inpatient facility services pre-service review notifications:

• 48 hours to notify the member’s Plan of change in pre-service review
• 72 hours for emergency/urgent pre-service review notification

Note: Sanctions/penalties may be applied to the provider if pre-service review was not obtained for inpatient facility services for an out-of-area member, per the Par/Host Plan’s provider contract. The member will be held harmless. BlueCard members are responsible for ensuring that prior authorization/precertification is obtained for outpatient services.

This mandate reduces confusion and to ensure that BlueCard members are treated the same as local members. All facility prior authorization, precertification, admission and/or concurrent reviews and discharge planning must be completed by the Blue Cross and/or Blue Shield Plan through which the patient is enrolled.

To obtain prior authorization/precertification for your patients enrolled in BlueCard plans, you may:

• Call 1-800-676-BLUE (2583). After providing the three-letter prefix from the member’s ID card, you’ll be connected directly to the customer service team at the member’s Blue Plan.

If the member’s ID card does not include an alpha prefix, call the Utilization Management phone number on the ID card.

• Submit an electronic 278 transaction (Health Care Services Request for Review and Response). Most BlueCard electronic inquiries received Monday through Friday, during regular business hours, are answered within 48 hours.

INPATIENT CARE
Time Frames for Authorization Requests
Horizon BCBSNJ responds to all submitted information for inpatient admissions authorization within 24 hours of receipt of all required information.

Time Frames for Additional Information Requests
If Horizon BCBSNJ requests additional clinical information to approve or deny an authorization request, the hospital must respond to our request within 72 hours. If additional information is not received within 72 hours, the Hospital Case Management Department or the physician will be advised, in writing, of case closure via the daily adverse determination log.

When additional information is received, a review for medical necessity will occur.

INITIAL AND CONCURRENT REVIEW
It is important to provide the Notice of Admission (NOA) within 24 hours of the admission to ensure the Horizon BCBSNJ inpatient case manager has the information necessary to conduct the review. A Horizon BCBSNJ registered nurse will be assigned to your facility to review clinical information on a daily, or as-needed, basis.

Your Horizon BCBSNJ case manager will also help your hospital plan for and obtain the necessary authorizations for discharge planning and transition of care needs. Nationally recognized guidelines are used to assess the medical appropriateness of inpatient admissions and continued stays. These guidelines include, but are not limited to, the Milliman Care Guidelines®. We will provide the criteria used for an individual determination upon request. Cases failing to meet the guidelines for medical necessity are reviewed by a licensed Medical Director.

Time Frames
A daily hospital UM log will be provided to the hospital’s designated representative, noting the case numbers and approval status for reviewed inpatient admissions. A sample of the daily inpatient hospital log is shown at the end of this section.

After Hours Access
On weekends, holidays and after regular business hours, Horizon BCBSNJ staff are available to provide utilization management services and help with basic discharge planning. During these times, do not call your facility-assigned registered nurse. Instead, call our After Hours Access Line at 1-888-223-3072.

No NOA/Lack of Clinical Information Determinations
If additional clinical information is needed, the Hospital Case Management Department or the physician will be notified, in writing, of the information needed via the daily adverse determination log. If additional information is not received within 72 hours, the Hospital Case Management Department or the physician will be advised, in writing, of case closure via the daily adverse determination log. When additional information is received, a review for medical necessity will occur. When complete admission/concurrent review information is:

• Received, an approval, denial or determination of an alternate level of care will be communicated to the hospital’s Case Management or Utilization Review Department within 24 hours of receipt. Not received prior to the patient’s discharge due to the member not providing correct or complete insurance information to the hospital, the hospital should contact their assigned Horizon BCBSNJ inpatient case manager for a retrospective review.

Note: While we expect Notification of Admission to occur within 24 hours of hospitalization, we realize there are times when the patient’s complete insurance information may not be available. In alignment with our claim submission requirements, we will accept requests for clinical retrospective review up to 18 months after the date of claim rejection.

Adverse Determinations
Any adverse determination decided prior to discharge will be communicated to the hospital’s Case Management or Utilization Review Department both verbally and in writing via the daily UM log. This communication will include the rationale for the determination and the applicable appeals rights. Adverse determination letters will be sent to the hospital within two business days of the last determination. Letters will also be mailed to the member’s attending physician and the member.

