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Skilled Nursing Facility Billing Update

horizonbcbsnj — Mon, 13 Jan 2020 14:27:00 +0000

Skilled Nursing Facility Billing Update Mon, 01/13/2020 - 09:27

Beginning October 1, 2019, Horizon BCBSNJ aligned our approach to the processing of Skilled Nursing Facility (SNF) claims with that of the Centers for Medicare & Medicaid Services (CMS) services rendered to patients enrolled in any Horizon BCBSNJ Medicare Advantage (MA) plans.

On October 1, 2019, CMS replaced the Resource Utilization Group, Version IV (RUG-IV), with the Patient Driven Payment Model (PDPM), a new case-mix classification system for classifying SNF patients in a Medicare Part A plan covered stay into payment groups under the SNF Prospective Payment System (PPS).

CMS requires SNFs to bill for services under PDPM using the Health Insurance Prospective Payment System (HIPPS) code that is generated from a five-day PPS assessment and Interim Payment Assessment (IPA) with an assessment reference date on or after October 1, 2019.

For more information, please visit CMS’s Patient Driven Payment Model webpage.

If you have questions, please contact your Horizon BCBSNJ Ancillary Contracting Specialist.

Reimbursement Rates for 2020 Procedure Codes

horizonbcbsnj — Mon, 13 Jan 2020 14:25:19 +0000

Reimbursement Rates for 2020 Procedure Codes Mon, 01/13/2020 - 09:25

Each year, the American Medical Association (AMA) editorial board updates the list of procedure codes by adding new codes and revising or deleting certain existing codes.1 The Centers for Medicare & Medicaid Services (CMS) reviews this updated information and assigns Relative Value Units (RVUs) based on its analysis of the labor and resource input costs to each newly identified CPT code. Once CMS makes its RVU information available, Horizon BCBSNJ uses this data to help us establish new rates for these new codes.

CMS began releasing RVU information in December 2019. Horizon BCBSNJ is in the process of obtaining all necessary information required to update our pricing files.

We anticipate that our pricing file updates will be completed no later than February 1, 2020.

The processing of certain 2020 claims that include new or revised procedure codes may be delayed until our files are updated. All impacted claims will be finalized following the completion of our file updates. Please do not resubmit claims or submit claim appeals.

We apologize for any inconvenience this may cause.

¹Information on the new and updated CPT codes is available on the AMA website.

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

Proteomic Testing for Targeted Therapy in Non-Small Cell Lung Cancer

horizonbcbsnj — Wed, 08 Jan 2020 16:08:35 +0000

Proteomic Testing for Targeted Therapy in Non-Small Cell Lung Cancer Wed, 01/08/2020 - 11:08

Medical policy type

Revised

Third Party URL

https://services3.horizon-bcbsnj.com/hcm/MedPol2.nsf/MedicalPolicies/HNBE-9QKQVX

2020 hospital manual

horizonbcbsnj — Mon, 06 Jan 2020 11:18:07 +0000

2020 hospital manual Mon, 01/06/2020 - 06:18

2020_Horizon_Hospital_Manual.pdf

Radiology/Imaging Services Program: PET Scan Services Update

horizonbcbsnj — Fri, 03 Jan 2020 07:51:20 +0000

Radiology/Imaging Services Program: PET Scan Services Update Fri, 01/03/2020 - 02:51

In February 2020, Horizon BCBSNJ will implement changes to the services included as part of our Radiology/Imaging Services Program administered by eviCore healthcare (eviCore).

eviCore will conduct Prior Authorization/Medical Necessity Determination (PA/MND) reviews of the following PET Scan service procedure codes when rendered on or after February 3, 2020:

78429
78430
78431
78432
78433

Review the complete list of services that require PA/MND review as part of this program.

For more information about these and other eviCore programs, visit HorizonBlue.com/evicore. If you have questions, please contact your Network Specialist or Ancillary Contracting Specialist.

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

PA/MND reviews

To submit a PA/MND request to eviCore (or to validate that a PA/MND was requested and/or approved) please:

Visit eviCore.com or
Call 1-866-496-6200, between 7 a.m. and 7 p.m., Eastern Time

Review the guidelines eviCore uses to conduct PA/MND reviews as part of this program.

Horizon Behavioral Health℠ Program: 2020 Management Changes

horizonbcbsnj — Mon, 30 Dec 2019 17:29:44 +0000

Horizon Behavioral Health℠ Program: 2020 Management Changes Mon, 12/30/2019 - 12:29

Horizon BCBSNJ is in the process of transitioning the administrative and clinical management of the Horizon Behavioral Health program – behavioral health services and benefits – from our current program administrator, Beacon Health Options (formerly ValueOptions), to our internal operations.

The transition will occur in a phased approach.

Effective December 30, 2019 all administrative and clinical management for our Medicare Advantage plans will be managed by Horizon BCBSNJ's internal operations.

Behavioral health specialists will need to work with Beacon Health Options for certain processes until on or about April 1, 2020 for all other Horizon BCBSNJ plans – including fully insured plans/products, self-insured (Administrative Services Only [ASO]) employer group plans including the State Health Benefits Program (SHBP) and the School Employees' Health Benefits Program (SEHBP) and the Federal Employee Program® (FEP®).

Access the Horizon Behavioral Health program webpage for information about the program and to review Horizon Behavioral Health Network Specialists assignments.

Patient Health Support

horizonbcbsnj — Mon, 30 Dec 2019 14:14:20 +0000

Patient Health Support Mon, 12/30/2019 - 09:14

CASE MANAGEMENT PROGRAM

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.

Care managers:

Provide information that can help empower members to make informed decisions about their health care.
Coordinate health care services so they are received at the most appropriate level and setting to help maximize the member’s benefits.
Refer members to other valuable programs, including our Chronic Care Program, our health care ethics counseling resource, or to a social worker or registered dietician.
Provide information on community resources and health and wellness programs.

Case management is free to all eligible members. Participation is voluntary. Medical and personal information is kept confidential and shared only with those involved in the patient’s care.

Case Management programs are available to help members with:

Chronic Kidney Disease (CKD, including members receiving dialysis)
High-risk maternity care
Oncology
Supportive care
Transplants
Other general and pediatric conditions

Case Management Program Eligibility

Members who have serious or complex medical conditions, which may be long-term, catastrophic or terminal, are eligible for case management.

Providers refer most participants enrolled in the program; however, members may also request case management services. Others are asked to participate based on review of claims data and/or their utilization of services.

Care managers continue to work with members – and your office or facility – for as long as the member is enrolled and meets our case management criteria.

For more information about Horizon BCBSNJ Case Management Programs, visit HorizonBlue.com/patient-health-support or call 1-888-621-5894, option 2.

CHRONIC CARE PROGRAM

The right preventive care and early detection of disease are critical to healthy living. Horizon BCBSNJ offers the Chronic Care Program to eligible members who have been diagnosed with one of the chronic conditions listed below:

Asthma
Chronic Obstructive Pulmonary Disease (COPD)
Coronary Artery Disease (CAD)
Diabetes
Heart Failure

The Chronic Care Program is designed to reinforce the health goals established between you and your patient, by providing additional lifestyle and medication compliance education, through periodic educational mailings and phone support from registered nurses and registered dietitians.

To enroll eligible members using our referral form, visit HorizonBlue.com/patient-health- support, scroll down to the Chronic Care heading and click Chronic Care Program referral form.

To receive information on the programs, call 1-888-333-9617.

Not all programs may be available for all products or lines of business.

PRECIOUS ADDITIONS® PROGRAM

The PRECIOUS ADDITIONS program is a free, mail only, voluntary educational resource that provides members with valuable health information on their pregnancies.

To receive the most benefit from this program, eligible Horizon BCBSNJ members must enroll in PRECIOUS ADDITIONS early in the first trimester.

Patient Self-Enrollment

Encourage your eligible Horizon BCBSNJ pregnant patients to enroll in PRECIOUS ADDITIONS.
Members can enroll:

Online through HorizonBlue.com/preciousadditions.
By calling Member Services at 1-800-355-BLUE (2583).
Once enrolled in the program, your patient will receive useful information, including:
- A pregnancy journal.
- A children’s health guide.
- Newborn enrollment procedures.
- Information about reimbursement (up to $50) for the cost of completing one prenatal/Lamaze course.

Members may call 1-800-355-BLUE (2583) to learn more about the PRECIOUS ADDITIONS Program or to disenroll.

HIGH RISK MATERNITY PROGRAM

Your patients who are identified as high risk may be eligible to enroll in our Complex Case Management’s High Risk Maternity Program.

Through this program, nurse care specialists address members’ concerns about their pregnancy and assist them in making informed decisions regarding facility and care options.

Your patients may call 1-888-621-5894, option 2, to learn more about the High Risk Maternity Program.

24/7 NURSE LINE

Most Horizon BCBSNJ members are eligible to take advantage of the 24/7 Nurse Line.

Members can speak to experienced registered nurses who are specially trained to offer prompt general health information. Health care resources are available 24 hours a day, seven days a week, at no cost to our members. The phone number for the 24/7 Nurse Line is displayed on each eligible member’s ID card.

Nurses do not diagnose or recommend treatment, but they can assist our members by:

Providing general health information, which can help members determine when to seek medical attention.
Being available after hours to answer general health questions and provide general health information.
Encouraging preventive health services while supporting informed health decision making.
Educating members on which questions to ask during an office visit to promote effective communication between you and your patient.

24/7 Nurse Line Chat

Our 24/7 Nurse Line also offers members access to an online chat feature where members can interact online in real-time with a health care resource about various health and wellness issues.

To access the 24/7 Nurse Line chat feature, members can sign in to HorizonBlue.com, click Doctors & Care, then click 24/7 Nurse Line, and then click the Nurse Chat button. A new window will open with instructions to initiate a chat with a health care resource.

The 24/7 Nurse Line is for informational purposes only. Nurses cannot diagnose problems or recommend specific treatment. They are not a substitute for a physician’s care. Nurse Line services are not an emergency or urgent care service and may be discontinued at any time. In the event of an emergency, members should call 911 or the local emergency number and/or their doctor.

Availability of certain programs may require additional purchase by employer groups.

Patient-Centered Programs

horizonbcbsnj — Mon, 30 Dec 2019 14:12:15 +0000

Patient-Centered Programs Mon, 12/30/2019 - 09:12

As the state’s largest and most experienced health insurer, Horizon BCBSNJ is leading the transformation of health care delivery in New Jersey. We are committed to creating innovative physician/hospital-payer agreements that foster value-based care.

Our Value-Based Programs are deeply rooted in the fundamentals of the triple aim – improving patient outcomes, enhancing the patient experience and reducing overall costs.

Doctors and hospitals that are part of our Value-Based Programs coordinate patients’ health care needs and help ensure patients receive the highest quality of care in the right setting and at the right time. This patient-centered approach provides personalized and comprehensive health care that allows patients to become engaged in their health care. Participation in our program does not decrease or limit any current benefits.

Learn more.

Inquiries, Complaints and Appeals

horizonbcbsnj — Mon, 30 Dec 2019 14:05:53 +0000

Inquiries, Complaints and Appeals Mon, 12/30/2019 - 09:05

Horizon BCBSNJ’s goal is to provide prompt responses to our participating physicians’ and other health care professionals’ inquiries and timely resolution of complaints brought to Horizon BCBSNJ’s attention. To help you with such issues, you are encouraged to use our IVR system or to speak with a Physician Services Representative by calling 1-800-624-1110, Monday through Friday, between 8 a.m. and 5 p.m., ET.

PROVIDER INQUIRIES

An inquiry is a verbal or written request for administrative action or information, or an expression of opinion or comment regarding any aspect of Horizon BCBSNJ’s (or its subsidiaries’ or affiliates’) health care plans, or those of its Administrative Service Only (ASO) accounts¹.

Examples of inquiries include, but are not limited to, questions regarding eligibility of members, benefits or a particular claim’s status.

To speed our ability to assign, investigate and resolve your inquiries, please complete and submit our Inquiry Request and Adjustment Form (579). Submission addresses are noted on the 579 form. To access our Inquiry Request and Adjustment Form, visit HorizonBlue.com/form579.

1 Certain ASO accounts handle inquiries and complaints related to their self-insured plans. In such cases, Horizon BCBSNJ will refer you to the proper person or office for you to pursue your inquiry or complaint.

PROVIDER COMPLAINTS

A complaint is a verbal or written expression of dissatisfaction made by a physician or other health care professional, on his/her own behalf, regarding any aspect of Horizon BCBSNJ’s (or its subsidiaries’ or affiliates’) health care plans, or the plans of its ASO accounts, including Horizon BCBSNJ’s administration of those plans generally or with respect to a specific action or decision made or taken by Horizon BCBSNJ in connection with any of those health care plans.

Examples of complaints include, but are not limited to:

Administrative difficulties
Claims issues
Credentialing

Complaints relating to claims may typically involve:

Contract benefit issues
CPT-4 code inconsistencies
Incorrect coding
Reimbursement disagreements
Rebundling of charges

Complaints do not include issues related to specific utilization management determinations. The process for challenging utilization management determinations is described later in this section.

No physician or other health care professional who exercises the right to file a complaint shall be subject to any sanction, disaffiliation and termination or otherwise penalized solely due to such action.

You may submit complaints in writing, to:

Horizon BCBSNJ Physician Services
PO Box 199
Newark, NJ 07101-0199

TIME LIMITS FOR INQUIRY OR COMPLAINT FILING

You may submit a written or verbal complaint within 18 months from the date of the Horizon BCBSNJ decision or action with which you are dissatisfied.

There is no time limit for you to make an inquiry, with the exception that an inquiry related to a specific claim cannot be made beyond the longer of the timely claims filing time period requirement within your contract or the relevant member or covered person’s underlying benefits contract.

There is also no limit applicable for the filing of a complaint relating to matters in general with which you are dissatisfied that do not involve a specific decision or action taken by Horizon BCBSNJ.

RESOLVING YOUR INQUIRIES AND COMPLAINTS

Horizon BCBSNJ will attempt to address your inquiries and complaints immediately, whenever possible. Inquiries and complaints will typically be responded to no later than 30 days from Horizon BCBSNJ’s receipt.

If an inquiry or complaint involves urgent or emergent care issues, responses are expedited consistent with the circumstances and patient need involved. Our final response will describe what further rights you may have concerning the matter in question.

Those who remain dissatisfied with the outcome of their inquiries and complaints at the conclusion of the internal inquiry and complaint process have the right to contact the following state agency:

Department of Banking and Insurance Consumer Protection Services

PO Box 329
Trenton, NJ 08625-0329
1-888-393-1062

WHAT IS AN HCAPPA CLAIM APPEAL?

A claim appeal is a written request made by a participating physician or other health care professional asking for a formal review by Horizon BCBSNJ of a dispute relating to the reimbursement of claims. This includes, but is not limited to, a request for a formal review of a Horizon BCBSNJ Claim Payment Determination described as follows.

PROVIDER CLAIM REIMBURSEMENT APPEAL PROCESS

The Health Claims Authorization, Processing and Payment Act (HCAPPA) affects only insured products offered by Horizon BCBSNJ and its subsidiaries. The law does not apply to Administrative Services Only (ASO) plans, the New Jersey State Health Benefits Program (SHBP) and School Employees’ Health Benefits Program (SEHBP) and federal programs, including Federal Employee Program® (FEP®) and Medicare.

If your complaint involves a specific Claim Payment Determination that relates to your treatment of an insured member, written appeals must be initiated on the New Jersey Department of Banking and Insurance’s (DOBI) required form on or before 90 calendar days following receipt of the health insurer’s claim determination.

The DOBI form, the Application for Independent Health Care Appeals Program may be found within the Forms section of HorizonBlue.com/providers. This form may also be found on state.nj.us/dobi.

You should include all pertinent information and documents necessary to explain your position on why you dispute the health insurer’s determination of the claim.

Claim appeals for medical services* should be mailed to:

Horizon BCBSNJ Appeals Department
PO Box 10129
Newark, NJ 07101-3129

* The HCAPPA appeal process is not the correct process for medical necessity determinations. Medical necessity determination disputes should be appealed through the Independent Health Care Appeals Program (IHCAP).

A health insurer is required by law to make a determination (either favorable or unfavorable) and notify the physician or other health care professional of its decision on or before 30 calendar days following its receipt of the appeal form.

If a favorable determination is made for the physician or other health care professional, the health insurer must make payment within 30 calendar days of notification of the appeal determination together with any applicable prompt pay interest, which shall accrue from the date the appeal was received.
If an unfavorable determination is made for the physician or other health care professional, the health insurer must provide the physician or other health care professional instructions for referral to external arbitration.

If the physician or other health care professional is not timely notified of the determination, or disagrees with the final decision, the physician or other health care professional may refer the dispute to external arbitration.

WHAT IS AN HCAPPA CLAIM PAYMENT DETERMINATION?

A claim payment determination is Horizon BCBSNJ’s decision on a submitted claim or a claims-related inquiry or complaint. Claim payment determinations may involve recurring payments, such as a base monthly capitation payment made to a participating physician or other health care professional pursuant to the terms of the contract.

A claim dispute that concerns a utilization management determination, where the services in question are reviewed against specific guidelines for medical necessity or appropriateness to determine coverage under the benefits plan, may not be appealed under this process. These decisions are considered adverse utilization management determinations and follow a different process.

HCAPPA EXTERNAL APPEALS ARBITRATION

The New Jersey Department of Banking and Insurance (DOBI) awarded the independent arbitration organization contract to MAXIMUS, Inc.

Parties with claims eligible for arbitration may complete an application and submit it, together with required review and arbitration fees, directly to MAXIMUS, Inc. External appeals are not submitted through Horizon BCBSNJ.

Visit njpicpa.maximus.com for additional information and applications.

Physicians and other health care professionals must initiate a request for an external appeal of their claim within 90 calendar days of their receipt of the health insurer’s internal appeal decision.

However, to be eligible for this second level arbitration appeals process, disputes must be in the amount of $1,000 or more. Physicians and other health care professionals may aggregate claims (by carrier and covered person or by carrier and CPT code) to reach the $1,000 minimum.

The independent arbitrator’s decision must be issued on or before 30 calendar days following receipt of the required documentation.

The decision of the independent arbitrator is binding.

Payment must be issued within 10 business days of the arbitrator’s decision.

