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COVID-19

Welcome Kit

Welcome to the Horizon Managed Care Network and/or the Horizon PPO Network. We want to make your introduction to our business as easy as possible so you can focus your attention on serving our members. To help assist with the day-to-day interactions with us, below are some of the important resources and tools available to you.

Appointment Availability Access Standards

To help ensure that members receive the quality care they need when they need it, we have established appointment availability access standards for Primary Care Physicians (PCPs), Ob/Gyns and Specialist Practitioners, including specific access standards for Behavioral Health providers. It is important that you become familiar with these standards. We conduct random annual evaluations of practices and will monitor practices that do not meet our standards.

Accurate Directory Information is Important

It’s important that the information we display within our Doctor & Hospital Finder is current and accurate so our members can easily locate you and access the care and services they need from you.

Be sure to make update your profile whenever you have changes –including your office’s email address to ensure important communications reach you. It’s easy to update your information using our Provider Data Maintenance Tool. Your NaviNet Security Officer can access the Provider Data Maintenance Tool to quickly and conveniently make changes to your provider information which we display to your Horizon BCBSNJ and Horizon NJ Health patients.

Our Doctor & Hospital Finder will indicate the Horizon plans in which you participate.

Braven Health℠ Plan Information and Provider Participation Details

Braven Health℠ is an insurance company created through a partnership with Horizon BCBSNJ, Hackensack Meridian Health (HMH) and RWJBarnabas Health. Braven Health offers Medicare Advantage plans to beneficiaries in certain New Jersey counties.

HEDIS®, Medicare Star Rating and CAHPS® Resources

We maintain accreditation with the National Committee for Quality Assurance (NCQA). Accreditation requires our compliance with a unified set of standards, measuring the plan’s performance with the Healthcare Effectiveness Data and Information Set (HEDIS®). Additionally, the Centers for Medicare & Medicaid Services (CMS) derives its Five-Star Quality Rating System from several HEDIS measures and identifies practitioners whose patients are receiving quality care based on these standards. We encourage you access our available resources to help you incorporate these quality measures into your daily practice to help improve your patients’ health outcomes.

We also have a Patient Engagement Playbook that will help you improve the patient experience.

NaviNet®

All participating physicians and health care professionals are required to register for NaviNet within 30 days of their effective date of participation.

Through NaviNet, your office has access to the important Horizon information and self-service tools needed to conduct business with us on a day-to-day basis.

Electronic Fund Transfer (EFT)

Electronic Funds Transfer (EFT) is a fast and easy way to receive reimbursement in an electronic format from Horizon.

Electronic Data Interchange (EDI)

Electronic Data Interchange (EDI) services provide a more efficient and rapid exchange of information between physicians, other health care professionals and customers. Electronic transactions for claims and remittance advises result in decreased paperwork, reduced errors, faster payment and better service

Horizon Behavioral Health℠ Program

We have a dedicated team to help ensure that behavioral health services, including mental health and substance use disorder treatment is integrated into the overall care provided to our members. We provide important information on the Horizon Behavioral Health program, including important resources for behavioral health providers.

How to Submit Prior Authorizations

Prior authorizations (PAs) are required for certain services provided to our members, including but not limited to, inpatient admissions, various procedures, prescription medications and physical and occupational therapies. Authorization requests must be submitted to Horizon online using our Utilization Management Request Tool or our Drug Authorizations Tool. Both tools can be accessed from NaviNet.

Risk Adjustment

Risk adjustment is a statistical process that takes into consideration the underlying health status of insurance plan enrollees when assessing health care outcomes and health care costs related to a given population.

For risk adjustment to work, practices must accurately capture and submit claim and encounter data that reflects the primary conditions, co-existing conditions and present co-morbidities of the patients they treat.

Accurately coding patient diagnoses on claims provides us not only with the information we need to report to various federal agencies, but also with an enhanced view of your patients’ health.

We strongly encourage that you review our Risk Adjustment Coding Checklist and other information about risk adjustment, including our risk adjustment-related activities.

Interactive Voice Response System

We encourage you to use our easy-to-use Interactive Voice Response (IVR) system to access information 24 hours a day, seven days a week, generally including weekends and holidays, and get instant answers to many questions previously handled only by our service representatives.

Simply call:

  • Physicians and other health care professionals: 1-800-624-1110 (Physician Services)
    or
    Facilities and hospitals: 1-888-666-2535 (Institutional Services)

Referral Submissions through the IVR System

Primary Care Physicians (PCPs), Ob/Gyns and specialists participating in our managed care network may use our IVR system to submit referrals for their patients enrolled in Horizon Managed Care plans.

CPT® is a registered mark of the American Medical Association.

CAHPS® is a registered mark of the Agency of Healthcare Research and Quality. HEDIS® is a registered mark of the National Committee on Quality Assurance.

NaviNet® is a registered mark of NaviNet, Inc.