PEER-TO-PEER DISCUSSIONS
Horizon BCBSNJ provides treating practitioners and/or other hospital-based staff physicians with the opportunity to informally discuss any non-behavioral health utilization management medical necessity denial decision with a Horizon BCBSNJ physician or other appropriate reviewer. A peer-to-peer discussion must be requested within 72 hours of notification of the adverse determination. Horizon BCBSNJ notifies each treating practitioner how to contact Horizon BCBSNJ‘s physician or other appropriate reviewer to discuss a denial. Horizon BCBSNJ does not consider the discussion between the Horizon BCBSNJ physician and or other appropriate reviewer and the member’s treating practitioner to be an initiation of a formal appeal request, although a formal appeal based on the outcome of the discussion may be requested.

If Horizon BCBSNJ issues a denial due to a lack of necessary information and subsequently receives a phone call or the required information, the Horizon BCBSNJ practitioner who issued the initial denial may review the case with the new information and overturn it.

On weekends, holidays and after regular business hours, treating practitioners should submit peer-to-peer requests to our After Hours Access Line at 1-888-223-3072.

DISCHARGE/TRANSITION PLANNING
Transitioning a patient to the next level of care requires collaborative planning. Proactive discharge planning helps to ensure safe and appropriate plans for patients upon discharge and helps to avoid unnecessary readmissions. A “readmission” means an individual is discharged from a network hospital and admitted to the same or another applicable hospital within a 30-day time period.

All discharge planning should be initiated within 24 hours of admission. We encourage transition planning to begin on the first day of admission with ongoing revisions throughout the hospital stay. We request that the transition checklist for patient hospital discharges be completed and faxed to your Horizon BCBSNJ case manager. Download the Transition Checklist for Horizon BCBSNJ Patients Hospital Discharge Form.

Allow a minimum of six hours to process discharge planning coverage requests. Same-day discharge requests needed in less than six hours, may not be processed by the end of that business day. For holiday, weekend and after regular business hours discharges, please call the After Hours Access Line at 1-888-223-3072. In this instance, the discharge request may not be processed by the end of business that day.

Transfer
Horizon BCBSNJ’s approval is required for any transfer of a member to an alternate acute facility or an alternate level of care facility, subacute, skilled or custodial unit/facility.

Transportation
Reimbursement for ambulance transportation at the end of any hospital stay varies and is subject to benefit and medical necessity determinations by Horizon BCBSNJ. Transportation for Horizon BCBSNJ members can be reviewed with the assigned case manager.

HOSPITAL APPEALS
Horizon BCBSNJ offers network hospitals a forma process to appeal an adverse utilization management determination (e.g., denial of procedures or services; denial of inpatient admissions; denial of day(s) within an admission; or assignment of alternate level of care). The appeal must be received within 180 calendar days of the date of the written adverse determination and must contain the information outlined in this section. Horizon BCBSNJ retains the right to accept only those appeals submitted by a hospital or contracted third party acting on behalf of the hospital if the procedures outlined in this section are followed. Once an appeal request is received, Horizon BCBSNJ conducts a full and fair investigation of the issue and provides a timely written response. If appealing on behalf of a member, please ensure the letter of appeal clearly states “appealing on behalf of member” and proper member consent is attached to the appeal request.

Information Required for UM Appeals
The appeal must be submitted in writing. It must be written and signed by a health care professional (doctor or RN) and include the following information:

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

UM Appeal Submission
Mail medical UM appeals to:
Horizon BCBSNJ Appeals Department
Utilization Management Appeals
Mail Station PP-12E
PO Box 420
Newark, NJ 07101-0420

Mail behavioral health UM appeals to:
Horizon BCBSNJ Appeals Department
Horizon Behavioral Health
Utilization Management Appeals
Mail Station PP-12J
PO Box 110
Newark, NJ 07101-0110

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

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

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

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

Appeals Related to Medical Necessity/ Appropriateness Determinations

Level 1 Appeals
This appeal is reviewed by a Horizon BCBSNJ Medical Director who did not participate in the original determination. The appeal is completed within 30 calendar days of receipt of the appeal and the determination is communicated in writing to the facility. The communication will contain information and directions for requesting a level 2 appeal, as applicable.

Level 2 Appeals
This appeal must be received within 60 calendar days of the date of the level 1 determination letter. It must include the reason a second review is requested and must be for the same dates and services indicated on the level 1 appeal. The request should not include a second copy of the medical record.

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

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

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

CASE MANAGEMENT PROGRAM
The Case Management Program is designed to help our members get the care and services they need For more complex care or cases requiring additional resources, your Horizon BCBSNJ inpatient case manager may refer you to our Care Management Department. The Case Management Program, offered through the Horizon BCBSNJ Clinical Operations Department, is designed to help our members get the care and services they need. Our specially-trained care managers are registered nurses who work with our members and your office or facility staff to help members understand their health care options and coordinate their health care services.