PROVIDER CLAIM PAYMENT APPEAL PROCESS: THIRD-PARTY REPRESENTATION

Participating and nonparticipating physicians and other health care professionals may wish to use the services of a third-party organization or service to file a claim appeal on their behalf. If so, Horizon BCBSNJ has specific requirements that must be met to safeguard the patient health information entrusted to us by our members or covered persons.

Call Physician Services at 1-800-624-1110 for more details on these requirements.

INQUIRIES, COMPLAINTS AND APPEALS ON BEHALF OF MEMBERS

Horizon BCBSNJ offers complaint and appeal processes for members/covered persons.

These member-based processes relate to our utilization management decision-making, as well as all other non-utilization management issues. As with our physician-based processes, these processes are designed to handle our members’ or covered persons’ concerns in a timely manner.

Our members may seek your help in pursuing an inquiry, complaint or appeal on their behalf. You must obtain the patients’ consent to appeal on their behalf.

NONUTILIZATION MANAGEMENT MEMBER INQUIRIES AND COMPLAINTS

Member inquiries and complaints are handled through our Member Services Department at 1-800-355-BLUE (2583), Monday through Wednesday and Friday, between 8 a.m. and 6 p.m., and Thursday, between 9 a.m. and 6 p.m. Eastern Time.

Our Member Services Representative can respond to member inquiries or complaints, or those made by a physician or other health care professional on behalf of a member with their consent. Our service staff is often able to immediately resolve questions at the point of contact.

Inquiries or complaints may also be submitted in writing to:

Horizon BCBSNJ Member Services
PO Box 820
Newark, NJ 07101-0820

Physicians and other health care professionals are reminded that he/she must have the consent of the member before inquiring on their behalf.

Member inquiries and complaints are typically responded to within 15 days from receipt when they involve any claims for a benefit that requires Horizon BCBSNJ’s approval in advance prior to receipt of services (a pre-service determination), and 30 days from receipt in all other instances (a post-service claim).

If a member inquiry or complaint involves urgent or emergent care issues, responses are expedited consistent with the circumstances and patient need involved.

Our final response will describe what further rights the member may have concerning the matter in question.

FILING AN APPEAL ON BEHALF OF A MEMBER

Prior to receiving services, a covered person or a person designated by the covered person may sign a consent form authorizing a physician or other health care professional acting on the covered person’s behalf to appeal a determination by the carrier to deny, reduce or terminate benefits. The consent is valid for all stages of the carrier’s informal and formal appeals process and the Independent Health Care Appeals Program.

The covered person has the right to revoke his/her consent at any time.

When appealing on behalf of the member, HCAPPA requires that the physician or health care professional provide the member with notice of the appeal whenever an appeal is initiated and again at each time the appeal is continued to the next stage, including any appeal to the Independent Utilization Review Organization (IURO).

NONUTILIZATION MANAGEMENT DETERMINATION APPEALS

Member Appeals – Requesting an Appeal1

Following the receipt of the complaint determination, in appropriate instances, the member/covered person, or a physician or other health care professional on behalf of, and with the consent of the member or covered person, may request an appeal either orally, in person or by phone or in writing as instructed by Horizon BCBSNJ in its complaint determination.

Horizon BCBSNJ’s written complaint determinations will detail the member’s appeal rights. Members are directed to send their appeal requests, whether by phone or in writing, to the appeals unit at the address and phone number supplied.

An Appeals Coordinator investigates the case and collects the information necessary to forward the case to the Appeals Committee.

Within five calendar days of receiving the appeal request, the Appeals Coordinator sends the member/covered person a letter acknowledging the request for appeal, describing the Appeals Committee process and advising of the actual hearing date.

1 Members/covered persons enrolled in certain plans, such as ASO and self-insured accounts, may not have the appeal rights described here.

Resolving the Member’s Appeal

Cases are scheduled within five days of receiving the request for an appeal related to a pre-service determination and within 10 days for an appeal related to a post-service claim. Appeals that involve requests for urgent or emergent care may be expedited.

The member/covered person is given the option of attending the hearing in person or via phone conference. The Appeals Coordinator makes the appropriate arrangements.

Members/covered persons, or physicians and other health care professionals on behalf of, and with the consent of, members or covered persons, who participate in the hearing are notified of the Committee’s decision verbally, on the day of the hearing, whenever possible. Written confirmation of the decision is sent to the member/or covered person and/or the physician or health care professional who pursued the appeal on their behalf, within two business days of the decision.

Members/covered persons who choose not to appear are notified of the Committee’s decision in writing within two business days of the decision.

Appeals are decided within 15 days of receipt for pre-service determinations and 30 days of receipt for post-service claims.

Letters of decision advise members what other remedies may be available to them if they remain dissatisfied with the resolution reached through the internal complaint system.

Expedited Complaints and Appeals

Member complaints and appeals may be expedited if the complaint or appeal involves a request for urgent or emergent care. Horizon BCBSNJ reserves the right to decide if the complaint or appeals process should be expedited in instances where the member/covered person or their representative is not a physician.

Expedited complaint review determinations are made as soon as possible, in accordance with the medical urgency of the case, which in no event shall exceed 72 hours.

In cases where an expedited appeal is required, the chairperson of the Appeals Committee will convene an expedited Appeals Subcommittee, which will review the case and render a determination to the appellant within 72 hours, or sooner, if the medical circumstances dictate.

The member/covered person, or the physician or other health care professional acting on behalf of and with the consent of the member/covered person, will be notified of the outcome of the expedited complaint or appeal within 72 hours of receipt of the complaint or appeal.

UTILIZATION MANAGEMENT OR MEDICAL APPEALS

Medical Appeals

Members and physicians and other health care professionals, on behalf of the member and with the member’s written consent, generally have the right to pursue an appeal of any adverse benefit determination involving a medical necessity decision made by Horizon BCBSNJ.

An adverse benefit determination involving a medical necessity decision is a decision to deny or limit an admission, service, procedure or extension of stay based on Horizon BCBSNJ’s medical necessity criteria. Adverse benefit determinations may usually be appealed up to three times.

Individual consumer plans and some ASO/self-insured plans only allow one level of appeal.¹

¹Members/covered persons enrolled in some plans do not have the appeal rights described here. For example, our Medicare Advantage members follow a different appeal policy, and members/covered persons of certain plans, such as individual consumer, ASO accounts and self-insured accounts, may not have the appeal rights described here.

First Level Medical Appeals

You will be advised how to initiate a first level medical appeal at the time the adverse benefit determination is made.

First level medical appeals are reviewed by our Medical Director or Medical Director’s designee. First level urgent and emergent medical appeals are reviewed within 24 hours. Non-emergent medical appeals are reviewed within 10 calendar days.

If the denial is upheld, members, physicians or other health care professionals, on behalf of the member and with the member’s written consent, may submit a second level medical appeal.

Second Level Medical Appeals

If a second level medical appeal is received, it is submitted to the Appeals Committee, which is made up of Horizon BCBSNJ Medical Directors and staff, physicians from the community and consumer advocates. The member/covered person is given the option of attending the hearing in person, or via phone conference, and the Appeals Coordinator makes the appropriate arrangements. Appeals that involve requests for urgent or emergent care may be expedited.

Members/covered persons, or physicians and other health care professionals on behalf of and with the written consent of members/covered persons, who participate in the hearing are notified of the Committee’s decision verbally by phone on the day of the hearing whenever possible.

Written confirmation of the decision is sent to the member/covered person, and/or the physician or other health care professional who pursued the appeal on their behalf, within five business days of the decision.

Expedited second level medical appeals are decided as soon as possible in accordance with the medical urgency of the case, but will not exceed 72 hours from our receipt of the first level medical appeal request whenever possible.

Standard second level medical appeals involving requests for services, supplies or benefits which require our prior authorization or approval in advance to receive coverage under the Plan are reviewed and decided within 15 calendar days of our receipt.

All other second level medical appeals are decided within 20 business days of our receipt. Second level medical appeals should be mailed to the address provided in the first level medical appeal determination letter or can be verbally requested by calling the phone number listed on the first level

medical appeal determination letter.

Third Level Medical Appeals

If the Appeals Committee upholds the second level medical appeal, the member or the member’s physician or other health care professional, acting on behalf of the member and with the member’s written consent, may request a third level medical appeal with the Independent Health Care Appeals Program (IHCAP). The Independent Utilization Review Organization (IURO) only considers appeals on denials based on medical necessity. Denials based on contract issues are not reviewed by the IURO. The case will be reviewed by a medical expert under contract with an IURO.

Instructions on how to file with the IURO are included with the denial letter from the second level medical appeal, where applicable. Third level medical appeals must be filed within four months from the receipt of the notice of determination of the second level medical appeal.

The IURO will review the appeal and respond to the member or facility, physician or other health care professional within 45 calendar days.

The IURO decision is binding. Members of certain plans, such as self-funded plans and some Medicare plans, may not appeal to the IURO. Some employers may offer an additional level of appeal.

Appeals Relating to Medicare Members

Medicare Advantage members follow a different appeal policy. For more information visit HorizonBlue.com/medicare.

Speaking with a Medical Director

Our Utilization Management (UM) policy is to always allow the treating or attending physician the opportunity to discuss any utilization management denial determination with the Horizon BCBSNJ reviewing physician who issued the decision.

Each denial determination includes the reviewing physician’s name and phone number. Participating physicians can also be connected to that Horizon BCBSNJ reviewing physician by calling

1-800-664-BLUE (2583).

UM Protocols and Criteria Available

Horizon BCBSNJ makes available to you our individual protocols and criteria that we use to make specific UM decisions on HorizonBlue.com/medicalpolicy.

If you require a printed copy of this information, contact your Network Specialist.

Member Rights and Responsibilities

horizonbcbsnj — Mon, 30 Dec 2019 14:04:17 +0000

Member Rights and Responsibilities Mon, 12/30/2019 - 09:04

The Horizon BCBSNJ Member Rights and Responsibilities have been reprinted in this section. They are also available by visiting HorizonBlue.com/rights.

As a member, you have the right to:

Receive information about Horizon BCBSNJ and its services, policies and procedures, products, physicians, appeals procedures, member rights and responsibilities, coverage limitations and other information about the organization and the care provided.
Be provided with the information needed to understand your benefits and obtain care through the Horizon Managed Care Network.
Obtain a current directory of participating physicians in our network, upon request. The directory includes addresses, phone numbers and a listing of physicians who speak languages other than English.
Receive prompt notification of termination of your PCP or material changes in benefits, services or the Horizon Managed Care Network within 30 days prior to the date of any change or termination, as appropriate.
Obtain information about whether a referring physician has a financial interest in the facility or services to which a referral is being made.
Know how Horizon BCBSNJ pays its physicians, so you know if there are financial incentives or disincentives tied to medical decisions.
Receive from your physician or health care professional, in terms you understand, an explanation of your complete medical condition, such as information regarding your health status, medical care or treatment options, including alternative treatments that may be self-administered, recommended treatment, risk(s) of the treatment, expected results of the treatment and reasonable medical alternatives, whether or not these are covered benefits. The member also has the right to be provided the opportunity to decide among all relevant treatment options
Have your Horizon BCBSNJ plan pay for a medical screening exam in an emergency facility to determine whether a medical emergency condition exists (subject to the terms and conditions of the member’s benefit contract).
Go to an Emergency Room without prior approval when it appears to you that serious harm could result from not obtaining immediate treatment.
Choose from appropriate, participating specialists following an authorized referral (if necessary), subject to the specialist’s availability to accept new patients.
Obtain assistance and referrals to participating health care professionals who have experience in treatment of patients with chronic disabilities.
Be provided with information in a way that works for you (in languages other than English and in alternate formats such as large print).
If you need help understanding this Horizon BCBSNJ information, you have the right to get help in your language at no cost to you. To speak to an interpreter, call 1-800-355 BLUE (2583) during normal business hours.
Ensure timely access to covered services and medications, as applicable.
Receive information about Horizon BCBSNJ and its services, policies and procedures, products, physicians, appeals procedures, member rights and responsibilities, coverage limitations and other information about the organization and the care provided.
Be provided with the information needed to understand your benefits and obtain care.
Obtain a current directory of participating physicians, upon request. The directory of participating physicians is also posted on the website. It includes addresses, phone numbers and a listing of physicians who speak languages other than English.
Receive prompt notification of termination of your PCP, if applicable, or material changes in benefits, services or network within 30 days prior to the date of any change or termination, as appropriate.
Obtain information about whether a referring physician has a financial interest in the facility or services to which a referral is being made.
Know how Horizon BCBSNJ pays its physicians, so you know if there are financial incentives or disincentives tied to medical decisions.
Receive from your physician or health care professional, in terms you understand, an explanation of your complete medical condition, such as information regarding your health status, medical care or treatment options, including alternative treatments that may be self-administered, recommended treatment, risk(s) of the treatment, expected results of the treatment and reasonable medical alternatives, whether or not these are covered benefits. The member also has the right to be provided the opportunity to decide among all relevant treatment options. If you are not capable of understanding the information, the explanation shall be provided to your next of kin or guardian and documented in your medical record.
Have full, candid discussions about the risks, benefits and consequences regarding appropriate or medically necessary diagnostic and treatment or non-treatment options with your participating physicians, regardless of cost or benefit options.
Refuse treatment and to express preferences about future treatment options.
Choose and change your PCP, as applicable, within the limits of your benefits and the physician’s availability.
Have access to your PCP, if applicable, and available services when medically necessary. This includes the availability of care 24 hours a day, seven days a week, 365 days a year for urgent or emergency conditions.
Call the 911 emergency response system or an appropriate local emergency number in a potentially life-threatening situation, without prior approval. The 911 information is listed on your Horizon BCBSNJ ID card.
Have your Horizon BCBSNJ plan pay for a medical screening exam in an emergency facility to determine whether a medical emergency condition exists.
Go to an Emergency Room without prior approval when it appears to you that serious harm could result from not obtaining immediate treatment.
Choose from appropriate, participating specialists following an authorized referral (if necessary), subject to the specialist’s availability to accept new patients.
Obtain assistance and referrals to participating health care professionals who have experience in treatment of patients with chronic disabilities.
Know all the rights afforded by law or regulation as a patient in a licensed health care facility, including the right to refuse medication and treatment after possible consequences have been explained in a language you understand and be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation.
Receive a written explanation why approval of a covered service requested by you or your physician was denied or limited under your Horizon BCBSNJ plan.
Have a Horizon BCBSNJ physician determine to deny or limit your admission, service, procedure or extension of stay. Our physician who made the decision must directly communicate with your physician or supply your physician with his/her phone number. You also have the right to know that the person denying or limiting a covered service is a physician.
Be free from balance billing by participating physicians for medically necessary services that were authorized or covered by Horizon BCBSNJ (not including co-payments, co-insurance and deductible).
File a complaint or appeal with Horizon BCBSNJ or the New Jersey Department of Banking and Insurance. You have the right to receive an answer to your complaint or appeal within a reasonable period of time.
Know that neither you nor your physician can be penalized for voicing a complaint or appeal about your Horizon BCBSNJ plan or the care provided.
Participate with your physicians in decision-making regarding your health care.
Be treated with courtesy and consideration, and with respect for your dignity. You also have the right to privacy.
Request and receive a copy of your Private Information maintained in Horizon BCBSNJ’s records.
Exercise your privacy right by requesting an amendment of your Private Information that is believed to be inaccurate.
Formulate and have end of life and advance directives implemented.
Make recommendations for changes to Horizon BCBSNJs Member Rights and Responsibilities Policy.
Receive covered services from a voluntarily terminated health care professional who was under contract with us at the time treatment was initiated, for up to four months, where medically necessary. Other timeframes may apply to obstetrical care, post-operative care, oncological treatment or psychiatric treatment.
Right of a covered person to be treated with dignity, courtesy and consideration out of respect for the members’ need for privacy.
Horizon BCBSNJ or its participating providers will not penalize you for exercising your rights.

Our statement of member responsibilities includes the following provisions:

Our members have the responsibility to:

Read and understand this Horizon BCBSNJ Member Handbook, your EOC and all other member materials.
Use the PCP you selected to receive in-network benefits.
Coordinate most nonemergency care through your PCP.
Provide, to the extent possible, information regarding your health that Horizon BCBSNJ and its physicians and other health care professionals need in order to care for you.
Know how to change your PCP.
Obtain referrals from your PCP, as appropriate, and use the Horizon Managed Care Network to receive the in-network level of benefits.
Understand your health problems and participate in developing mutually agreed upon treatment goals and medical decisions regarding your health (to the degree possible).
Follow the plans and instructions for care that you agreed upon with your physician. If you choose not to comply, you will advise your physician.
Be considerate and courteous to physicians and staff.
Make payment for copayments, deductibles and coinsurance as listed in your EOC.
Know your rights and responsibilities as a Horizon BCBSNJ member.
Pay for charges incurred that are not covered under the policy or contract.

Correct Coding Update: Other Medical and Surgical Services during a Postoperative Period

horizonbcbsnj — Mon, 30 Dec 2019 13:00:00 +0000

Correct Coding Update: Other Medical and Surgical Services during a Postoperative Period Mon, 12/30/2019 - 08:00

Horizon Blue Cross Blue Shield of New Jersey continues to enhance our claim auditing for professional claims.

Effective February 1, 2020, Horizon BCBSNJ will update our claim auditing to systemically process professional claims for certain medical and surgical services in accordance with the Centers for Medicare & Medicaid Services (CMS), National Correct Coding Initiative (NCCI) guidelines noted below.

Other Medical and Surgical Services during a Postoperative Period

Deny 0-, 10- or 90-day surgical procedures performed within 90 days of a 90-day surgical procedure.
Deny separate reimbursement for services typically considered part of a minor 10-day surgical procedure. Deny 0-day and 10-day surgical procedures performed within 10 postoperative days of a 10-day procedure.
Deny separate reimbursement for services typically considered part of a major 90-day surgical procedure.
Deny 0-day and 10-day surgical procedures performed within 10 postoperative days of a 10-day surgical procedure when submitted by the same Provider ID, regardless of Tax ID and specialty.
Deny 0-, 10- or 90-day surgical procedures billed by the same Provider ID, regardless of Tax ID and specialty within 90 days of a 90-day surgical procedure.

