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Welcome to the 2021 Results and Recognition Program’s presentation on Resources to Improve Quality.

The objectives of this presentation is for you all to understand HEDIS and the goal of the Quality Programs, as well as identify available resources offered by Horizon to assist your site in improving quality care and improve your success in the Results & Recognition Program also known as the R&R Program.

Horizon leverages the R&R Program to improve clinical outcomes performance on HEDIS measures and promote the care received by our members. Horizon BCBSNJ has experienced improved HEDIS performance since the inception of the R&R Program in 2016.

What exactly is HEDIS? For those of you who are not familiar, it stands for Healthcare Effectiveness Data & Information Set. HEDIS is a set of standardized performance measures that was developed by National Committee for Quality Assurance, known as NCQA. HEDIS makes it possible for the public to compare health plans on somewhat of an "apples-to-apples" basis by collecting data on the performance of health care providers. HEDIS is not exclusive to Horizon as 90% of our country’s health plans use HEDIS to measure performance on many different dimensions of care & service. HEDIS has 91 measures in total consisting of adult & pediatric measures. However, for our R&R Programs, we’re only focusing on a selected few. HEDIS monitors measures related to areas such as preventive care & screenings, chronic care, medication management and a few other areas.

The intent of our program is really to improve the health & wellness of our members by meeting HEDIS benchmarks and Star ratings. In addition, the program helps to facilitate accountable care across the network, help our providers be mindful of population health management, which we’ll discuss a little later on, and improve the care of our member populations through enhanced collaboration.
The provider’s benefits include receiving incentives tied to the selected HEDIS & Star measures. We offer best practices for preventive screenings, immunizations and treatment of chronic conditions. You will work with a Clinical Quality Improvement Liaison who will perform monthly touchpoints & report analysis and support you in areas related to quality improvement and practice transformation. You will also receive education through monthly webinars, and resources to promote best practices, as well as receive detailed monthly performance & gap reports showing your site’s current performance.

So the first resource is having a designated Clinical Quality Improvement Liaison, known as a CQIL.

You and your staff will receive a dedicated CQIL.
This person will be your single point of contact on quality for all lines of business and will offer support through monthly touchpoints or as needed.
Your CQIL will provide a comprehensive overview of the R&R program for all LOBs, provide education on the HEDIS measures and other areas, as well as offer support and resources to promote quality improvement and practice transformation.
The CQILs also collaborate with other departments, such as Horizon’s member outreach team and your PC&S representative, just to ensure everyone is on the same page with supporting you and your patients, which are our members.

Horizon Healthy Journey

This program focuses on all stages of life. We have a dedicated Population Health Management team whose focus is to reach out to members, through various methods, in helping to remind them of preventative care services, which can also help in closing care gaps. The program also offers opportunities for education and chronic disease management. The team uses data collected from member enrollment and claims and implements targeted interventions appropriate for the member’s demographic, condition or care gaps. There are different ways in which the outreaches are done such as live calls & direct mailings. There are member reward programs as well. They also utilize of vendors for care coordination and in-home screenings. In the bottom right corner, you will see the number of outreaches done last year, so this a very busy & focused team. The number for our Healthy Journey team is listed here if you have any questions for them please feel free to reach out. This number can also be shared with your patients.

Here are some examples of the direct mailings that the Horizon Healthy Journey team has sent out. The top mailing is a reminder sent to women to remind them of the importance of breast cancer screening. The bottom left is a card mailed to parents or guardians reminding them of members turning 1 year of age of the importance of well-care visits, immunizations, lead & dental screenings, and even offers assistance with transportation. Then you have a Cervical Cancer screening postcard sent to women reminding of the importance of having a pap exam done.

Here are additional examples of the direct mailings for reminders on getting the flu vaccine and prostate cancer screening, as well as a flyer educating members of how diabetes affects the body.

Our next resource is Care Management.

We have a Care Management program that is comprised of a team of nurses. The terms Care Management & Case Management are often used interchangeably. Care Management is not part of Horizon Health Journey but does it does offer an additional layer of support for our members. If a member is being case managed by Horizon, you will see this on your member gap report with the risk level they are being managed at. That risk level is determined when the Care Manager assesses the member by way of a health needs survey, which is usually done by phone. Depending on the score of the health needs survey; this will determine if the member is at a risk level 1, 2 or 3. The higher the score, the more complexed the member’s needs are. The program is available for both adults and children. Also, all FIDE-SNP members are case-managed. The contact information is noted here if you feel a member would benefit from being case managed. This number can be shared with members if needed.

What exactly do our Care Managers do? They are the primary contact for coordination of any services required by the special needs member, such as provider visits, pharmacy matters, home care agencies, transportation, and translation services just to name a few areas. They provide education to help manage the member’s chronic conditions, and be a resource to answer questions about the member’s health & benefits. They’re also a resource for other areas such as housing, behavioral health services, food, and finance. Care Managers provide assistance with referrals to special care facilities for highly specialized care, standing referrals for long-term specialty care, referrals to behavioral health providers and they also assist with provisions for all medically necessary dental services for members with developmental disabilities.
Again, if you have a patient who you think can benefit from these services and just really needs that extra support, please contact this department.