Hospitals are responsible for discharge planning. Horizon BCBSNJ will help you arrange post-hospital care for our members. Simple discharge planning needs can be authorized through your Horizon BCBSNJ inpatient case manager. Use the Utilization Management section of this manual for more information on discharge/transition planning.

For more information about our Case Management program, review the Patient Health Support section of this Hospital Manual.

MEDICAL INJECTABLES PROGRAM (MIP)
Horizon BCBSNJ is committed to providing our members with access to high-quality health care that is consistent with nationally recognized clinical criteria and guidelines. As part of that commitment, we collaborate with specialty pharmaceutical management company, Magellan Rx Management, to administer our Medical Injectables Program (MIP).

Magellan Rx Management (MRxM) conducts medical necessity and appropriateness reviews (MNARs) for specific injectable medications. MRxM conducts reviews of injectable medications administered:

• At a freestanding or hospital-based dialysis center
• In an outpatient facility
• In a patient’s home
• In a physician’s office

MRxM will not perform MNARs on injectable medications administered:

• During an inpatient stay,
• In an observation room; or
• In an Emergency Room.

Reimbursement of claims will be delayed or denied if an MNAR determination is not obtained prior to the administration of any of the medical injectables included in this program. To learn more, visit HorizonBlue.com/mip.

Injectable medications included in the MIP
A list of the injectable medications that are subject to MNAR as part of the MIP is available by visiting HorizonBlue.com/mip and selectin List of injectable medications and the HCPCS codes subject to medical necessity and appropriateness review.

PLANS INCLUDED IN THE MIP
The MIP applies to services provided to members enrolled in the following Horizon BCBSNJ roducts/plans:*

• HMO
• EPO
• OMNIA Health Plans
• POS
• Direct Access
• PPO
• Indemnity/Traditional
• BlueCard Home
• New Jersey State Health Benefits Program (SHBP) or School Employees’ Health Benefits Program (SEHBP) plans.
• Medicare Advantage plans.

MIP Exclusions
The MIP does not apply to, and MNAR determination is not required for, those injectable medications provided to:

• Members enrolled in Horizon NJ Health.
• Members enrolled in the Federal Employee Program (FEP).
• Members enrolled in Medigap plans.
• Members whose Horizon BCBSNJ coverage is secondary to another insurance plan.
• Members receiving services rendered during an Emergency Room visit or in an observation room, or during an inpatient stay.

Magellan RX Management Contact Information
Visit IH.MagellanRx.com or call at 1-800-424-4508.

Medical Necessity and Appropriateness Review Process
Ordering physicians may obtain a MNAR at IH.MagellanRx.com.

MNAR Process
Ordering physicians may obtain a MNAR at IH.MagellanRx.com. To access MRxM’s online tool, visit IH.MagellanRx.com, click the Health Plan Partners icon, log in and:

1. Select Get an Authorization, read the overview and click Continue.
2. Enter the Member/Patient information, click Search.
3. Select a provider from the dropdown menu.
4. Enter the Brand Name/Generic Name or Procedure Code and click Search. Then select the appropriate drug brand link in the results list.
5. Select the Yes or No radio button to add (or not add) additional medication(s). Then click Continue.
6. Click the ICD-10 Code lookup icon, enter your search criteria, click Search and then select the appropriate ICD-10 code. On the Reason Selection page, enter remaining details and then click Continue.
7. On the Question and Answer page, answer clinical questions and select Next.
8. On the Submission Confirmation page, click Submit after confirming that the information entered is correct.

Urgent MNAR Requests
Urgent requests to obtain a MNAR determination may be initiated by calling MRxM at 1-800-424-4508. A request is considered urgent if:

• Following the standard MNAR process may seriously jeopardize the life, or health of the member, or the ability of the member to regain maximum function.
• Following the standard MNAR process would subject the member to severe pain that could not be adequately managed without the medical pharmaceutical treatment being requested.

Information required to complete a MNAR
Ordering physicians should have the following information available when contacting MRxM to obtain a pre-service MNAR determination:

• Ordering provider name, address and office phone and fax numbers.
• Rendering provider name, address and office phone and fax numbers (if different from ordering provider).v
• Member name, date of birth, gender and identification number.
• Member height, weight and/or body surface area.
• Anticipated start date of treatment (if known).
• Requested injectable medication(s).
• Dosing information and frequency.
• Diagnosis (ICD-10 code) and disease state severity.
• Past therapeutic failures (if applicable).
• Concomitant medications.

Additional information may be required depending on the injectable medication. For more specific criteria, visit HorizonBlue.com/mip to access comprehensive MNAR clinical reference sheets available for the injectable medications in this program.