These guidelines will apply to claims finalized February 1, 2020 and after for services rendered to:

Patients enrolled in Horizon BCBSNJ fully insured plans for all dates of service.
Patients enrolled in New Jersey State Health Benefits Program/School Employees Health Benefits Program (SHBP/SEHBP) plans for dates of service January 1, 2020 and after.

If you have any questions, call Physician Services at 1-800-624-1110, Monday through Friday, between 8 a.m. and 5 p.m., Eastern Time.

The NCCI guidelines above were included as part of claim adjustment efforts designed to ensure that history claims were processed in accordance with nationally recognized coding and code-editing guidelines. Claim adjustments were announced within the News and Legal Notices section of our website on September 14, 2017, January 5, 2018, September 21, 2018, and September 10, 2019.

Identification

horizonbcbsnj — Mon, 30 Dec 2019 12:35:42 +0000

Identification Mon, 12/30/2019 - 07:35

The member’s ID card is an important tool in determining the product in which your patient is enrolled. Most cards include general coverage and copayment information, as well as important phone numbers. Both the front and back of the ID card contain important information.

The member’s identification (ID) number is the most important link between you, your patient and Horizon BCBSNJ. It is critical that you include all characters when submitting claims to us.

As a physician or other health care professional who participates in our Horizon Managed Care Network and/or our Horizon PPO Network, you must, according to the terms of your Agreement, accept our allowance for eligible services provided to Horizon BCBSNJ members (less any applicable copayment, coinsurance or deductible amounts) as payment in full.

For more information about allowances for services provided to members in various Horizon BCBSNJ plans, see the Claims Submissions and Reimbursement section.

SAMPLE ID CARDS

Horizon BCBSNJ’s ID cards comply with Blue Cross and Blue Shield Association (BCBSA) branding regulations and New Jersey Department of Banking and Insurance (DOBI) regulations.

Our ID cards contain the important information you need in a uniform and consistent layout so that Horizon BCBSNJ ID cards – and all other Blue Plan ID cards – are easy to read and use.

The images that follow are not actual ID cards. They are for educational purposes only.

Member ID name.
Member ID number.
Coverage verification data.
The name of the product.
Copayment information, including inpatient hospital copayment. This information will vary based on the plan.
PPO-in-a-suitcase logo indicates BlueCard PPO coverage, if applicable.
The Primary Care Physician’s (PCP) name (if a PCP is required under the plan).
Claim filing information. This information will vary based on the plan.
Logo indicating prescription drug coverage, if the member has Prime Therapeutics LLC prescription drug coverage through Horizon BCBSNJ.
Website address.
Service phone numbers. This information may vary based on the plan.
Indication of whether the plan is insured or self-funded. A self-funded ID card will state, Horizon BCBSNJ provides administrative services only and does not assume any financial risk forclaims.

Sample National ID Card

Member ID name
Member ID number.
Member name.
Member ID number.
Coverage verification data.
The name of the plan.
Copayment information, including inpatient hospital copayment. This information will vary based on the plan.
PPO-in-a-suitcase logo indicates BlueCard PPO coverage, if applicable.
Claim filing information. This information will vary based on the plan.
Logo indicating prescription drug coverage, if the member has Prime Therapeutics, LLC. prescription drug coverage through Horizon BCBSNJ.
Website address.
Service phone numbers. This information may vary based on the plan.
Indication of whether the plan is insured or self-funded. A self-funded ID card will state, Horizon BCBSNJ provides administrative services only and does not assume any financial risk forclaims.

FEDERAL EMPLOYEE PROGRAM® (FEP®):

ID CARDS

Member name.
Member ID number.
All characters in this field are important and must be included in all transactions.
For FEP plans, the ID number always begins with the R prefix and is followed by eight digits.
Enrollment Code.
- 104 identifies Standard Option self coverage.
- 105 identifies Standard Option self and family coverage.
- 106 identifies Standard Option self plus one coverage.
- 111 identifies Basic Option self coverage.
- 112 identifies Basic Option self and family coverage.
- 113 identifies Basic Option self plus one coverage.
- 131 identifies Blue Focus self coverage
- 132 identifies Blue Focus self and family coverage
- 133 identifies self plus one coverage
Effective date of the subscriber’s contract.
The ID card will also have either PPO or Basic in the upper right corner of the ID card, inside the outline of the U.S. map.

Horizon Hospital Network

horizonbcbsnj — Mon, 30 Dec 2019 12:33:50 +0000

Horizon Hospital Network Mon, 12/30/2019 - 07:33

Horizon BCBSNJ is committed to providing our members access to a wide range of quality acute care facilities located conveniently throughout the region.

Periodically, hospitals may be added to or removed from the network. Blue Review and messages on HorizonBlue.com/news will advise you of these changes. Participating physicians and other health care professionals should use the Horizon Hospital Network so that members receive the highest level of benefits available under their benefit plans.

To find participating hospitals, visit HorizonBlue.com/doctorfinder.

HIPAA

horizonbcbsnj — Mon, 30 Dec 2019 12:32:17 +0000

HIPAA Mon, 12/30/2019 - 07:32

Horizon BCBSNJ (and its affiliated covered entities) is considered a health plan under federal law and a covered entity under the Health Insurance Portability and Accountability Act of 1996, Pub. L. 104-191 (HIPAA). This means that Horizon BCBSNJ is subject to the administrative simplifications requirements of HIPAA, including its regulations on electronic standard transactions and code sets, privacy, security and National Provider Identifier (NPI) – just as you are, if you or your business associates on your behalf, engage in electronic health coverage transactions, such as for medical claims or encounter submissions.

You are responsible for complying with all applicable state and federal laws and regulations regarding the privacy and security of medical records and other individually identifiable (protected) health information, which Horizon BCBSNJ calls Private Information. In addition, for those hospitals, facilities, physicians and other health care professionals which are covered entities under HIPAA, that includes the obligation to comply with the privacy and security requirements of HIPAA, its NPI requirements and many of its other rules.

As you know, the federal rules generally allow you to use and disclose Private Information without an authorization from your patient for treatment, payment and health care operations (TPO), as well as for a number of other permissible purposes. This includes uses and disclosures made for the TPO purposes of other covered entities, like Horizon BCBSNJ (with limited exceptions).

If you have questions in reference to HIPAA, we suggest that you contact HIPAA consultants and/or

attorneys.

Coordination of Benefits

horizonbcbsnj — Mon, 30 Dec 2019 11:50:06 +0000

Coordination of Benefits Mon, 12/30/2019 - 06:50

Coordination of Benefits (COB) applies when expenses for covered services are eligible under more than one insurance program. Usually, one health insurance company has primary responsibility and there is at least one other health insurance company with responsibility for any remaining patient liability. On occasion, an automobile insurance or workers’ compensation insurance carrier will be involved.

Regardless of which insurance carriers are responsible, the combined payments are never greater than the actual charges of services and generally are not more than the primary carrier’s contract rate. This portion of the manual offers some guidelines to help in COB situations.

Remember to ask your patient if they have other health insurance coverage.

Obligations of Physician to Obtain COB Information and to Bill Primary First

Claims should be submitted to the primary carrier first. You must help with processing forms required to pursue COB with other health care plans and coverages (including and without limitation, workers’ compensation, duplicate coverage and personal injury liability). You are required to make diligent efforts to identify and collect information concerning other health care plans and coverages at the time of service. Where Horizon BCBSNJ is, or appears to be, secondary to another plan or coverage, you must first seek payment from such other plan or coverage according to the applicable rules for COB.

HCAPPA Revised COB Rules

The New Jersey state law known as the Health Claims Authorization, Processing and Payment Act (HCAPPA) states that no health insurer can deny a claim while seeking COB information unless good cause exists for the health insurer’s belief that other coverage is available; for example, if the health insurer’s records indicate that other insurance coverage exists. Horizon BCBSNJ will continue to gather information from members regarding other benefits in an effort to maintain accurate records and have the appropriate health insurer be financially responsible.

Patient Who has Two or More Insurance Plans (other than Medicare, Motor Vehicle Accidents or Workers’ Compensation)

If you are providing care to the covered spouse of a Horizon BCBSNJ subscriber who also has his/her own health plan, the spouse’s health plan is always primary UNLESS all of the following are true:

The spouse is retired.
The spouse is also eligible for Medicare.
Our subscriber is covered as an active employee and Medicare is not primary under the Medicare Secondary Payer rules. In this event, the Horizon BCBSNJ coverage is primary, Medicare is secondary and the spouse’s health plan is tertiary.

If you are providing care to a Horizon BCBSNJ subscriber who also has coverage as a subscriber with another health plan and the subscriber is:

An active employee of one group and a retired employee of another. The plan from the group where the employee is active is primary.
A retired employee of two groups. The plan in effect the longest is primary.
An active employee of two groups. The plan in effect the longest is primary.

When providing care to a dependent child, whose parents are not separated or divorced and:

The parents both have health insurance, determine from their benefit plans whether the Birthday Rule or the Gender Rule will apply. In most cases, the Birthday Rule will apply.

When providing care to a dependent child, whose parents are separated or divorced:

The plan of the parent who has financial responsibility for health care expenses (as determined by the court) is the primary plan, regardless of who has custody of the child.
For claims for a dependent child whose parents are separated or divorced, but a court has not stipulated financial responsibility, the unmarried parent who has custody is primary. The other parent is secondary.
Any coverage through a stepparent married to the custodial parent would be next, and the noncustodial parent’s coverage last.

BIRTHDAY RULE

Under the Birthday Rule, to determine the primary carrier, you need the month and day of the parents’ birth dates; the year is never considered. The parent whose birthday falls earlier in the year has the primary plan for the dependent child. If both parents have the exact same birthday (month and day), the plan in effect the longest is primary. The Birthday Rule will only apply if both carriers use the Birthday Rule.

GENDER RULE

Under the Gender Rule, the father’s plan is primary for the dependent child. If one parent’s contract uses the Birthday Rule and the other contract uses the Gender Rule, then Gender Rule determines the father’s plan as primary.

MOTOR VEHICLE ACCIDENTS

If the primary carrier is:

The auto insurance, you must submit your claim to them. After you receive the Explanation of Payment (EOP) from the auto insurance carrier, send it to us with a completed claim form, an itemized bill and a copy of the member’s Explanation of Benefits (EOB). Electronic claims cannot be accepted because of the additional information required to process the claim.
If the primary carrier is Horizon BCBSNJ, we will need a copy of the automobile declaration sheet with the date of accident between the policy effective date and cancellation date. Be sure to attach an itemized bill and completed claim form.

Automobile insurance is not primary for motorcycle accidents for owner/operators of a motorcycle.
However, passengers of motorcycle accidents need to submit any accident-related claims to their auto insurance carrier for consideration.

WORKERS’ COMPENSATION

Workers’ compensation covers any injury which is the result of a work-related accident. Employers purchase insurance which covers work-related illnesses or injuries.

Horizon BCBSNJ does not provide reimbursement for services rendered to treat work-related illnesses or injuries or for services or supplies which could have been covered by workers’ compensation.

Always bill the workers’ compensation carrier directly for work-related illnesses or injuries.

If Horizon Casualty Services, Inc. is the workers’ compensation carrier, mail medical bills to:

Horizon Casualty Services, Inc.
PO Box 10175
Newark, NJ 07101-3175

REGULATIONS ON NEW JERSEY INSURED GROUP POLICY

Special rules apply for Coordination of Benefits (COB) where the Horizon BCBSNJ policy is an insured group policy issued by Horizon BCBSNJ 11:4-28.7, as amended effective January 1, 2003, provides for different COB rules (as to insured group policies issued in New Jersey) depending on what basis the primary and secondary plans pay and whether the physician is or is not in the network of either or both plans.

If Horizon BCBSNJ is the primary payer, these rules do not apply.

If the Horizon BCBSNJ insured group policy is secondary, and the physician or other health care professional is in Horizon BCBSNJ’s network, these rules apply:

Where both the primary and secondary plans pay on the basis of a contractual fee schedule and the physician is in the network of both plans, Horizon BCBSNJ pays the cost sharingof the covered person under the primary plan up to the amount Horizon BCBSNJ would have paid if primary, provided that the total amount paid to the physicians from the primary plan, Horizon BCBSNJ, and the covered person does not exceed the contractual fee of the primary plan and provided that the covered person is not responsible for more than the cost sharing under our plan. (N.J.A.C. 11:4- 28.7(e)1.)
Where the primary plan pays on the basis of Usual, Customary and Reasonable (UCR) and Horizon BCBSNJ pays on the basis of a contractual fee schedule, the primary plan pays its benefits without regard to the other coverage and Horizon BCBSNJ pays the difference between billed charges and the benefits paid by the primary plan up to the amount we would have paid if primary. Our payment is first applied to the covered person’s cost sharing under the primary plan. The covered person is only liable for cost sharing under our plan if he/she has no liability for cost sharing under the primary plan and the total payments of the primary and our plan are less than billed charges. The covered person is not responsible for billed charges in excess of the amounts paid by the primary and secondary plans and cost sharing under either plan. The covered person can never be responsible for more than the cost sharing under the secondary plan. (N.J.A.C. 11:4-28.7(e)2.)
Where the primary plan pays on the basis of a contractual fee schedule but the secondary pays on the basis of UCR, and the physician or other health care professional is in the network of the primary plan, the secondary plan pays any cost sharing of the covered person under the primary plan up to the amount the secondary would have paid if primary. (N.J.A.C. 11:4-28.7(e)3.)
Where the primary plan is an HMO plan but the physician or other health care professional is out of network and services are not covered by the primary plan, Horizon BCBSNJ pays as if it were primary. (N.J.A.C. 11:4-28.7(e)4.)
Where the primary plan pays capitation and Horizon BCBSNJ’s plan is an HMO plan that pays on a contractual fee schedule and the physician or other health care professional is in the network of both plans, Horizon BCBSNJ pays the cost sharing of the covered person under the primary plan up to the amount Horizon BCBSNJ would have paid if primary. (N.J.A.C. 11:4-28.7(e)5.)
Where the primary plan pays capitation, contractual fee schedule or UCR, and Horizon BCBSNJ’s plan pays on a capitated basis, Horizon BCBSNJ pays its capitation and the covered person has no responsibility for payment of any amount for eligible services. (N.J.A.C. 11:4-28.7(e)6.)
Where the primary and Horizon BCBSNJ’s plan are both HMO plans and the physician or other health care professional is not in the primary plan’s network, and the primary has no liability, Horizon BCBSNJ pays as if primary. (N.J.A.C. 11:4-28.7(e)7.)

MEDICARE ELIGIBILITY

There may be instances when an individual who has coverage with us may also be entitled to Medicare coverage. This section will help you to determine which plan will pay as primary.

COB when Medicare is involved is usually called Medicare Secondary Payer (MSP). MSP does not apply to members who have individual contracts. Medicare is always primary for individual contract holders.

There are three ways a person can become eligible for Medicare:

Attaining age 65
Becoming disabled
Having end-stage renal disease (ESRD)

Attaining Age 65

When individuals reach age 65 and have contributed enough working quarters into the Social Security system, they are entitled to Medicare Part A benefits at no cost. To receive Medicare Part B benefits, they must pay premiums through monthly deductions from their Social Security checks.

For individuals who have not contributed enough quarters in the Social Security system, there are two ways they may receive Medicare Part A benefits:

Through a spouse who has contributed enough quarters to the Social Security system. This is identified by the letter B following the spouse’s Medicare claim number on his or her Medicare ID card.
Purchase Medicare Part A benefits. This is identified by the letter M following the Medicare claim number on his or her Medicare ID card.

Becoming Disabled

Disabled individuals under age 65 are entitled to Medicare under the disability provisions of the Social Security Act. They must be unable to work and must have been receiving Social Security disability payments for 24 months. Beginning with the first day of the 25th month of receiving Social Security payments, they are entitled to Medicare Part A benefits at no cost. Medicare Part B benefits may be purchased.

Having End-Stage Renal Disease (ESRD)

A person becomes eligible for Medicare under the ESRD provisions after beginning a regular course of renal dialysis. He/She is entitled to Medicare benefits after completing a three-month waiting period beginning the first day of the month after the start of a regular course of renal dialysis. The waiting period continues until the first day of the fourth month following the initiation of renal dialysis. On the first day of the fourth month, such a person is entitled to Medicare Part A at no cost.

Medicare Part B benefits may be purchased.

The three-month eligibility waiting period for ESRD Medicare benefits may not apply when the Medicare-eligible individual:

Receives a kidney transplant. In this circumstance, the individual is entitled to Medicare the first day of the month in which the transplant occurred.
Initiates a course of self-dialysis training during the three-month waiting period. In this circumstance, the individual becomes entitled to Medicare the first day of the month of his or her eligibility.

MEDICARE SECONDARY PAYER

There are three ways a Medicare-eligible person may be primary with us under an employer group health program:

Working-aged
Disabled
End-stage renal disease (ESRD)

See chart on the next page for more detailed information.

Working-Aged

When a person becomes entitled to Medicare at age 65, there is the possibility that he or she has health insurance through an employer group health account. It is important to know whether the policyholder (subscriber) is retired or actively working.

To determine who is primary, three questions need to be asked of the Medicare beneficiary who has a group health policy through Horizon BCBSNJ:

Are you or your spouse actively employed?
Are there 20 or more employees (regardless if full-time or part-time employees) where you or your spouse work?
Are you covered under that insurance policy?

If the answers to all three questions are YES, then the Horizon BCBSNJ group health policy would be primary to Medicare for the Medicare-eligible person.

Special Enrollment Period for Medicare Part B Benefits

A Medicare-eligible person may choose not to purchase Medicare Part B since it may not be necessary if the group is primary. When Medicare becomes primary, the subscriber may sign up for Medicare Part B benefits, with no increase in premiums. Coverage begins the first day of the month following the month the primary coverage ends. The person must sign up immediately upon becoming eligible once Medicare is primary, since the Medicare Part B benefits will only begin the first of the month that he/she signs up. This is called the Special Enrollment Period (SEP).

If an individual is entitled to Medicare because of age and is covered under the MSP provisions, he/she has the right to select Medicare as primary. If the person selects Medicare as primary, he/she must be dropped from his/her employer’s group health benefits with the exception of prescription drug and dental coverage. The employer may not subsidize a supplemental Medicare plan under these circumstances.

If Medicare is primary and the subscriber chooses not to purchase Medicare Part B benefits, we will never pay more than we would have if that individual had Medicare Part B benefits. In addition, this person would not be eligible for the SEP and would face increased premiums and be restricted when he/she signs up for Medicare Part B benefits.