Now, what is the Provider’s responsibility as it relates to Care Management services?
Some Provider responsibilities include: Reviewing of the proposed care plan -
Providing additional information to assure the care plan is complete and accurate, and updated as needed -
Utilizing the monthly Quality Performance Reports to identify if a member on your panel is already being Case Managed - Providers can update each care plan as needed and return it to the Care Manager via fax, or update the information in NaviNet or Horizon Docs -
Providers can also consider reviewing the plan with the member, and communicating with the Interdisciplinary Care Team and encourage the member to participate in CM as well as encouraging the member to participate and engage with their Care Manager for improved health outcomes, which really is the biggest take-away here.

Provider Relations

Provider Contracting & Strategy, also known as PC&S, are called the face of the organization to providers and some of their functions include: Collaborating with internal business partners to ensure the network is able to achieve quality standards –
Providing competitive unit pricing and support for all interactions with providers –
They maintain and grow the Provider Network in accordance with Regulatory Standards and helps with sales growth – They also support as a required liaison with regulatory agencies, media & other constituents. PC&S reps are assigned by county. If you are not sure who your PC&S rep is, you CQIL can advise you. This information can also be found in NaviNet.

The PC&S reps can assist you with questions regarding:
Horizon NJ Total Care,
Member Eligibility,
Procedural Standards,
Provider Expectations,
They can provide general information on Billing,
They can answer questions related to the Consumer Assessment of Healthcare Providers and Systems known as CAHPS as well as the STARS,
They can also be a resource for other matters.

Some other Resources that are available to you

We are dedicated to keeping the people of NJ healthy. Our community health representatives, which we call Team NJ, holds a very special place in this. But since last year up to this point, it has been challenging because we are dealing with the impact of the COVID pandemic and have not been able to be out in the field as before. A major area that Team NJ focuses on is health education. They have a team of health educators that conduct workshops. These workshops provide important health information for the community and discuss facts about disease, risk factors, early detection, diagnosis & treatment, and health behaviors & lifestyles. Horizon utilizes evidence-based, best practice research by institutions like the Centers for Disease Control and Prevention, the National Institutes of Health and other federal governmental agencies.
If you are interested in scheduling a workshop or would like general information about them, please reach out to our Health Education Team members whose contact information is noted here.

There are multiple online services via NaviNet that can greatly benefit providers.
Navinet offers a single sign-on where you can access services for multiple health plans, not just Horizon. It provides efficient electronic transactions through its multi-payer database, and this can help reduce administrative costs and time, and it is always a good idea to check Navinet first if you have a claim inquiry. When you join Navinet you obtain access to administrative reports, claim inquiries as I just mentioned, online referrals and benefit information. If you’re not already enrolled with Navinet, the instructions are listed here and this information can be found in the Provider Administrative Manual.

The Provider Administrative Manual is not exclusive to the R&R Programs. It is a guide for administrative procedures of Horizon NJ Health and is updated periodically. It can assist with questions on referrals, benefits, appeals and claim submission, and a slew of other topics.
The manual is available on-line, which is the best way to access so you have the most recent version. However, if you would prefer a hard copy, please feel free to call the toll-free number noted here to make that request.

The Provider HEDIS Tips Booklet is a resource we provide to the R&R Providers. It lists some key HEDIS measures in the R&R Program, corresponding suggested billing codes and documentation requirements. Please always keep in mind that any codes used must support the services rendered and be reflected in the medical record documentation. If you have not received the 2021 version of this document, please reach out to your CQIL.

The Provider Practice Transformation Manual is another resource that is provided to you. It provides information regarding the Quality Program Measures and Best Practices, the Providers’ role in HEDIS, the CAHPS Survey as well as the HOS surveys as well as Horizon Healthy Journey. Your CQIL can provide a copy of this to you.

Horizon also has a website site for providers. This website has a vast amount of information from Manuals & user guides, HEDIS resources, different products & programs; there’s even information regarding Covid-19 and telehealth.

In addition, Horizon has a site for our members that will give them information for handbooks, understanding their coverage, a hospital/doctor finder & urgent care centers, advance directives, and other information.

In 2020, Horizon BCBSNJ launched a Resource Center, which contains materials, & resources that will assist Network Providers with quality improvement efforts. The Quality Resource Center can be accessed by signing into NaviNet. Please access the Resource Center for copies of the Quality Program Manual, Supplemental Data Provider Instructions, EHR Submission Instructions, and other resources.

This is a quick reference contact guide for some key departments within Horizon and again your CQIL can provide a copy of this. This is a screenshot of the first two pages; the entire document entails 7 pages.

The R&R Program honors the information provided by Bright Futures, which is a national health promotion and prevention initiative led by the American Academy of Pediatrics. All of their resources are theory and evidence-based so you know that any information you obtain here is concrete and reliable. If you have a pediatric population, it will be worth your while to explore this site, if you haven’t already. They also offer educational materials, for example, Well Visit toolkit forms.

So last but not least, The Centers for Disease Control and Prevention, known as the CDC. This is a national public health institute in the United States, which I’m sure you’re all aware of, and it is a US federal agency under the Department of Health and Human Services. The main goal is to protect public health and safety through the control and prevention of disease, injury and disability in the US and internationally. The CDC also conducts research and provides information on many different health topics. It is one of the best resources you can access to obtain up-to-date information on current matters on disease control & prevention.

This concludes the presentation on Resources and I hope you found the information useful.
If you have any questions, your CQIL is always your first line of support; however, you are welcome to send questions to the email noted here which is
You may also reach out to your CQIL to request a copy of this slide deck. Thank-you again.

Discuss Horizon Healthy Journeys, Care Management, Provider Relations, Horizon Community Outreach and other Horizon-offered resources.