MNAR Time Frames
Once all the required information is provided to MRxM, a determination can be issued. The request may be delayed if additional clinical documentation is required.

Urgent requests will be completed as soon as possible following the receipt of all necessary information. Non-urgent requests will be completed as soon as possible based on the medical urgency of the case, but in no more than three business days of receiving all necessary information.

Tracking and Determination Record Numbers
An MRxM tracking number (which consists of only numbers) is assigned at the initiation of a MNAR request. An MRxM determination record number (which can be identified by the letter I as the second to last character) is assigned when a final determination is a made.

MNAR Denials and Appeals
MRxM will issue a letter for all adverse decisions of requests for MNAR. Appeal instructions will be included in all denial letters. Generally, a provider may dispute an adverse decision that was based on medical necessity by following the instructions below.

• For non-Medicare members, call MRxM at 1-800-424-4508.
• For Medicare members, the appeal must be submitted in writing to:
  Magellan Rx Management
  Attn: Appeals Department
  PO Box 1459
  Maryland Heights, MO 63043
  Appeal Fax: 1-888-656-6805

Peer-to-Peer Consultations
Physicians who do not agree with MRxM’s determination may discuss the case in detail with a MRxM Medical Director by calling 1-800-424-4508, Monday through Friday, between 8 a.m. and 5 p.m., Eastern Time (ET).

Medical Injectables
Through our MIP, we require the review of certain injectable medications to ensure that these medications are administered within our Medical Policy criteria and guidelines as well as to improve quality of care and patient safety.

• Continue to contact Magellan Rx Management to initiate a medical necessity and appropriateness review for medical injectable drugs that are to be administered in one of the following places of service:

  - At a freestanding or hospital-based dialysis center.

  - In an outpatient facility.

  - In a doctor’s office.

• Contact CareCentrix for the pre-service review of medical injectable drugs that are to be administered in a patient’s home. The list of injectable medications that require review is available on HorizonBlue.com/mip.

UM Determinations

UM Decisions
Prior authorization decisions will be made as soon as possible and in accordance with applicable law, rules, regulations and accreditation standards. The turnaround time for non-urgent prior authorization requests (measured from the receipt of the request to decision [approval/denial] notification) is up to 14 calendar days of receipt. The turnaround time for urgent prior authorization requests is within 72 hours of receipt.

If additional information is needed to make a decision, the request may be pended or denied for lack of clinical information to support the request consistent with applicable law and accreditation standards. Following approval, an authorization/approval is generated and faxed (or made viewable via the CareCentrix Portal) to the servicing/requesting Horizon Care@Home program participating provider.

For Medicare Advantage members, copies of the approval are also mailed to the patient and referring physician.

Adverse Determinations
An adverse determination of a prior authorization request is a decision that the requested services will not be covered based on a determination that the services are not deemed to be medically necessary, are not a covered service or are not covered based on other factors as described by CareCentrix in their adverse determination letter or otherwise communicated. Any adverse determination of a prior authorization request based on medical judgment will be made by a board certified/board eligible licensed physician, operating with an active, unrestricted license.

An adverse determination will be communicated to the requesting physician verbally or in writing, and to the member in writing, and include at least: (1) the clinical rationale and reason(s) for the determination; (2) instructions for arranging peer-to-peer discussion with the licensed physician who made the determination (provided such discussion has not already occurred, in which case the communication of denial shall indicate that such a peer to peer discussion has already taken place); (3) instructions for requesting a written statement of the clinical rationale for the denial, including the clinical review criteria used in making the determination, if such is not included in the adverse determination notice; (4) instructions for appealing the denial to Horizon BCBSNJ or CareCentrix, as appropriate and peer matched reviewer/advisor information if one was used to review the case; and (5) all other required content under all applicable laws, rules and regulations.

Claim Processing & Billing through the Horizon Care@Home program
CareCentrix will submit claims to Horizon BCBSNJ on behalf of their Horizon Care@Home program participating providers. Following our adjudication and payment of a claim, CareCentrix:

• Provides reimbursement to the individual Horizon Care@Home program participating provider (at their contracted rate with CareCentrix) for services rendered or supplies provided.
• Will collect any member cost-sharing responsibility owed.

Members with BlueCard Benefits
Based on Blue Cross and Blue Shield Association (BCBSA) DME claim submission guidelines, DME claims must be submitted to the Blue Cross Blue Shield plan in the state where the item is delivered. If a DME item is not delivered, the claim must be submitted to the Blue Cross Blue Shield plan in the state where the item is purchased.