AGE 65 or older and:

Medicare Beneficiary is ...	Medicare is Primary	Group is Primary
• Actively working for an employer with fewer than 20 employees.	X
• Actively working for an employer with 20 or more employees.		X
• Retired but have group coverage through your spouse who is actively working for an employer with fewer than 20 employees.	X
• Retired, but have group coverage through your spouse who is actively working for an employer with 20 or more employees.		X
• Retired, spouse retired.	X

Under age 65 years, on Medicare due to disability and:

Medicare Beneficiary is ...	Medicare is Primary	Group is Primary
• Actively working for an employer with fewer than 100 employees.	X
• Actively working for an employer with more than 100 employees.		X
• Not an active employee, but have group coverage through a family member who is actively working for an employer with fewer than 100 employees.		X
• Not an active employee, but have group coverage through a family member who is actively working for an employer with 100 or more employees.	X
• Not an active employee, but have group coverage through a family member who is not actively working.	X

Eligible for Medicare due to end-stage renal disease (ESRD) after March 1, 1996 regardless of age:

Medicare Beneficiary is ...	Medicare is Primary	Group is Primary
• Within the first 30 months of Medicare eligibility.*	X
• Beyond 30 months of Medicare eligibility.		X
• Medicare eligibility due to age or disability occurred prior to ESRD eligibility and Medicare was the primary payer due to other Medicare secondary payer rules.		X

If you need help understanding if Medicare or a group health plan is primary, call the CMS Benefits Coordination & Recovery Center (BCRC) at 1-855-798-2627.

* This does not apply if the member was Medicare-eligible due to age or disability prior to ESRD eligibility and the group health plan was primary due to other Medicare Secondary Payer rules. In this case, the group health plan would remain primary for the first 30 months of ESRD eligibility.

MEDICARE EXCEPTIONS

Medigap

MSP regulations only apply when the insurance coverage is through an employer. A Medicare supplemental policy, or Medigap policy, may be offered by an employer (if there are less than 20 employees or if the employee is not actively working) or it may be purchased on an individual basis; however, a Medicare supplemental policy will never be primary over Medicare.

Medicare Part A

If there are no Medicare Part A benefits, MSP regulations do not apply. Medicare Part A services are billed to the group health plan.

Individuals who have purchased Medicare Part A benefits are identified with an M at the end of the Medicare claim number on their Medicare ID card.

Disabled

Individuals entitled to Medicare due to disability must be under the age of 65, otherwise the working-aged provisions apply. You should ask the following questions to determine primacy:

Are you, your spouse or a family member actively employed?
Are there 100 or more employees (regardless if full-time or part-time) where you, your spouse or family member works?
Are you covered by that insurance policy?

The two important differences between the MSP working-aged and the disability provisions are:

Who the active employee is; and
The number of employees in the group.

Unlike the working-aged provisions, under the MSP disability provision, the Medicare-eligible individual may be covered by a family member other than his/her spouse. This typically occurs when a parent or legal guardian covers a disabled dependent – either child or adult.

Under the disability provisions, the employer must employ 100 or more employees. It is important to verify the number of employees because the patient may be part of a subgroup within a group, such as the New Jersey State Health Benefits Program (SHBP) and School Employees’ Health Benefits Program (SEHBP). There may be local municipalities with fewer than 100 employees, but the larger group has greater than 100 employees. The number of employees in the entire employer group is considered when making the determination of eligibility for Medicare due to disability.

Examples:

The patient is entitled to Medicare due to disability. He is not actively working, but his wife is and she has family health coverage through her employer, which has more than 100 employees. The patient would be primary under his wife’s group health policy since she is actively employed by an employer of 100 or more employees and her group health insurance covers him.
A patient is entitled to Medicare due to disability and is covered under his mother’s insurance. She is actively employed and has family group health coverage through the employer who employs more than 100 individuals. In this case, the son’s primary insurance is the mother’s group health insurance plan.
The patient is Medicare-eligible due to disability and is actively employed by a municipality that provides group health coverage. While she is no longer collecting Social Security disability payments, she still continues under the Medicare program. The municipality has only 35 employees but their health coverage is through the New Jersey State Health Benefits Program (SHBP) and School Employees’ Health Benefits Program (SEHBP), and the state employs more than 100 individuals. The group health insurance would be primary for the patient and Medicare would be secondary.
A local union may appear to employ fewer than 100 employees, however, the patient’s coverage is through the Health and Welfare Fund for all union members. If just one of the local unions that belong to that Health and Welfare Fund has 100 or more employees, then any local union covered by the Health and Welfare Funds health plan would be covered by the MSP regulations.

End-Stage Renal Disease (ESRD)

A person becomes Medicare-eligible due to ESRD when he or she begins a regular course of renal dialysis. There is a three-month waiting period to receive Medicare Part A and Part B benefits (unless an exception applies).

When a person is entitled to Medicare due to ESRD, the MSP regulations will apply when:

The patient has group health coverage of their own or through a family member (including spouse).
That group health coverage is through a current or former employer. When the Medicare beneficiary meets the above conditions, he/she is primary under the group health coverage for a specific period of time known as the Coordination of Benefit (COB) period. The COB period always begins on the first date of entitlement, and all medical services are covered by the group health coverage – not just renal services.

If the individual became entitled to Medicare due to ESRD, they have a 30-month COB period, beginning with the first date of entitlement.

Medicare was already paying primary for a Medicare-eligible individual due to attaining age 65 or disability because they did not fall under either the Working-Aged or Disability provisions.

Payment Summaries and Vouchers

horizonbcbsnj — Mon, 30 Dec 2019 11:35:15 +0000

Payment Summaries and Vouchers Mon, 12/30/2019 - 06:35

NASCO PAYMENT SUMMARY
We use the NASCO® Processing System (NPS) to adjudicate claims for customers enrolled in Horizon POS, FEP, Medigap plans, large national accounts and claims for customers enrolled in an out-of-state Blue Cross and/or Blue Shield Plan.

Information about claims processed on the NPS is communicated to you on a NASCO Payment Summary.

For information about the NPS or the NASCO Payment Summary, please call the Physician Services number indicated on the patient’s member ID card.

EXPLANATION OF PAYMENT
Horizon BCBSNJ’s Explanation of Payment helps you obtain the information you need quickly and easily in a simple-to-read format. It includes summary sections, a message center and the following:

A cover page that includes payment summary information.
Bolding of patient names to differentiate the patient from the subscriber.
A layout that simplifies navigation of the voucher.
Remark and reason code messages below the patient claim detail explaining any payments/nonpayments.

If you have questions, please call your Network Specialist or call Physician Services at 1-800-624-1110.

Payment Summary
This is a summary of the gross claim amount, late interest, account receivables (A/R) applied and the check amount. The check amount is the actual payment after consideration of the late interest and A/Rs applied.

Claim Detail
This section lists all claims sorted by product and patient. Claim detail includes remark and reason code messages directly below the patient claim detail providing further explanation. We provide detailed information regarding claims denials. For example, enhanced messages provide specific details about claims processed against an authorization where one or more of the following have been exceeded:

Days
Hours
Services
Units
Visits

The message will contain both the quantity authorized and also the units of measure of that quantity.

Account Receivable Summary
This section highlights all outstanding payments due to Horizon BCBSNJ, detailing the patients’ claim where the A/R was initiated and indicating any monies deducted from your reimbursement to satisfy the A/R. We have limited the number of times a single A/R will appear in the account receivable summary section of subsequent paper and online UPS vouchers. An A/R will only appear in the account receivable summary section when:

The A/R is initiated.
Monies are received from a physician and applied toward that A/R.
The A/R is activated (45 days after an A/R is initiated if monies have not already been received to satisfy it).
Claim reimbursements are applied toward the active A/R.
The A/R is completely satisfied.

Late Interest Summary
This area details the claims that require Horizon BCBSNJ to pay a late interest payment. The late interest payment will be added to the claim payment on this form.

BILLING HORIZON MYWAY PATIENTS

Horizon MyWay Visa®/Debit card
You should wait until you receive an Explanation of Payment (EOP) from Horizon BCBSNJ before billing patients for coinsurance and deductibles, since you may not know the correct amount to collect at the point of service. Your contract prohibits you from balance billing members.

Special Payment Options
To simplify payment to you, Horizon MyWay members with an HSA, HRA or FSA may have a Horizon MyWay Visa/debit card and/or personalized checks to pay for medical expenses not covered under their health plan. These will process like regular debit cards and checks.

Members can use the Visa/debit card or checkbook to pay copayments and other eligible medical expenses.

Members without a card can pay online or through the Horizon MyWay mobile app, which offers a range of tools to helps them manage their health spending and supplemental accounts.

HORIZON MYWAY HRA EXPLANATION OF PAYMENT
You may receive an additional Explanation of Payment (EOP) for Horizon MyWay HRA patients. This is in addition to the initial Horizon BCBSNJ EOP advising you of available funds in the member’s HRA. This explanation may include payment from that account and an explanation of the final member liability. See the following pages for a sample HRA EOP.

Review the following information to help you understand this statement.

Horizon Allowed – The amount that Horizon BCBSNJ originally allowed on the medical explanation of payment.

Horizon Medical Payment – The amount that Horizon BCBSNJ originally paid on the medical explanation of payment.

Customer Liability – The amount of customer liability that Horizon BCBSNJ originally indicated on the medical explanation of payment.

Approved Amount – The amount that will be drawn out of the member’s HRA account.

This Payment – The amount that will be factored into the total HRA check amount paid to the practice.

Patient Responsibility – The remaining customer liability after any payments from the member’s HRA.

Policies, Procedures and General Guidelines

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Policies, Procedures and General Guidelines Mon, 12/30/2019 - 06:33

This section contains information about the policies, procedures and guidelines you are required to follow as a participating physician or other health care professional. Failure to comply with any of the following policies and procedures may constitute a breach of your Agreement(s).

CONTRACTUAL LIMITS

All benefits are subject to contract limits and Horizon BCBSNJ’s policies and procedures, including, but not limited to, prior authorization and utilization management requirements.

LABORATORY SERVICES

You are required to refer Horizon BCBSNJ patients and/or send Horizon BCBSNJ patients’ testing samples to participating clinical laboratories. Failure to comply with this requirement may result in your termination from the Horizon BCBSNJ networks.

Horizon BCBSNJ’s Managed Care laboratory network includes Quest Diagnostics in addition to Laboratory Corporation of America® (LabCorp®). LabCorp and Quest provide national in-network clinical laboratory services for your Horizon BCBSNJ managed care patients (i.e., members enrolled in Horizon HMO, Horizon EPO, OMNIA Health Plans, Horizon Direct Access, Horizon POS or Horizon Medicare Advantage plans¹).

You may refer members enrolled in Horizon PPO and Indemnity plans (and/or send their testing samples to LabCorp, Quest Diagnostics and/or BioReference Laboratories, Inc., or to one of our other participating clinical laboratories or hospital outpatient laboratories at network hospitals). .

As a reminder, our networks include a number of participating laboratories that can provide a variety of specialized laboratory services. To view a full listing of our participating clinical laboratories, visit HorizonBlue.com/doctorfinder and:

Select Other Healthcare Services from the What are you looking for? menu.
Select Laboratory – Patient Centers or Laboratory – (Physician Access Only) under the Service Type dropdown menu and click Search.

You may refer a Horizon BCBSNJ patient who has out-of-network benefits (or send his or her testing sample) to a nonparticipating clinical laboratory, if that patient chooses to use his or her out-of-network benefits and you follow the guidelines in our Out-of-Network Referral Policy.

Pathology services provided in a hospital setting to members enrolled in Horizon BCBSNJ managed care plans by a practice that participates in the Horizon Managed Care Network are allowed as an exception to the above-described network use requirements.

You must agree that in-network laboratories are authorized to release the results of all laboratory tests performed for Horizon BCBSNJ members to Horizon BCBSNJ.

Note: Certain self-insured employer groups for whom we administer health care benefits have established special benefit arrangements that allow their enrolled members to use the nonparticipating clinical laboratory affiliated with each employer group as exceptions to the guidelines of our Out-of-Network Consent Policy. These special benefit arrangements apply ONLY to members/ dependents enrolled in these employer group plans.

ATLANTICARE CLINICAL LABORATORIES

Participating physicians and other health care professionals treating managed care members in southern NJ counties may also refer their Horizon BCBSNJ patients to Atlanticare Clinical Laboratories.

LabCorp maintains a collaborative relationship with AtlantiCare Clinical Laboratories that helps reduce members’ out-of-pocket costs. This arrangement applies to routine tests, as well as the most contemporary and sophisticated reference tests.

To learn more about locations:

Access the Online Doctor & Hospital Finder on HorizonBlue.com/doctorfinder.
Visit LabCorp.com or call 1-888-LabCorp(522-2677).
Visit AtlantiCare.org.

BioReference Laboratories Contact Information

For questions or service, or for specimen pickup, call BioReference Laboratories at 1-800-229-5227.

Quest Diagnostics Contact Information

For questions or service call Quest at 1-866-MYQUEST (697-8378).

LabCorp Contact Information

For questions or service, call LabCorp at 1-800-631-5250. For specimen pick-up, call LabCorp at 1-800-253-7059.

ELIGIBLE LABORATORY PROCEDURES

As a participating physician, you will only be reimbursed for performing certain laboratory services in your office.

You will not be reimbursed for, and may not collect charges from your patients for laboratory services performed in your office that are not included on the list below.

This list, organized by specialty, indicates the laboratory service procedure codes for which you will be reimbursed (in accordance with your specialty affiliation).

Specialist Codes

Dermatologist	87220
Endocrinologist	82947, 82948
Genetic Testing and Reproductive Health Solutions	81420
Hematologist/Oncologist	85025, 85027, 85032, 85041, 85044, 85045, 85046, 85048,
Infectious Disease	87205, 87220, 87210
Nephrologist	81000, 81001, 81002,
	81003
Ob/Gyn	87220, 87210, 81025,
	81000, 81001, 81002,
	81003
Reproductive	89300, 89310, 89320,
Endocrinologist	89329, 84144, 89330,
	83002, 82670, 83001,
	84702
Rheumatologist	85025, 85027, 85651,
	85652, 83872, 89060
Urologist	81000, 81001, 81002,
	81003, 87086, 87088,
	89300, 89320

IN-OFFICE RADIOLOGY SERVICES

As a participating physician, you will only be reimbursed for performing certain diagnostic-related radiology/imaging tests in your office.

Participating PCPs, specialists and other health care professionals will be reimbursed for only those exams that they are privileged to perform in an office setting.

A complete list of the radiology/imaging procedures that may be performed by certain specialties in an office setting is available on HorizonBlue.com/radiologyimaging.

For all other radiology services, please refer your Horizon BCBSNJ patients to a participating radiology center. You can find the names and locations of all participating radiology centers through our Online Doctor & Hospital Finder.

For Advanced Imaging Services, you must call eviCore healthcare for scheduling all prior authorization or medical necessity review at 1-866-496-6200.

PHARMACY SERVICES

As a participating physician or other health care professional, you should write prescriptions for prescription drugs listed as Preferred on the formulary prescription drug list for those Horizon BCBSNJ members who have prescription drug coverage, unless it would not be medically appropriate to do so.

The prescription Drug List includes at least one Preferred prescription drug within each drug category. The list was developed by the Pharmacy & Therapeutics Committee (P&T), which is comprised of New Jersey independent physicians and clinical pharmacists. The Horizon Prescription Drug List was developed through careful analysis of the medical literature on clinical effectiveness and secondarily based on cost effectiveness.

To review this list and other prescription drug lists, visit HorizonBlue.com/formulary.
Alternatively, e-prescribe technology allows physicians to review our drug formulary at the point of care, eliminating any uncertainties about which medications are preferred, require PA, or have other special requirements.

Our Medicare Advantage formularies can be found at HorizonBlue.com/medicare/formulary.

PHARMACY PRIOR AUTHORIZATION

Pharmacy Prior Authorization (PA) ensures appropriate utilization of certain drugs, promotes treatment protocols and generic drug utilization, actively manages prescription drugs with serious side effects and positively influences the process of managing prescription drug costs.

Prescription drugs that have medical utility for only a select group of patients require PA before coverage is approved. Specific guidelines, developed and approved by physicians and pharmacists, have to be met for certain drugs to be approved and covered under our prescription drug benefit plans. The P&T Committee establishes PA criteria after evaluating medical literature, physician opinion, and the U.S. Food and Drug Administration (FDA)-approved labeling information.

View the current list of prescription drugs requiring PA at HorizonBlue.com/priorauthorizations.

PA Program

Our PA program also helps us ensure that generic drugs are prescribed rather than brand name drugs, when medically appropriate.

You will need to submit a request for PA review (for certain prescriptions written for those Horizon BCBSNJ members whose benefit plans require PA for prescription drugs) when you prescribe:

A brand name drug when a direct generic equivalent is available.
A non-Preferred brand.

To minimize the number of PA requests you receive, please ensure that, whenever medically appropriate, your Horizon BCBSNJ patients are prescribed generic or Preferred brand drugs.

We encourage prescribers to use our online drug authorization process to submit a PA request. The drug authorization process is free and easy to use. Simply register at NaviNet.net/HorizonPA. The Drug Authorization tool can be found by accessing the Horizon BCBSNJ page within the My Health Plans menu. Then select Drug Authorizations.

PRESCRIPTION DRUG DISPENSING LIMITATIONS

Certain prescription drugs have specific dispensing limitations for quantity, age, gender and maximum dose. To arrive at these quantity or safety limits, Horizon BCBSNJ follows recommendations by the FDA, coupled with our analysis of prescription drug dispensing trends and standard clinical guidelines. These dispensing limitations are drug-specific and are designed to provide a safe and effective amount of prescription drug to the member.

MEDICATION THERAPY MANAGEMENT PROGRAM

As part of our commitment to provide physicians with important information to support appropriate drug therapy, we offer our Medication Therapy Management (MTM) program.

Through the MTM program, we identify patients enrolled in our Medicare Advantage with Prescription Drug and Medicare Part D plans who may be at risk for medical or drug adverse events. We then work with you and your patients to reduce that risk.

The MTM program encourages these members to use prescription drugs according to national clinical guidelines and to take their prescription drugs appropriately and in accordance with their physicians’ instructions.

MTM Participant Identification

Members are identified for participation in the MTM program from prescription claims history as outlined by CMS. Eligible members who meet all three of the following criteria are automatically enrolled* in the program. Members:

Must have two or more chronic diseases.
Must take five or more covered Medicare Part D drugs per month.
Must incur at least $3,000 annually or at least $750 per quarter in covered Medicare Part D drug expenses.

The MTM program includes regular communications to members and physicians.
Members may opt-out of the program at any time by calling the Member Services number on the back of their ID card.

MTM Program Activities

Horizon Healthcare of New Jersey, Inc. pharmacists conduct routine medication profile reviews. When a medication concern is treat the same condition; excessive dosing of medications; drug-to-drug interactions), the pharmacist will contact your office.

Depending on the medication concern identified, the pharmacist may also contact the member to address the issue.

• Each member who participates in the MTM program will be offered an annual Comprehensive Medical Review (CMR) by a pharmacist via mail and/or phone. The CMR assesses medication therapies and helps to optimize patient outcomes by reviewing all medications being taken by the member, including prescription drugs, over-the-counter medications, herbal therapies and dietary supplements. A written summary of the CMR discussion will be provided to the member and may be sent to his/her physician(s) for review as needed.

• All Medicare Advantage with Prescription Drug coverage and Medicare Part D members enrolled with us will also receive a quarterly newsletter, Healthy Horizons. This newsletter provides information and resources to help members maximize their health. It includes updates on the latest prescription drug treatments, reminders about the importance of taking prescription drugs appropriately and lifestyle tips to help individuals with certain medical conditions better manage their health.

The success of the MTM program is measured through the acceptance of the recommended interventions, as well as by clinical outcomes such as reductions in hospitalization or Emergency Room visits, or reduced number of physician encounters. The MTM program complements and coordinates with the Chronic Care Program in which your patients may already be enrolled.

For additional information, contact your Network Specialist.

SPECIALTY PHARMACY

The Horizon BCBSNJ Specialty Pharmaceutical Program can help you obtain office-based and administered specialty medications from a contracted specialty pharmacy provider that will directly supply your office, at your convenience.

When you participate in this voluntary program, you’ll obtain specialty pharmaceuticals directly from a specialty pharmacy. Under this program, your office should not submit claims for specialty medications when obtained from our specialty pharmacy providers. These selected providers will bill Horizon BCBSNJ directly for the cost of the medication.

To access information about the Specialty Pharmaceutical Program for therapies, or for information about the Specialty Pharmacy Program for self-administered therapies obtained by members through their pharmacy benefit, visit HorizonBlue.com/specialtyrx.

Specialty pharmacy claims for office-based therapies must be sent to the Blue Plan in the service area where the ordering physician is located. The claim will process according to the pharmacy’s relationship with that Blue Plan.

For example, if the ordering physician is located in New Jersey, send the claim to Horizon BCBSNJ and the claim will process according to the pharmacy’s participating status with Horizon BCBSNJ.

However, if the ordering physician is located in Pennsylvania, the claim must be sent to the Blue Plan in Pennsylvania and will process according to the pharmacy’s contractual relationship with the Pennsylvania Blue Plan and consistent with the member’s Home Plan benefits.

MEDICAL NECESSITY DETERMINATIONS FOR INJECTABLE MEDICATIONS

To help ensure that our members receive the appropriate and medically necessary care regarding the use of certain intravenous immunoglobulin (IVIG), oncology and rheumatoid arthritis injectable medications, Horizon BCBSNJ instituted a Medical Injectables Program (MIP) in collaboration with Magellan Rx Management, a specialty pharmaceutical management company.

Physicians must obtain a Medical Necessity and Appropriateness Review (MNAR) prior to administering certain injectable medications to avoid a delay or denial of claims pending receipt of information needed to determine medical necessity. As a participating physician, you may not balance bill the member for denied or pended claims that result from your noncompliance with our MIP.

HOME INFUSION MEDICAL INJECTABLE DRUGS

Magellan Rx Management and CareCentrix will have shared responsibilities for home infusion medical injectable drugs when performed by participating Horizon Care@Home ancillary services providers.

INJECTABLE MEDICATION FEE INFORMATION

Injectable Medication Fee Schedule information is available online. Registered NaviNet users should:

Log on to NaviNet.net and select Horizon BCBSNJ from the My Health Plans menu.
Mouse over Claim Management and select Fee Schedule Inquiry.
On the Fee Schedule Inquiry page, select your Billing (Tax) ID number, County and Specialty.
Enter the specific CPT and/or HCPCS codes for that specialty and view our allowances for those specific services.

Horizon BCBSNJ updates our Injectable Medication Fee Schedule information on a quarterly basis.

Revised information will be available on HorizonBlue.com/mip following the implementation of each quarterly update.

BEHAVIORAL HEALTH AND SUBSTANCE USE DISORDER CARE

Check your patient’s ID card for the name and phone number of the behavioral health and substance misuse care administrator that administers benefits for your patient. Whether it is an emergency or a request for inpatient or outpatient services, either you or the member should call the appropriate behavioral health care administrator. With few exceptions, Horizon BCBSNJ contracts with Beacon Health Options to administer our members’ behavioral health and substance use disorder benefits.

You may call Horizon Behavioral Health at 1-800-626-2212 to refer most patients for behavioral health or substance use disorder care. A referral is not required if services are approved by Horizon Behavioral Health. If Horizon Behavioral Health does not administer your patient’s behavioral health and substance use disorder benefits, please contact the behavioral health and substance use disorder administrator listed on the back of your patient’s ID card.

AUDIOLOGY AND HEARING AID BENEFITS

Audiology Distribution, LLC, doing business as HearUSA, works with Horizon BCBSNJ to administer hearing benefits and provide related products and services through their network of independently practicing audiologists, hearing care professionals and company-owned HEARx Centers.

Horizon BCBSNJ works with HearUSA and their HEARx Centers to provide audiology services, hearing aids and discounts on certain services to our enrolled members. The following information outlines the role that HearUSA plays in various member benefits.

The benefit information provided is not a guarantee of reimbursement. Claim reimbursement is subject to member eligibility, and all member and group benefit limitations, conditions and exclusions. Confirm member audiology benefits and hearing aid benefit amounts before providing services.

Members enrolled in Horizon Medicare Advantage plans that include audiology/hearing benefits* receive audiology/hearing aid benefits through HearUSA as follows:

In-network routine hearing services (including annual routine hearing exam, hearing aids that are medically necessary, hearing aid batteries, and/or the evaluation for fitting hearing aids) must be coordinated through HearUSA.

Members must call HearUSA at 1-800-442-8231 to schedule all in-network routine hearing services.

Members enrolled in Horizon Medicare Advantage plans that do not include out-of- network benefits have no benefits for routine hearing services that are not coordinated through HearUSA.
Those members enrolled in Horizon Medicare Advantage plans that include out-of-network benefits who choose to use their out-of-network benefits (understanding that they will incur more cost sharing responsibility) may obtain an annual routine hearing exam from a non-HearUSA provider without first calling HearUSA.

These members have no similar OON benefits for hearing aids that are medically necessary, hearing aid batteries, and/or the evaluation for fitting hearing aids. These services must be coordinated through HearUSA.

*Members enrolled in Horizon Medicare Blue (PPO) or Horizon Medicare Blue Group (PPO) plans have no benefits for routine hearing exams and/or hearing aids.

Members enrolled in any other Horizon BCBSNJ managed care plan (Horizon HMO, Horizon Direct Access, Horizon EPO, Horizon POS, etc.) may receive audiology/hearing aid benefits through HearUSA as follows:

Though not required, these members may choose to use HearUSA or any other participating Horizon Managed Care Network audiologist on an in-network basis.
Please note that benefits for audiology and hearing aids for members enrolled in other Horizon BCBSNJ managed care plans may vary. Please confirm member benefits before providing services.

Members enrolled in any other Horizon BCBSNJ plan may receive audiology/hearing aid benefits through HearUSA as follows:

Any enrolled Horizon BCBSNJ member is entitled to receive a 15 percent discount on the cost of a hearing aid purchased from HearUSA.

Use our Online Doctor & Hospital Finder to locate a HEARx Center. Visit HorizonBlue.com/doctorfinder and:

Select Other Healthcare Services in the What are you looking for? menu.
Choose the member’s plan.
Select Audiology within the Service Type menu.
Enter a ZIP Code or City, State,County.
Click Search.

VISION CARE

Most members are eligible for one routine eye examination per year with a participating optometrist or ophthalmologist. These services do not require a referral from a PCP for those managed care plans that require referrals.

PCP referrals for those plans that require referrals must be obtained for any follow-up treatment for problems detected during an annual exam. Follow-up treatment or visits for eye disorders must be managed and referred by the PCP.

The routine vision examination covered for children through age 17 years is a vision screening by a pediatrician only. Coverage for refractive services (92015) varies from plan to plan. Call Physician Services at 1-800-624-1110 to verify coverage.

MAMMOGRAPHY BENEFITS

New Jersey health plans must provide coverage of mammograms at specified intervals for women based on age and/or medical necessity. Existing coverage for female members includes:

One baseline mammogram examination for women who are at least 35 years of age.
A mammogram examination every year for women age 40 and over.
A mammogram examination at ages and intervals deemed medically necessary by a woman's doctor in the case of a woman who is under 40 years of age and has a family history of breast cancer or other breast cancer risk factors.

Expanded coverage for female members now includes:

An ultrasound evaluation, a magnetic resonance imaging (MRI) scan, a three-dimensional (3D) mammography and other additional testing of an entire breast or breasts, after a baseline mammogram examination, if:
- The mammogram demonstrates extremely dense breast tissue;
- The mammogram is abnormal within any degree of breast density including not dense, moderately dense, heterogeneously dense or extremely dense breast tissue; or if
- The patient has additional risk factors for breast cancer, including but not limited to, family history of breast cancer, prior personal history of breast cancer, positive genetic testing, extremely dense breast tissue based on the Breast Imaging

Reporting and Data System established by the American College of Radiology or other indications as determined by the patient's doctor.

Note: The coverage required for an ultrasound evaluation, MRI scan, 3D mammography or other additional testing may be subject to utilization review, including periodic review of the medical necessity of the additional screening and diagnostic testing.

Expanded coverage may not be available to members enrolled in Administrative Services Only (ASO) health insurance plans that have opted not to adopt the New Jersey breast cancer screening mandate.

OB/GYN SERVICES

Female members can go directly to a participating Ob/Gyn for treatment of routine gynecological and obstetrical conditions without a referral from their PCP. However, prior authorization is still required for certain services.

Routine gynecological and obstetrical conditions do not include infertility-related services. Members who have infertility benefits must access those benefits in accordance with their contracts.

Participating obstetricians may directly provide or refer* members to participating physicians and other health care professionals for the following services when these services are medically necessary (and authorized as appropriate):

Home uterine monitoring.
Elective hysterectomies.
Fetal non-stress tests (authorization required after the first three).
Terbutaline pump.
All pregnancy ultrasounds (Medical Necessity Determination after the first two).

Certain professional services and all hospital activity needed during the pregnancy (except outpatient radiology and same-day surgeries) must receive prior authorization.

* The Ob/Gyn may not refer to another specialist if the subsequent visit is not Ob-related.

INFERTILITY SERVICES

Physicians and other health care professionals must notify Horizon BCBSNJ and obtain approval for certain infertility treatments. This applies to Horizon HMO, Horizon POS and Horizon Direct Access plans. It is your responsibility to obtain this approval where required.

For additional information, call Physician Services at 1-800-624-1110.

OUT-OF-NETWORK REFERRAL POLICY AND PROCEDURE

Horizon BCBSNJ’s Out-of-Network Referral Policy* encourages our members to use participating physicians, other health care professionals and facilities, and helps ensure that our members fully understand the increased out-of-pocket expense they will incur for out-of-network care.

* The Out-of-Network Referral Policy does not apply to members enrolled in plans that do not include out-of-network benefits [e.g., Horizon HMO, Horizon EPO, OMNIA Health Plans, Horizon Medicare Blue Value (HMO) etc.].

Our Out-of-Network Referral Policy applies to referrals made to any nonparticipating physician, other health care professional or facility (including clinical laboratories and ambulatory surgery centers). All physicians and other health care professionals who participate in our managed care and/or PPO networks are required to adhere to our Out-of-Network Referral Policy.

Horizon BCBSNJ expects participating physicians and other health care professionals to ensure that, whenever possible, their Horizon BCBSNJ patients and patients enrolled through other Blue Cross and/or Blue Shield Plans are referred to participating physicians, other health care professionals or facilities unless the member wishes to use his or her out-of-network benefits and understands that higher out-of-pocket expenses will be incurred.

Participating physicians and other health care professionals should contact us for authorization if they believe that the necessary expertise does not exist within our network or that there is no available participating physician, other health care professional or facility to provide services to the member. If Horizon BCBSNJ agrees that a participating physician, other health care professional or facility is not available, the member’s in-network coverage will apply to the out-of-network referral.

Prior to referring a Horizon BCBSNJ member for out-of-network services, participating physicians and other health care professionals are required to do the following:

Advise the member of the nonparticipating status of the physician, other health care professional or facility, the out-of-network benefit level that will apply to those services and the member’s responsibility for increased out-of-pocket expenses (including deductible, coinsurance and any amount that exceeds the plan’s allowance).
Advise the member of a participating physician, other health care professional or facility that could provide the same services, unless one does not exist within our network.
Advise of any financial interest in, or compensation made by, the nonparticipating physician, other health care professional or facility.
Complete an Out-of-Network Consent Form (2180), signed and dated by the member, and retain that document as part of the patient’s medical record. In the event of an audit, this form must be provided within 10 business days.

Note: You must obtain the appropriate approval from Horizon BCBSNJ for those services that require prior authorization.

To access our Out-of-Network Referral Policy, registered NaviNet users should log on to NaviNet.net, select 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. If you are not registered with NaviNet, visit NaviNet.net and select Sign up.

To access our Out-of-Network Consent Form, visit HorizonBlue.com/consent.

Contact your Network Specialist if you have questions.

When out-of-network claims are received, the participating ordering and/or rendering physician or other health care professional is contacted via letter and asked to provide us with a copy of the member’s signed Out-of-Network Consent Form (2180). Specialists are not to balance bill members for any administrative charges related to the Out-of-Network Consent Form (2180).

If a signed form is not provided within 10 business days or if a participating physician otherwise fails to abide by our policy, he or she may be subject to loss or restriction of network participation and/or termination.

Horizon BCBSNJ reserves the right to audit a participating physician and other health care professionals medical records pertaining to, but not limited to, the member’s signed Out-of-Network Consent Form (2180) as well as claims to out-of-network facilities.

If you require an assistant surgeon to participate in surgical services rendered to a Horizon BCBSNJ member, please verify that the assistant surgeon participates in the appropriate Horizon BCBSNJ network/plan according to that member’s benefits.

If you are planning to use a nonparticipating assistant surgeon (for a member who has and wishes to use his/her out-of-network benefits), you must first:

Advise the member of the nonparticipating status of the assistant surgeon, the out-of-network benefit level that will apply to those services and the member’s responsibility for increased out-of-pocket expenses.
Complete an Out-of-Network Consent Form (2180) (signed and dated by the member) and retain that document as part of the patient’s medical record. In the event of an audit, this form must be provided within 10 business days.

All participating physicians and health care professionals are required to follow our Out-of-Network Consent Policy to help ensure that members fully understand the increased out-of-pocket expense they will incur for out-of-network care.

You must obtain the appropriate approval from Horizon BCBSNJ for services that require prior authorization.

REIMBURSEMENT FOR ASSISTANTS AT SURGERY SERVICES

We do not reimburse for assistants at surgery in surgical procedures if use of an assistant at surgery is not established as medically necessary and appropriate for that procedure.

To avoid misunderstandings regarding reimbursement of assistants at surgery, we encourage you to check on reimbursable procedures in advance by reviewing our medical policy for Assistants at Surgery. Review the information in our Medical Policy Manual at HorizonBlue.com/medicalpolicy.

You are responsible for ensuring that assistants at surgery (where medically necessary) are participating. If a nonparticipating assistant at surgery is used, unless Horizon BCBSNJ has authorized the use of that nonparticipating assistant at surgery, then Horizon BCBSNJ will consider you responsible for the difference between the participating and nonparticipating rates and for ensuring that the member is not balanced billed over and above our allowed amount.

HOSPITAL AND OTHER INPATIENT CARE

To maximize their benefits, members should use network hospitals or facilities (e.g., residential treatment centers or skilled nursing facilities).

Inpatient care will be provided in semi-private accommodations.

When medically necessary, members can be referred to a nonparticipating facility if their need for medical treatment cannot be accommodated through our Horizon Hospital Network. Such referrals must be made to fully licensed, accredited facilities and must be authorized by Horizon BCBSNJ if treatment is to be covered for plans with no out-of-network benefits, or covered at an in-network level for plans that do have out-of-network benefits.

You must obtain authorization for all elective inpatient stays. An authorization number must be given to the member to present to the facility upon admission. Facility authorizations cover all inpatient services, including preadmission testing, anesthesia, laboratory, pharmacy and other specialty services related to the admission.

In emergency situations, you must notify us at 1-800-664-BLUE (2583).

INPATIENT TRANSFER FROM A NONPARTICIPATING HOSPITAL TO A PARTICIPATING HOSPITAL

Members emergently admitted to a nonparticipating hospital will be transferred to a participating hospital as soon as they are medically stable. In the case of surgical admissions, burn unit patients, critically ill neonates or cases where child delivery has already taken place, no immediate transfer will be initiated.

Transferring members to network hospitals help us to ensure that our members are not exposed to the high out-of-pocket expense associated with out-of-network care. It also allows participating physicians, familiar with the patient, to be involved in their care while in the hospital.

If one of your patients is admitted to a nonparticipating hospital, contact us immediately. One of our Concurrent Review Nurse Coordinators (CRNC) will assist in transferring the patient to a participating hospital.

The CRNC will contact the:

Utilization review department of the nonparticipating hospital.
Attending physician at the nonparticipating hospital.
Member’s primary physician and encourage regular contact between the primary physician and the attending physician.

If the member is ready for transfer, the CRNC will:

Provide the primary physician with a list of participating specialists at the receiving hospital.
Contact the member and explain the reason for the transfer.
Contact the nonparticipating hospital’s social worker.
Arrange for ambulance transport to the receiving hospital.