Use of nonparticipating home health care service providers
We remind participating physicians and other health care professionals that you are required to adhere to our Out-of-Network Referral Policy. This policy requires that you, whenever possible, refer Horizon BCBSNJ members to participating providers (including Horizon Care@Home participating ancillary services providers) unless:

• The member has, and wishes to use, his or her out-of-network benefits;
• Understands that a much greater member financial liability may be involved; and
• Signs a completed copy of our Out-of-Network Consent Form.

To access our Out-of-Network Referral Policy, registered NaviNet users affiliated with participating practices should log on to NaviNet.net, access the Horizon BCBSNJ from the My Health Plans menu, and:

• Select Provider Reference Materials.
• Mouse over Policies & Procedures.
• Select Policies, then Administrative Policies.
• Select Out-of-Network Referral Policy.

Participating physicians and other health care professionals who do not comply with our Out of Network Referral Policy will be at risk of an audit regarding their compliance with Horizon BCBSNJ policies and procedures. Please note that prior authorization requirements still apply (for home health care services that require prior authorization) to services provided by a home health care provider that is not participating in the Horizon Care@Home program.

AIM SPECIALTY HEALTH
Certain self-insured employer group health plans administered by Horizon BCBSNJ use an integrated advanced imaging and sleep management program for their members.

Horizon BCBSNJ contracts with AIM Specialty Health® to provide evidence-based clinical guidelines for elective, outpatient CT, MRI, nuclear cardiology, PET, echocardiography exams and sleep management exams for educational and quality purposes. This is not a formal utilization management program. Imaging studies performed in conjunction with Emergency Room services, inpatient hospitalization, outpatient surgery (hospitals and free-standing surgery centers), urgent care centers or 23-hour observations are not included in this program.

The goal of this program is to provide you and certain Horizon BCBSNJ members with information to make informed choices. The program could mean significant savings for certain members who have coinsurance plans and pay a percentage of costs out of pocket.

Check your member’s ID card to verify if your patients are included in the program. Physicians can request a review of anticipated services at aimspecialtyhealth.com/goweb or by calling 1-866-766-0250. This number is also displayed on the back of the member’s ID card.

AIM, on behalf of Horizon BCBSNJ, will also use the Blue Cross and Blue Shield Association’s National Consumer Cost Transparency (NCCT) data set for transparency purposes. AIM will share NCCT imaging facility cost information with staff during the clinical review process to promote awareness. AIM will also make outbound phone calls to members to inform them of the imaging facility options available.

Horizon BCBSNJ members will not be denied access to services if they do not choose the lower cost option and outreach will exclude pediatric and cancer patients. This Horizon BCBSNJ program through AIM Specialty Health is applicable only to beneficiaries enrolled in certain National Account self-insured groups. It does not replace our existing programs with eviCore healthcare, which serve the majority of our insured membership, including the New Jersey State Health Benefits Program (SHBP).

Musculoskeletal Program
The AIM Specialty Health Musculoskeletal Program engages providers in the management of the complexities associated with musculoskeletal and interventional pain management services. The Musculoskeletal Program covers services in the outpatient setting, using evidence based clinical guidelines to help reduce inappropriate care, overtreatment, and excessive costs while helping to ensure safe and effective care.

The program offers a prospective review of certain services to promote improved quality of care for all plan beneficiaries and to assess whether the proposed services are medically necessary and appropriate when evaluated against AIM Specialty Health’s evidence-based clinical criteria and guidelines.

To maximize the benefits achieved by this program, doctors and other health care professionals ordering outpatient musculoskeletal services for their patients must call AIM prior to such services being rendered to allow AIM’s prospective review to occur and for the doctors and other health care professionals to receive the qualitative feedback afforded by these AIM quality improvement programs.

If the planned services do not meet AIM’s guidelines for medical necessity, AIM may suggest that the doctor or other health care professional consider offering an alternative service or withdraw the requested service entirely. This program is only available to members of ASO/self-insured groups who have opted in at this time.

SURGICAL AND IMPLANTABLE DEVICE MANAGEMENT PROGRAM
Horizon BCBSNJ collaborates with TurningPoint Healthcare Solutions, LLC (TurningPoint) to administer our Surgical and Implantable Device Management Program.

As part of this program, TurningPoint conducts Prior Authorization & Medical Necessity Determination (PA/MND) reviews of certain Orthopedic services and Cardiac Services (many of which include implantable devices), and other related services, requested by participating and nonparticipating physicians.

View more information about this program, including a full listing of the procedures/impacted services and CPT codes that are subject to PA/MND review under this program on HorizonBlue.com/turningpoint.