The attending physician and primary physician must maintain regular contact to determine the status of the patient and to follow the procedures for transfer, which include:

Contacting the receiving hospital and arranging for admission.
Arranging for an attending physician at the receiving hospital (if the primary physician will not be the attending physician).

Note: If the patient is not stable for transfer, the primary physician and/or the attending physician must advise the CRNC of the medical necessity for the transfer not to occur.

REFERRING TO NONPARTICIPATING PHYSICIANS AND OTHER HEALTH CARE PROFESSIONALS

On rare occasions, you may need to refer a patient to a nonparticipating physician. Doing so requires authorization for members enrolled in Horizon BCBSNJ plans with no out-of-network benefits and for members enrolled in Horizon POS plans, if benefits are to be accessed on an in-network basis. These requests are handled on an individual basis and require medical review.

Access our Online Doctor & Hospital Finder at HorizonBlue.com/doctorfinder for information about the participation status of specific physicians or other health care professionals.

COPAYMENTS AND ALLOWED AMOUNTS

Copayment amounts vary from plan to plan. It is possible that a member’s copayment may be greater than our allowance for the services provided.

You are permitted to collect the copayment indicated on the member’s ID card at the time of service, but if our allowed amount for the service you provided (indicated on your EOP) is less than the copayment amount collected, you may need to refund the difference to the member.

COPAYMENT COLLECTION

Participating physicians and other health care professionals may collect applicable office visit copayments at the time of service.

However, in certain situations, the office visit copayment listed on a Horizon BCBSNJ member ID card should not be collected at the time of service.

When a Patient Does Not See a Health Care Professional

When a patient enters the office but does not see a physician, specialty care physician or other health care professional, the copayment should not be collected. Examples of these visits include, but are not limited to, allergy injections, blood pressure and weight checks.

Patients Enrolled in Consumer-Directed Healthcare (CDH) High-deductible Plans

High-deductible health insurance plans offered in conjunction with a Health Savings Account (HSA) are required to apply all services, excluding preventive care services, toward the plan’s deductible. The high-deductible health insurance plans we offer to employer groups for use in conjunction with Health Reimbursement Arrangements (HRAs) follow this same plan design.

Office visit copayments for members enrolled in CDH plans only apply after a patient’s deductible has been satisfied.

Please submit your claims and wait until you receive our Explanation of Payment (EOP) and CDH EOP (for those members enrolled in HRA plans) before billing the member for any amount, including office visit copayments.

Copayments and Dual Eligible Patients

Patients enrolled in any Horizon BCBSNJ plan who have secondary coverage through Horizon NJ Health (New Jersey Medicaid benefits) are not responsible, and should not be billed, for any copayment or coinsurance amounts under their primary coverage.

Participating physicians and other health care professionals agree not to bill or seek to collect any copayment or coinsurance from any such person, but to seek payment from Horizon NJ Health for any remaining balances.

Patients Enrolled in Plans Without Copayments Some Horizon BCBSNJ plans do not include a member copayment. If the member ID card does not indicate a copayment, please do not collect any amount from the patient at the time of service.

COPAYMENTS AND PREVENTIVE CARE SERVICES

As mandated by the ACA, most health insurance plans allow members to receive preventive care services without copayments or other cost sharing. This means that preventive services, including screenings, checkups and counseling, are covered with no out-of-pocket costs if the member sees an in-network health care professional and receives only preventive care services during the visit. Please do not collect preventive care copayments from your Horizon BCBSNJ patients.

However, based upon the services that are provided during the course of a scheduled preventive visit, it may be appropriate for you to collect a nonpreventive copayment from a Horizon BCBSNJ member. We encourage you, in such circumstances, to discuss with your patients the nonpreventive treatment/services that they received.

Note: The ACA allows group health plans offering custom benefits to opt to retain a copayment for preventive care services.

For more information about preventive services, visit HealthCare.gov.

MAKING ARRANGEMENTS FOR THE PAYMENT OF DEDUCTIBLE LIABILITY AT THE TIME OF SERVICE

Although we prefer that participating practices submit claims and wait for our Explanation of Payment (EOP) prior to collecting any member liability amounts other than copayments, we understand the challenges that participating practices are facing in regard to the collection of amounts that are applied toward deductibles.

Participating practices are no longer prohibited from making arrangements with members for the payment of amounts that will be applied toward deductibles.

Participating practices may choose to establish a “time-of-service” payment arrangement policy for the collection of amounts that will be applied to member deductibles.

Participating practices may NOT seek amounts that will be applied to member deductibles at the time of service from:

Members enrolled in Horizon Medicare Advantage plans.
Members enrolled in high-deductible health insurance plans that work in conjunction with an employer-sponsored Health Reimbursement Arrangement (HRA).

Participating practices may NOT seek any projected coinsurance amounts at the time of service from members. Participating practices are required to submit claims and wait for our Explanation of Payment (EOP) prior to collecting coinsurance amounts.

Guidelines for Practices

Participating practices that choose to implement a “time-of-service” collection policy must comply with the following guidelines:

In no case shall treatment be refused to a Horizon BCBSNJ member if he or she is not able to pay a requested amount at the time of service.
Practices may make arrangements for the payment of an amount that is determined to be accurate with reasonable certainty based on:
- Our allowance for the service(s) provided.
- Your validation of the members’ estimated deductible liability.

Please keep in mind 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.

Practices should work with members to establish fair and appropriate payment plan options and to take certain circumstances into consideration when establishing those payment arrangements (for example, members who may visit multiple doctors and/or health care professionals on a single day, or members who may bring multiple dependents for services on the same day).

In the event that an amount collected by a participating practice needs to be refunded to a member, we expect that refund to occur no later than 30 days after a member overpayment is identified.

Non-Waiver of Member Liability

Participating physicians, other health care professionals and practices shall not waive any appropriately applied member liability (including copayments, coinsurance or deductible amounts, as well as other amounts associated with exclusions or limitations contained within a covered person’s health benefit plan).

PROFESSIONAL RESPONSIBILITY

Physicians and other health care professionals should not recommend any treatment they feel is unacceptable.

You have sole responsibility for the quality and type of health care service you provide to your patients. You should refer patients to other physicians and health care professionals as medically appropriate and medically indicated.

You are free to communicate openly with a member about all appropriate diagnostic testing and treatment options, including alternative medications, regardless of benefit coverage limitation.

CREDENTIALING AND RECREDENTIALING OBLIGATIONS

You are required to comply with the standards of participation identified in the Horizon BCBSNJ’s Credentialing and Recredentialing Policy for Participating Physicians and Health Care Professionals.

We strongly encourage you to review this policy at HorizonBlue.com/credentials.

Participating physicians and other health care professionals are required to report any changes in their credentialing information, including, for example, any disciplinary action by the applicable licensing authority, any criminal conviction and the pendency of any investigation for matters related to their professional practice.

Physicians and other health care professionals who fail, at any time, to meet any of the standards, as determined by our Credentialing Committee, are subject to loss or restriction of network participation and termination of their Agreement.

Participating physicians and other health care professionals are subject to loss or restriction of network participation and termination of their contract if (among other circumstances):

They are subject to disciplinary action, including, but not limited to, voluntarily and involuntarily submission to censure, reprimand, nonroutine supervision, nonroutine admissions review, monitoring or remedial education or training;
Their license, accreditation or certification is restricted, conditioned, reclassified, suspended or revoked, whether active or stayed, and whether by the applicable authority, or any federal or state agency, or any hospital, managed care organization or similar entity;
They are the subject of an investigation for matters related to their professional practice; or
They are convicted of a criminal offense.

CREDENTIALING DOCTORS AND OTHER HEALTH CARE PROFESSIONALS

To access information we require to add doctors or other health care professionals to an existing practice visit HorizonBlue.com/whyjoin.

This page includes our Requirements for Physicians and our Requirements for Other Health Care Professionals. These documents provide instructions and access to all the necessary forms and information we require to complete initial credentialing of a doctor or other health care professional in either our Horizon Managed Care Network or our Horizon PPO Network.

Dual Credentialing

Horizon BCBSNJ does not credential doctors or other health care professionals in more than one specialty.

Recredentialing Process

As required by New Jersey state guidelines and accreditation bodies, all health care professionals must be recredentialed every 36 months. Our recredentialing process begins approximately six months prior to the recredentialing date.

Physicians and other health care professionals who fail to provide the necessary information in a timely manner are subject to termination of their Agreement(s).

Standards for participation may be reviewed online in our Horizon BCBSNJ Credentialing and Recredentialing Policy for Participating Physicians and Health Care Professionals.

We work with Medversant, a leader in technology solutions for the management of health care provider information, to help us carry out our recredentialing process, broadly outlined as follows:

Six months prior to your recredentialing due date, Medversant begins the recredentialing process by searching for current information on the Council for Affordable Quality Healthcare’s (CAQH) online data-collection service ProViewTM. If your information is up to date on ProView, the recredentialing process will continue.
If information is either not on CAQH ProView, or not updated on CAQH ProView, Medversant will reach out to you by phone, fax and mail to request that you provide updated and/or missing information.
If Medversant does not receive a response, Horizon BCBSNJ will mail two requests to your office. Horizon BCBSNJ’s first letter will be mailed 60 days before the recredentialing cycle ends. The final request will be sent via certified mail, 30 days before the recredentialing cycle ends.
If Medversant does not receive a response from these attempts, you will be terminated from Horizon BCBSNJ’s networks at the end of that month. No additional requests will be sent and no information will be accepted after the first of that month.

If you have questions, call Medversant at1-800-508-5799.

Recredentialing Vehicles

There are two ways to carry out your recredentialing responsibilities with Horizon BCBSNJ:

CAQH ProView.
New Jersey Universal Recredentialing Application Form.

CAQH ProView

We encourage you to use ProView to carry out your credentialing and recredentialing responsibilities with us.

Visit caqh.org and click CAQH ProView to access this valuable resource.

If you’re already registered with CAQH:

Review and/or update your information.
Re-attest that your information is true, accurate and complete.

If you’re not registered with CAQH:

Visit ProView.caqh.org/pr to self-register with CAQH. Upon completion of the self-registration process, you will receive a CAQH welcome email with your unique CAQH Provider ID number.
Visit caqh.org, mouse over CAQH Proview and select Log In.
Complete an online application (ensure that you select Horizon BCBSNJ so that we can access your information) and then attest that the information provided is true, accurate and complete.

New Jersey Universal Recredentialing Application Form

If you are unable to use CAQH ProView, complete a copy of the NJ Physician Recredentialing Application Form available on the New Jersey Department of Banking and Insurance website at state.nj.us/dobi/.htm.

Print copy recredentialing information and required source documents may be submitted to Medversant at:

Medversant

355 S. Grand Ave,

Suite 1700

Los Angeles, CA 90071

You may also submit information to Medversant by fax at 1-877-303-4080 or by email at HorizonApp@medversant.com.

Recredentialing Tips

To ensure that the recredentialing process runs smoothly for you, confirm that:

All questions are answered.
All information and required source documents are current and included (for example, your proof of malpractice insurance – the item most frequently missing or expired, your federal Drug Enforcement Agency [DEA] certificate, your Controlled Dangerous Substance [CDS] certificate, etc.).
Information on the application matches the information on your source documents.
Your Attestation has not expired.

NETWORK PARTICIPATION AND MEDICARE PARTICIPATION

Horizon BCBSNJ’s Credentialing Department reviews the Centers for Medicare & Medicaid Services (CMS) Opt Out List on a quarterly basis.

Horizon Managed Care Network

As stated in our Credentialing and Recredentialing Policy for Participating Physicians and Health Care Professionals, “Physicians and health care professionals who have opted out of Medicare may not participate in the Horizon Managed Care Network.” Physicians or health care professionals who have opted out of (or have been excluded from) Medicare will be terminated from the Horizon Managed Care Network.

Horizon PPO Network

Physicians or health care professionals who have opted out of Medicare may continue to participate in our Horizon PPO Network. However, these practitioners are not eligible to receive reimbursement for services rendered to patients enrolled in one of our Medicare Advantage plans that include out-of-network benefits¹(except for emergency or urgent care services).

Continued Horizon PPO Network participation of physicians or health care professionals who have been excluded from Medicare is contingent upon the decision of our Credentialing Committee

1 The Horizon BCBSNJ Medicare Advantage plans that offer out-of- network benefits are: Horizon Medicare Access Group (HMO- POS), Horizon Medicare Blue Access Group w/Rx (HMO POS), Horizon Medicare Blue (PPO), Horizon Medicare Blue Group (PPO) and Horizon Medicare Blue Group w/Rx (PPO).

Note: The credentialing and recredentialing process for behavioral health providers is administered by Beacon Health Options and varies slightly from the above information. Refer to the Beacon Health Options Resource Manual for more information.

PROVIDER DIRECTORY MANAGEMENT POLICY

It’s critical that the provider file information we maintain and display is accurate and up-to-date as this information is used to populate our Doctor & Hospital Finder. Inaccurate or outdated information may result in a misrepresentation of your practice to patients and referring physicians or other health care professionals searching our Online Doctor & Hospital Finder.

Horizon BCBSNJ’s Provider Directory Management administrative policy addresses situations in which we are unable to validate whether information included within our provider files is current and accurate.

Our Provider Directory Management administrative policy outlines the process Horizon BCBSNJ staff and business partners acting on our behalf will take as they work to ensure that the information within our provider files is correct. This revised policy also outlines actions that will be taken in regard to provider directory inclusion and continued participation of practice location(s) and/or practitioners whose information we are unable to validate.

Based on the guidelines within our Provider Directory Management administrative policy:

Horizon BCBSNJ validates practitioner information every 90 days through outreach efforts conducted by our business partners, CAQH and Atlas Systems. These outreach efforts seek to validate that the information we have on file is accurate. Our business partners will pursue their outreach for a period of 90 days.
If the initial outreach efforts of our business partner(s) are not successful, Horizon BCBSNJ staff will conduct a secondary 90-day outreach effort to validate that the information we have on file is accurate. While this secondary outreach is conducted, the information pertaining to practitioners in question will be suppressed from appearing within our Online Doctor and Hospital Finder.
If, at the end of this second 90-day period, we are unable to validate that the information we have on file is accurate, the practice location(s) and/or practitioner in question will be terminated from all Horizon BCBSNJ networks.

We encourage you to review our Provider Directory Management administrative policy online.

To access this information, registered NaviNet users may sign in to NaviNet.net, select Horizon BCBSNJ from the My Health Plans menu and:

Mouse over References and Resources and click Provider Reference Materials.
Mouse over Policies & Procedures and click Policies.
Click Administrative Policies.
Click Provider Directory Management.

PRODUCTS THAT UTILIZE TIERING AND/OR

A SUBSET OF AN EXISTING HORIZON BCBSNJ NETWORK

Horizon BCBSNJ has revised our policy that outlines our process for selecting physicians and other health care professionals who will be included for participation in one or more of the products that utilize tiering and/or a subset of an existing Horizon BCBSNJ Network.

This policy applies to all physicians and health care professionals participating in the Horizon BCBSNJ Network for care rendered to members enrolled in one of the products that utilize tiering and/or a subset of an existing Horizon BCBSNJ Network.

We strongly encourage all participating physicians and other health care professionals to review this policy by visiting HorizonBlue.com/adminpolicy and selecting Participation Status in Products that Utilize Tiering and/or a Subset of an Existing Horizon Network.

MEMBERS WITHOUT PROPER ID CARDS

If a member is unable to present an ID card at the time of service, there are several ways to verify eligibility:

If you are a registered NaviNet user, you may check patient eligibility on NaviNet.net.
Managed Care PCPs may verify the member’s eligibility on the most recent Capitation Report or Membership Report. (If the member’s name is not on these reports, call Physician Services at 1-800-624-1110).
You may ask the member for a copy of his or her signed application or, for Medicare Advantage members, a copy of their confirmation of enrollment letter.
Your patient may present a proof of coverage letter or virtual ID card, obtained by signing on HorizonBlue.com. Treat the proof of coverage letters and virtual ID cards as you would any other Horizon BCBSNJ ID card.

If the member’s status is unclear after reasonable attempts to verify coverage, you have the option of billing the member for the visit. If the member is actively enrolled, we will ask that you reimburse the member.

ASKING A MEMBER TO SELECT ANOTHER PHYSICIAN

The patient/physician relationship is essential to the delivery of quality, coordinated health care. In rare instances, this relationship can become seriously eroded if, for example, a member does not comply with treatment regimens or is abusive to you or your staff.

In such situations, you may initiate a discussion with your patient, asking him or her to choose another physician.

If the member does not select a new physician, follow up with a letter to the member personally signed by you.

If the patient is enrolled in a managed care plan and you are the selected PCP, also mail a copy of this letter to us at the address below so we can contact the member and instruct him or her to select a new PCP.

Horizon BCBSNJ
PO Box 820

Newark, NJ 07101-0820

Until a new PCP is selected, you are required to continue to serve in this capacity.

CLOSING YOUR PANEL

If you are a PCP and have achieved a panel size of at least 250 members (per physician) or find that you cannot manage additional patients, you may choose to close your panel.

According to your Agreement, you may close your panel after you provide Horizon BCBSNJ with 90 days advance written notice of your intention to close your panel to new patients.

Please send a written request to your Network Specialist and include:

Your practice name and address.
Your NPI and Tax ID number.
A detailed explanation of your request.

Please allow 30 days from the date of your inquiry for confirmation of your request.

According to your Agreement, you may not close or limit your panel for Horizon BCBSNJ covered members if your panel remains open for other patients.

If you have closed your panel, you must continue to provide health care services to existing members in your practice. This includes existing patients who are newly enrolled members because their employer entered into an Agreement with us or who otherwise are newly enrolled with Horizon BCBSNJ. These requirements apply to insured plans and self-funded plans.

We will indicate in our Directory of Participating Physicians and Other Health Care Professionals and online Doctor & Hospital Finder that your panel is closed. If you close your panel, the directory will indicate your closed panel status in the next printing of the directory. In addition, our enrollment department will suspend further enrollment of new members into your panel.

If you decide to re-open your panel, you can do so seven days after Horizon BCBSNJ receives written notification from you.

TREATMENT OF FAMILY MEMBERS

Horizon BCBSNJ products typically exclude payment for services when the patient is a family member of the physician or other health care professional providing treatment.
Immediate relatives include:

Self
Spouse or domestic partner
Children (natural, adopted or stepchildren)
Parents (natural, step-parents or in-laws)
Grandparents
Grandchildren
Siblings (natural, stepbrother, stepsister or in-laws)

Do not submit claims to us for services provided to any of the above-referenced individuals.

Retainer-based Medicine

Horizon BCBSNJ prohibits participating physicians and other health care professionals from requiring Horizon BCBSNJ members to pay retainer fees* (annually or with any other frequency) to become, or continue to be, a member of their panel/ practice, receive treatment, receive an enhanced level of service, and or receive particular types of personalized services.

To access our Retainer-Based Medicine policy, visit HorizonBlue.com/providers, and:

Mouse over Policies & Procedures, select Policies, then select Administrative Policies.
Select Retainer-Based Medicine.

Participating physicians or other health care professionals who fail to comply with our policy may be subject to loss or restriction of network participation and/or termination.

* Retainer fees do not include fees permitted under a member’s health benefits plan, for example, applicable copayments, coinsurance and deductibles.

Physicians or other health care professionals who charge a retainer fee may continue to participate with Horizon BCBSNJ if they agree not to require Horizon BCBSNJ members to pay a retainer fee.

However, Horizon BCBSNJ will not display the listings of these physicians and/or other health care professionals in our online or printed provider directories.

NONSOLICITATION OF OUR CUSTOMERS

Horizon BCBSNJ provides information on our customers and health benefit plans (and administrative services arrangements) to enable physicians and other health care professionals to provide services to our members. This information is proprietary to Horizon BCBSNJ.

As a participating physician or other health care professional, you may not infringe on Horizon BCBSNJ’s relationship with any of our customers, including groups or members, by (directly or indirectly) soliciting any customer, member or group to enroll in any other health benefits plan (or administrative services arrangement).

Nor may you use any information as to Horizon BCBSNJ’s benefit plans (or administrative services arrangements) or customers for any competitive purpose or provide it to any person or entity for financial gain.

RESPONSIBILITY FOR THE USE OF PARTICIPATING TAX ID NUMBERS

Horizon BCBSNJ’s billing policy prohibits the use of participating tax identification number (TINs) as outlined below.

Multiple TINs at a Single Practice Location Horizon BCBSNJ’s billing policy prohibits a participating physician or other health care professional from using more than one participating tax identification number (TIN) to bill us for services provided at a single practice location.

Use of a Participating TIN by Nonparticipating Practitioners

Horizon BCBSNJ’s billing policy prohibits the use of a participating tax identification number (TIN), including a group TIN, by a nonparticipating physician or other health care professional.

If a nonparticipating physician or other health care professional joins your practice, you may not bill under the group TIN for services provided by this individual until he or she joins our network(s).

For information, visit HorizonBlue.com/whyjoin.

If a physician or other health care professional within your practice leaves our network and becomes nonparticipating, that individual may no longer bill for services provided under your group TIN.
If a nonparticipating physician or other health care professional bills for services provided under a participating TIN (including a group TIN), submitted services will be reimbursed at our participating allowance.

Horizon BCBSNJ will hold you, the group practice, responsible for the difference between our participating allowance and total billed charges and for ensuring that our member is not held responsible for any balance due (less any applicable deductible, coinsurance or copayment amounts).

If a participating physician or health care professional joins or is linked to a nonparticipating group, our systems will consider that group TIN as participating.

All claims submitted under that group practice’s TIN will be reimbursed at our participating allowance.

TERMINATING YOUR PARTICIPATION IN THE NETWORK

There are certain policies and procedures you must follow when your Agreement(s) (i.e., Horizon Healthcare of New Jersey, Inc. Agreement with Participating Physicians and Other Health Care Professionals and/or your Agreement with Participating Physicians and Other Health Care Professionals) are terminated. Following these policies and procedures will help to ensure that your patients continue to receive care by a participating physician or other health care professional.

You are also required to notify us if you are retiring or moving your practice out of the area pursuant to the termination provisions under your Agreement.

Termination Letters

If you decide to terminate your Agreement(s), write a letter indicating your intention. The termination letter must be signed personally by the physician or other health care professional. Fax the termination letter to the attention of your Network Specialist at 1-973-274-4302.

Termination letters may also be mailed to the attention of your Network Specialist at:

Horizon BCBSNJ Network Management

Three Penn Plaza East

PP-14C

Newark, NJ 07105-2200

Effective Date of Termination

Your effective date of termination (unless another date is agreed upon by you and Horizon BCBSNJ) will be:

90 days following the receipt of your termination letter from our Horizon Managed Care Network.
30 days following the receipt of your termination letter from our Horizon PPO Network.

These 90- and 30-day periods leading up to your effective date of termination do not run concurrently with our Continued Provision of Care periods (for more information please see the Continued Provision of Care section to the right).

Patients Undergoing a Course of Treatment

You are required to notify us of any Horizon BCBSNJ members undergoing a course of treatment. Please prepare a list of members and send it to your Network Specialist. We, in turn, notify those members who are receiving a course of treatment of your termination from the Horizon Managed Care Network or Horizon PPO Network prior to the effective date of your termination. Authorizations are established for any members who require continued care.

Our Request for Continuity of Practitioner Care for Medical Benefits form is available on HorizonBlue.com/cocmedicalform. It may be completed by a member or by your office on behalf of a member.

Continued Provision of Care

You must treat existing Horizon BCBSNJ managed care, PPO and Indemnity patients for up to four months beyond your effective date of termination if they are in the midst of an ongoing course of treatment (not including the 90- or 30-day period leading up to your effective date of termination).

An existing patient is defined as one to whom you provided care within the 12-month period immediately preceding the effective date of termination of your Agreement(s).

Additionally, members undergoing certain courses of treatment are granted longer periods of care as indicated below:

Oncological treatment (up to one year).
Post-operative follow-up care (up to six months).
Pregnancy – up to the postpartum evaluation (up to six weeks after delivery).
Psychiatric treatment (up to one year).

You are required to accept our reimbursement for services provided during these extended periods as payment in full, less any applicable copayments, coinsurance or deductible amounts. All benefits shall be subject to contract limits and Horizon BCBSNJ’s policies and procedures, including, but not limited to, payment at Horizon BCBSNJ’s fee schedule, prior authorization and utilization management requirements.

If you have questions, contact your Network Specialist.

Rescinding a Request to Terminate

If you decide to rescind a recently submitted termination request, contact your Network Specialist in writing within 30 days of the original termination letter.

SPECIALTY MEDICAL SOCIETY RECOMMENDATIONS

Horizon BCBSNJ recognizes that from time to time, specialty societies will issue recommendations for new or updated technologies or treatments. To submit a new recommendation for consideration by Horizon BCBSNJ’s Medical Policy Department, provide the following information:

A detailed description of the technology or treatment and the recommendation on the specialty society’s letterhead.
A list of the references and/or case studies used to determine the recommendation.
The contact information for a representative of the specialty society who can respond to questions related to this recommendation.

Submit information as soon as possible to:

Horizon BCBSNJ
Medical Policy Department
3 Penn Plaza East
PP-12S
Newark, NJ 07105-2200

MEDICAL EMERGENCY

A medical emergency is a medical condition manifesting itself by acute symptoms of sufficient severity including, but not limited to, severe pain, psychiatric disturbances and/or symptoms of substance use disorder such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:

Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy.
Serious impairment to bodily functions.
Serious dysfunction of a bodily organ or part.

With respect to a pregnant woman who is having contractions, an emergency exists where:

There is inadequate time to effect a safe transfer to another hospital before delivery.
The transfer may pose a threat to the health or safety of the woman or unborn child.

When you refer a member to the Emergency Room (ER), you must contact us within 48 hours.

Members who use the ER for routine care may be responsible for all charges except the medical emergency screening exam.

If emergency care is obtained with the assumption that the member’s health is in serious danger, but it is later determined that it was not an emergency, the medical emergency screening exam would still be covered.

URGENT CARE

Urgent care is defined as a non-life-threatening condition that requires care by a physician or health care professional within 24 hours.

In situations requiring urgent care, members are instructed to contact their primary care physician, who can then assess the situation and coordinate the appropriate medical treatment.

If you recommend urgent treatment in your office and the member goes to a hospital ER instead, the resulting charges will be the member’s responsibility.

Urgent Care Centers (UCCs) provide an alternative to the Emergency Room (ER) for an injury or illness that requires immediate care but is not life threatening. Treatment often costs considerably less than care in an ER and an average visit usually lasts less than one hour.

The UCCs in Horizon BCBSNJ’s network have extended and weekend hours. Treatment is available for wounds, sprains and other conditions that require attention within 24 hours, but do not pose a danger to a person’s life or long-term health. All UCCs participating with Horizon BCBSNJ can perform essential medical

services, diagnosis illness and treat emergent conditions.

Routine office visits, including preventive care, sports physicals, routine obstetric services, occupational medicine and physical therapy are not covered at UCCS.

COVERAGE ARRANGEMENTS

If you are a PCP, you agree to arrange for coverage for your managed care members by a qualified, licensed, insured and participating Horizon Managed Care Network physician any time you are not available.

The covering physician must comply with all Horizon BCBSNJ policies and procedures with respect to any health care services provided. Reimbursement to a physician covering for a fee-for-service PCP will be made directly to the covering physician. Capitated PCPs are responsible for all financial arrangements with their covering physicians.

For procedures related to coverage arrangements for providers participating in the Horizon Behavioral Health Program, visit www.BeaconHealthOptions.com/providers/

beacon/network/horizon-behavioral-health.

ACCESS STANDARDS

Horizon Blue Cross Blue Shield of New Jersey has established access standards for our doctors and other health care professionals to help ensure that members receive the quality care they need when they need it. Access listings of access standards for PCPs, OB/GYNs and Specialist practitioners.

CONFIDENTIALITY OF MEDICAL RECORDS AND PERSONAL INFORMATION

Physicians and other health care professionals, as well as hospitals and other facilities, are responsible for complying with all applicable state and federal laws and regulations regarding confidentiality of medical records and individually identifiable health information, including, without limitation, the privacy requirements of HIPAA (the federal Health Insurance Portability and Accountability Act of 1996, Pub. L. 104-19, and any regulations promulgated thereunder) no later than the effective date of those state and federal laws.

If the practitioner is a PCP and a member changes to a new PCP, the practitioner shall forward copies of the member’s medical records, upon request, to the new PCP within 10 business days from receipt of request or prior to the next scheduled appointment with the new PCP, whichever is earlier.

Note: This addition is in supplement to the existing requirement that the practitioner may release information to another health care professional. However, this language also emphasizes and ensures patient care coordination in a timely manner.

MEDICAL RECORDS REQUESTS BY PATIENTS

Members have the right to request and receive a copy of their medical records and request that the records be amended or corrected.

We reprint, on the following pages, an excerpt of the actual regulation of the State of New Jersey Board of Medical Examiners on the preparation and release of information if requested by the patient or an authorized representative.

From the State Board of Medical Examiners Statutes and Regulations

(13:35-6.5) Preparation of patient records, computerized records, access to or release of information; confidentiality, transfer or disposal of records.

(a) The following terms shall have the following meanings unless the context in which they appear indicate otherwise:

Authorized representative means, but is not necessarily limited to, a person who has been designated by the patient or a court to exercise rights under this section. An authorized representative may be the patient’s attorney or an employee of an insurance carrier with whom the patient has a contract which provides that the carrier be given access to records to assess a claim for monetary benefits or reimbursement. If the patient is a minor, a parent or guardian who has custody (whether sole or joint) will be deemed to be an authorized representative, except where the condition being treated relates to pregnancy, sexually transmitted disease or substance use disorder.

Examinee means a person who is the subject of professional examination where the purpose of that examination is unrelated to treatment and where a report of the examination is to be supplied to a third-party.

Licensee means any person licensed or authorized to engage in a health care profession regulated by the Board of Medical Examiners.

Patient means any person who is the recipient of a professional service rendered by a licensee for purposes of treatment or a consultation relating to treatment.

(b) Licensees shall prepare contemporaneous,

permanent professional treatment records. Licensees shall also maintain records relating to billings made to patients and third-party carriers for professional services. All treatment records, bills and claim forms shall accurately reflect the treatment or services rendered.

Treatment records shall be maintained for a period of seven years from the date of the most recent entry.

1. To the extent applicable, professional treatment records shall reflect:

The dates of all treatments;
The patient complaint;
The history;

iv. Findings on appropriate examination;

Progress notes;
Any orders for tests or consultations and the results thereof;
Diagnosis or medical impression;
Treatment ordered, including specific dosages, quantities and strengths of medications including refills if prescribed, administered or dispensed and recommended follow up;
The identity of the treatment provider if the service is rendered in a setting in which more than one provider practices;
Documentation when, in the reasonable exercise of the physician’s judgment, the communication of test results is necessary and action thereon needs to be taken, but reasonable efforts made by the physician responsible for communication have been unsuccessful; and

xi. Documentation of the existence of any advance directive for health care for an adult or emancipated minor and associated pertinent information. Documented inquiry shall be made on the routine intake history form for a new patient who is a competent adult or emancipated minor. The treating doctor shall also make and document specific inquiry of or regarding a patient in appropriate circumstances, such as when providing treatment for a significant illness or where an emergency has occurred presenting imminent threat to life, or where surgery is anticipated with use of general anesthesia.

Corrections/additions to an existing record can be made, provided that each change is clearly identified as such, dated and initialed by the licensee.
A patient record may be prepared and maintained on a personal or other computer only when it meets The patient record shall contain at least two forms of identification, for example, name and record number or any other specific identifying information;
An entry in the patient record shall be made by the physician contemporaneously with the medical service and shall contain the date of service, date of entry and, full printed name of the treatment provider. The physician shall finalize or sign the entry by means of a confidential personal code (CPC) and include date of the signing;
Alternatively, the physician may dictate a dated entry for later transcription. The transcription shall be dated and identified as preliminary until reviewed, finalized and dated by the responsible physician as provided in (b)3ii above; the following criteria:
- The system shall contain an internal permanently activated date and time recordation for all entries, and shall automatically prepare a back-up copy of the file;
- The system shall be designed in such a manner that, after signing by means of the CPC, the existing entry cannot be changed in any manner.
- Notwithstanding the permanent status of a prior entry, a new entry may be made at any time and may indicate correction to a prior entry;
- Where more than one licensee is authorized to make entries into the computer file of any professional treatment record, the physician responsible for the medical practice shall assure that each such person obtains a CPC and uses the file program in the same manner;
A copy of each day’s entry, identified as preliminary or final as applicable, shall be made available promptly:
- To a patient as authorized by this rule within 30 days of request (or promptly in the event of emergency); and
- To a representative of the Board of Medical Examiners, the Attorney General or the Division of Consumer Affairs as soon as practicable and no later than 10 days after notice; and
- To a physician responsible for the patient’s care;
A licensee wishing to continue a system of computerized patient records, which system does not meet the requirements of (b)3i through vii above, shall promptly, initiate arrangements for modification of the system which must be completed by October 19, 1993.

In the interim, the licensee shall assure that, on the date of the first treatment of each patient treated subsequent to October 19, 1992, the computer entry for that first visit shall be accompanied by a hard copy printout of the entire computer-recorded treatment record.
The printout shall be dated and initialed by the attending licensee. Thereafter, a hard copy shall be prepared for each subsequent visit, continuing to the date of the changeover of computer program, with each page initialed by the treating licensee. The initial printout and the subsequent hard copies shall be retained as a permanent part of the patient record.
Licensees shall provide access to professional treatment records to a patient or an authorized representative in accordance with the following:
- No later than 30 days from receipt of a request from a patient or an authorized representative, the licensee shall provide a copy of the professional treatment record, and/or billing records as may be requested. The record shall include all pertinent objective data including test results and x-ray results, as applicable, and subjective information.
- Unless otherwise required by law, a licensee may elect to provide a summary of the record in lieu of providing a photocopy of the actual record, so long as that summary adequately reflects the patient’s history and treatment. A licensee may charge a reasonable fee for the preparation of a summary which has been provided in lieu of the actual record, which shall not exceed the cost allowed by (c)4 below for that specific record.
If, in the exercise of professional judgment, a licensee has reason to believe that the patient’s mental or physical condition will be adversely affected upon being made aware of the subjective information contained in the professional treatment record or a summary thereof, with an accompanying notice setting forth the reasons for the original refusal, shall nevertheless be provided upon request and directly to:
- The patient’s attorney;
- The patient’s health insurance carrier through an employee thereof; or
- Another licensed health care professional;
- A governmental reimbursement program or an agent thereof, with responsibility to review utilization and/or quality of care.
Licensees may require a record request to be in writing and may charge a fee for:
- The reproduction of records, which shall be no greater than $1 per page or $100 for the entire record, whichever is less. (If the record requested is less than 10 pages, the licensee may charge up to $10 to cover postage and the miscellaneous costs associated with retrieval of the record.) If the licensee is electing to provide a summary in lieu of the actual record, the charge for the summary shall not exceed the cost that would be charged for the actual record; and/or
- The reproduction of X-rays or any material within a patient record which cannot be routinely copied or duplicated on a commercial photocopy machine, which shall be no more than the actual cost of the duplication of the materials, or the fee charged to the licensee for duplication, plus an administrative fee of the lesser of $10 or 10 percent of the cost of reproduction to compensate for office personnel time spent retrieving or reproducing the materials and overhead costs.
Licensees shall not charge a patient for a copy of the patient’s record when:
If the patient or a subsequent treating health care professional is unable to read the treatment record, either because it is illegible or prepared in a language other than English, the licensee shall provide a transcription at no cost to the patient.
The licensee shall not refuse to provide a professional treatment record on the grounds that the patient owes the licensee an unpaid balance if the record is needed by another health care professional for the purpose of rendering care.
Licensees shall maintain the confidentiality of professional treatment records, except that:
- The licensee shall release patient records as directed by a subpoena issued by the Board of Medical Examiners or the Office of the Attorney General, or by a demand for statement in writing under oath, pursuant to N.J.S.A. 45:1-18. Such records shall be originals, unless otherwise specified, and shall be unedited, with full patient names. To the extent that the record is illegible, the licensee, upon request, shall provide a typed transcription of the record. If the record is in a language other than English, the licensee shall also provide a translation. All X-ray films and reports maintained by the licensee, including those prepared by other health care professionals, shall also be provided.
The licensee shall release information as required by law or regulation, such as the reporting of communicable diseases or gunshot wounds or suspected child abuse, etc., or when the patient’s treatment is the subject of peer review.
The licensee, in the exercise of professional judgment and in the best interests of the patient (even absent the patient’s request), may release pertinent information about the patient’s treatment to another licensed health care professional who is providing or has been asked to provide treatment to the patient, or whose expertise may assist the licensee in his or her rendition of professional services.
The licensee, in the exercise of professional judgment, who has had a good faith belief that the patient because of a mental or physical condition may pose an imminent danger to himself or herself or to others, may release pertinent information to a law enforcement agency or other health care professional in order to minimize the threat of danger. Nothing in this paragraph, however, shall be construed to authorize the release of the content of a record containing identifying information about a person who has AIDS or an HIV infection, without patient consent, for any purpose other than those authorized by N.J.S.A. 26:5C-8. If a licensee, without the consent of the patient, seeks to release information contained in an AIDS/HIV record to a law enforcement agency or other health care professional in order to minimize the threat of danger to others, an application to the court shall be made pursuant to N.J.S.A. 26:5C-5 et seq.
Where the patient has requested the release of a professional treatment record or a portion thereof to a specified individual or entity, in order to protect the confidentiality of the records, the licensee shall:
- Secure and maintain a current written authorization, bearing the signature of the patient or an authorized representative;
- Assure that the scope of the release is consistent with the request; and
- Forward the records to the attention of the specific individual identified or mark the material Confidential.
- Where a third-party or entity has requested examination, or an evaluation of an examinee, the licensee rendering those services shall prepare appropriate records and maintain their confidentiality, except to the extent provided by this section. The licensee’s report to the third party relating to the examinee shall be made part of the record. The licensee shall:
- Assure that the scope of the report is consistent with the request, to avoid the unnecessary disclosure of diagnoses or personal information which is not pertinent;
- Forward the report to the individual entity making the request, in accordance with the terms of the examinee’s authorization; if no specific individual is identified, the report should be marked Confidential; and
- Not provide the examinee with the report of an examination requested by a third party or entity unless the third party or entity consents to its release, except that should the examination disclose abnormalities or conditions not known to the examinee, the licensee shall advise the examinee to consult another health care professional for treatment.
Reserved
If a licensee ceases to engage in practice or it is anticipated that he or she will remain out of practice for more than three months, the licensee or designee shall:
- Establish a procedure by which patients can obtain a copy of the treatment records or acquiesce in the transfer of those records to another licensee or health care professional who is assuming responsibilities of the practice. However, a licensee shall not charge a patient, pursuant to (c)4 above, for a copy of the records, when the records will be used for purposes of continuing treatment or care.
- Publish a notice of the cessation and the established procedure for the retrieval of records in a newspaper of general circulation in the geographic location of the licensee’s practice, at least once each month for the first three months after the cessation; and
- Make reasonable efforts to directly notify any patient treated during the six months preceding the cessation, providing information concerning the established procedure for retrieval of records.

Note: The Medical Record fee does not apply to Horizon BCBSNJ’s request for medical records.

CLINICAL PRACTICE GUIDELINES

Horizon BCBSNJ’s clinical practice guidelines (CPGs) are available to all participating physicians and other health care professionals.

These guidelines were adopted from nationally known organizations such as the Advisory Committee on Immunization Practices, the American Academy of Pediatrics, the American Academy of Family Physicians, the American Psychiatric Association, the Agency for Health Care Policy and Research, the American Society of Addictive Medicine and the American Diabetes Association. They also include Healthcare Effectiveness Data and Information Set (HEDIS®) technical specifications.

Horizon BCBSNJ CPGs

Registered NaviNet users can view, print or download our CPGs. Simply:

Visit NaviNet.net and log in by entering your User Name and Password.
Select Horizon BCBSNJ within the My Health Plans menu.
Mouse over References and Resources click Provider Reference Materials.
Under Additional Information, click Clinical Practice Guidelines.

If you are not registered for NaviNet, visit NaviNet.net and click Sign up. Copies of our CPGs can also be mailed to you. Call 1-877-841-9629 or email your request to: QualityManagement_Coordinator@HorizonBlue.com.

GENERAL RISK ADJUSTMENT

Horizon BCBSNJ requires physicians to cooperate with us on the implementation of initiatives to support Medicare, Medicaid and the Affordable Care Act Commercial Risk Adjustment provisions. You will be held responsible for the following:

You will allow physician and staff participation in periodic in-office training provided by us on key issues related to risk adjustment.
You will capture member diagnoses with the highest level of specificity available.
You will reach out to specific members, at our request, to schedule office visits. The criteria below only applies to Medicare and Commercial Risk Adjustment:

You will review and use member diagnostic information provided by Horizon BCBSNJ to comprehensively evaluate all health conditions for a member under your care.
For Medicaid: All pertinent risk adjustment diagnoses will be included on the claim submitted for payment even if you are capitated.
Important: you will make available all requested medical records for chart reviews and comply with our chart review processes.

It is also important that your medical records reflect the following:

All medical conditions that contributed to the office visit are documented and coded.
All causational relationships of various comorbidities (e.g., if retinopathy is caused by diabetes) are documented.
All historical conditions are appropriately coded with Z-codes.
All medical charts are signed as required by CMS.

Claims Submissions and Reimbursement

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Claims Submissions and Reimbursement Mon, 12/30/2019 - 06:16

You are required to:

Send claims to us for your Horizon BCBSNJ and BlueCard program patients.

We will process your claims and send you reimbursement for all eligible services. An Explanation of Payment (EOP) will be sent to you outlining patient liability. In some cases, we may reimburse our full allowance; however, some services or products may require a copayment, or be subject to a deductible or coinsurance.

Accept our allowance for eligible services as payment in full.

You are expected to bill members for the appropriate member liability (deductible and/or coinsurance), as indicated on the Explanation of Payment (EOP) you receive.

Horizon BCBSNJ will reimburse the lesser of your billed charge or our fee schedule amount, less applicable copayment, coinsurance or deductible amounts. For more information on your responsibilities and obligations, see the Policies, Procedures and General Guidelines section.

For physicians or other health care professionals participating only in our Horizon Managed Care Network who treat a member enrolled in a Horizon PPO or Horizon BCBSNJ Indemnity plan:

Claims will be processed according to the member’s out-of-network (OON) benefits.
Reimbursement will be calculated at the PPO OON allowance.
Members are liable only for copayment amounts, coinsurance and/or deductible amounts indicated on the EOP.
You cannot bill members for amounts in excess of the member liability as indicated on our Explanation of Payment (EOP).

For physicians or other health care professionals participating only in our Horizon PPO Network who treat a member enrolled in a Horizon BCBSNJ managed care plan that includes out-of-network benefits, for example, Horizon POS, Horizon Direct Access or NJ DIRECT:

Claims will be processed according to the member’s out-of-network (OON) benefits.
Reimbursement will be calculated at the PPO rate.
Members are liable for copayment, coinsurance and/or deductible amounts indicated on the EOP.

For physicians or other health care professionals participating only in our Horizon PPO Network who treat a member enrolled in a Horizon BCBSNJ Medicare Advantage plan that includes out-of-network benefits, for example, Horizon Medicare Blue PPO or members enrolled in other Blue Cross and/or Blue Shield MA PPO plans who reside or travel in our service area:

Claims will be processed according to the member’s out-of-network (OON) benefits.
Reimbursement will be calculated at the Centers for Medicare & Medicaid Services (CMS) allowance.
Members enrolled in Medicare Advantage plans are liable only up to the legally allowed amounts as determined by CMS.
Please note that participating PPO physicians/other health care professionals who have opted out of, or who are excluded from, Medicare are not eligible to receive reimbursement for services rendered to a Medicare Advantage member.

For physicians or other health care professionals participating only in our Horizon PPO network who treat a member enrolled in a Horizon BCBSNJ managed care plan that DOES NOT include out-of-network benefits, for example, Horizon HMO, Horizon EPO and Horizon Medicare Blue Value (HMO):

Claims will be denied (except for services that were authorized or provided in emergent situations).
Reimbursement will not be made.
Members (except those enrolled in Medicare Advantage plans) are liable up to your total billed amount.
Members enrolled in Medicare Advantage plans are liable up to the legally allowed amounts as determined by CMS.

Collection of Member Responsibility Amounts at the Time of Service.

Although we prefer that participating practices submit claims and wait for our Explanation of Payment (EOP) prior to collecting any member liability amounts other than copayments, we understand the financial challenges that many practices are facing in regard to the collection of patient responsibility amounts.

In addition to the collection of member copayment amounts, participating practices may make arrangements with members at the time services are provided for the payment of amounts that will be applied toward their deductibles.

Participating practices may NOT seek amounts that will be applied to member deductibles at the time of service from:

Members enrolled in Horizon Medicare Advantage plans.
Members enrolled in high-deductible health insurance plans that work in conjunction with an employer-sponsored HRA (Health Reimbursement Arrangement).
Collection of coinsurance amounts at the time of service.

In no case shall treatment be refused to a Horizon BCBSNJ member if he or she is not able to pay a requested amount at the time of service.

Collection Fees/Interest

To protect our members, Horizon BCBSNJ forbids participating physicians and other health care professionals from adding a collection fee, interest or other amount to the member liability until the member has had a reasonable opportunity to pay (i.e., a minimum of 30 days).

We encourage you to inform our members of your billing practices before member liabilities will not paid in a timely manner.

NATIONAL PROVIDER IDENTIFIER (NPI)

In accordance with Centers for Medicare & Medicaid Services (CMS) regulations, physicians and other health care professionals who conduct electronic transactions or submit claims to us through a third-party vendor are required to use a NPI. To avoid claim rejection, include NPI information on your standard transactions.

Apply for NPI

Horizon BCBSNJ requires all physicians to have a unique NPI. If you have not yet applied for a NPI, visit https://nppes.cms.hhs.gov/NPPES/welcome.do.

Registering Your NPI

To reimburse you correctly, your NPI(s) must be registered with Horizon BCBSNJ. Registration ensures that our internal systems accurately reflect your NPI information and prevents reimbursement delays. If you haven’t registered your NPI information with us, do so immediately.

To register by fax:

Visit HorizonBlue.com/individual NPI or HorizonBlue.com/group NPI
Complete the form and fax it to 1-973-274-4416

NPI and Group Tax ID Number Affiliation

Ensure that your NPI is linked/associated with your Group Tax ID number (TIN) and correctly registered in our files. A group NPI that is incorrectly associated to an individual physician’s TIN or Social Security Number may cause claims to be incorrectly processed. If your group practice NPI is incorrectly associated with an individual physician, visit CMS at CMS.gov to request a correction to the NPI. Once CMS has corrected its records, fax the updated information to 1-973-274-4416.

What to do if you move to a new location

You must notify the National Plan and Provider Enumeration System (NPPES) of your new location within 30 days of the effective date of the move.

CMS encourages health care professionals who were assigned a NPI and who are not covered entities, to do the same.

To submit your address change to NPPES, visit https://nppes.cms.hhs.gov and:

Click the link within the statement: If you are a Health Care Provider, you must click on National Provider Identifier (NPI) to login or apply for an NPI.
Click Login following the heading,Want to View or Update your NPI data?

To download a NPI update form, visit cms.gov/cmsforms and:

Click CMS Forms in the left navigation.
Click CMS 10114 to display the NATIONAL PROVIDER IDENTIFIER (NPI) APPLICATION/UPDATE FORM.

If you need to request a form, call the NPI Enumerator at 1-800-465-3203.

Horizon BCBSNJ also requests that if you update, add or change your NPI information/tax ID, fax the information to 1-973-274-4416.

CLAIMS SUBMISSIONS

Claims are a vital link between your office and Horizon BCBSNJ. Generally, claims must be submitted within 180 days of the date of service. Helpful Hints are provided in this section for your reference.

Rendering, referring and admitting NPI information on claims

Horizon BCBSNJ requires that your claim submissions include National Provider Identifier (NPI) information to identify referring and admitting physicians. Submit this NPI information on all claim submissions.

Electronic Submissions

Electronic claims submissions help speed our reimbursement to you. You must submit claims to us electronically.

Horizon BCBSNJ’s electronic Payor ID is 22099.

Our EDI Service Desk is available to discuss:

Your electronic claim submission options.
Enhancing your current practice management system with specifications for electronic submission to us.

For more information on submitting your claims electronically, call the EDI Service Desk at 1-888-334-9242 or email HorizonEDI@HorizonBlue.com.

Behavioral Health Care and Substance Use Disorder Care Claims

You can submit most behavioral health claims electronically. If you must submit printed claims, mail claims to:

Horizon BCBSNJ
Horizon Behavioral Health
PO Box 10191
Newark, NJ 07101-3189

When providing behavioral health and substance use disorder care, please check the patient’s ID card for information on the behavioral health and substance use disorder care information.

To assist us with the expeditious and accurate processing of your claims:

Ask for the patient’s ID card at each visit to have the most current enrollment information available. Always copy both sides of the ID card for your files.
Don’t confuse the subscriber with your patient. The patient is always the person you treat. Complete the patient information on your claim as it relates to the person being treated.
Use the subscriber’s and/or patient’s full name. Avoid nicknames or initials.
Complete the patient’s date of birth.
Claims must include the entire ID number. Always use the prefixes or suffixes that surround the ID number. The only exceptions are Federal Employee Program® (FEP®) products. For FEP® disregard any characters after the eighth numeric character following the R prefix.
Complete the group number field on the claim form when it appears on the ID card.
When you treat a patient due to an injury, be sure to include the date the injury occurred.
When appropriate, be sure to include the date of onset for the illness you are treating.
Include rendering, referring and admitting physician NPI information on all appropriate claim submissions.
When submitting claims under your NPI, remember that your tax ID number is also required.
Clearly itemize your charges and date(s) of service.

Use accurate and specific ICD diagnosis codes for each condition you are treating. List the primary diagnosis first. To report multiple ICD-10 codes (our systems can handle up to four), list each one with the corresponding procedure by numbers 1, 2 or 3.

Always use accurate five-digit CPT-4 or HCPC codes.
Please use valid, compliant codes for the date on which services were rendered.
When the patient’s primary insurance is traditional Medicare, claims are sent to Horizon BCBSNJ from CMS national crossover contractor, the Benefits Coordination & Recovery Center (BCRC). Claims are transmitted after the Medicare Payment Floor (14 days) is reached, regardless of when you receive a remittance advice. If you do not receive a payment summary from us, submit the claim 30 days after you receive the Medicare Remittance along with a copy of the Medicare Provider Summary.
If the patient has any other insurance, please record the patient’s Coordination of Benefits (COB) information on the claim form.

Helpful Hints for Paper Claims Submissions

If you submit paper claims, your claim submissions may be processed through Optical Character Recognition (OCR). Our enhanced OCR processing provides faster and more efficient adjudication and reimbursement than the traditional methods of manually processed paper claims. The efficiency of processing paper claims through OCR depends on your legible, compliant and complete claim submission. Claims incomplete and/or illegible in these areas may be delayed.

To maximize the benefits of OCR, we recommend the following when submitting your CMS 1500 form:

Always use an original CMS 1500 form for hard copy claim submissions. Do not use photocopies of the CMS1500 form.
Make sure the print on your CMS 1500 form is clear and dark, and that characters are centered in each box.
All characters on the CMS 1500 form need to be intact. We use OCR equipment that recognizes full characters only. If the characters are missing tops or bottoms of the letters, the OCR equipment will not function properly, causing claims processing delays. Use a laser printer for best results.
Do not highlight or circle information or apply extraneous stamps or verbiage to the forms. Highlighting, circling and stamps may prevent our scanners from correctly identifying characters.
Include rendering, referring and admitting physician NPI information on all appropriate claim submissions.
For information omitted from computer-prepared forms, use typewritten instead of handwritten data.
Do not staple any submitted documents.
Avoid duplicate claim submissions:
- Ensure that corrected claim submissions are accompanied by a completed copy of our Inquiry Request and Adjustment Form (579).
- Prior to resubmitting claims, check for claim status online at NaviNet.net or call 1-800-624-1110.

EDI TRANSACTION INVESTIGATION

From time to time, you may experience Electronic Data Interchange (EDI) transaction rejections.

Different from a claim denial, an EDI transaction rejection is not forwarded to our claim processing systems for adjudication.

The following information will help to expedite any transaction rejection investigations you may need to conduct with the EDI Service Desk.

Information Required for EDI Investigation

If you need help with EDI rejection messages for any of the transactions listed below, have the Horizon EDI Gateway Receipt Number or Carrier Reference Receipt Number available to provide to the EDI Service Desk Representative.

Professional claims
Eligibility status
Claim status

Remittance Advice

If you need help with a Remittance Advice/835 investigation, please also have the following information available:

Provider NPI and tax ID number
Check date
Check amount
Check number

You may reach the EDI Service Desk at 1-888-334-9242, Monday through Friday, between 7 a.m. and 6 p.m., Eastern Time, or by emailing HorizonEDI@HorizonBlue.com.

CLAIM ADJUSTMENT REQUESTS

Horizon BCBSNJ encourages all practices to submit claim adjustment requests electronically using the standard HIPAA 837P transaction, as appropriate. Submitting electronic claim adjustment requests simplifies the claim adjustment process and helps to speed adjudication and the payment to providers.

Providers may electronically submit any adjustments that DO NOT require the submission of additional supporting documentation (e.g., medical record, etc.) for:

Local claims (including SHBP and FEP).
BlueCard claims¹.

BlueCard claim adjustment requests to change subscriber ID, provider Tax ID number or provider suffix cannot be submitted electronically.

Please mail these claim adjustment requests to:

BlueCard Claims
PO Box 1301
Neptune, NJ 07754-1301

Contact the vendor or clearing house for information about 837 transactions.

For additional information, contact the Horizon BCBSNJ EDI Service Desk at 1-888-334-9242,

weekdays from 7 a.m. to 6 p.m., Eastern Time, or via email at HorizonEDI@HorizonBlue.com.

How to indicate that your 837 transaction is an adjustment request

Include the following required information within the 837 transaction.

Frequency code: The frequency code (values 7 or 8) associated with the place of service indicates that this transaction is an adjustment.
Adjustment reason: The adjustment reason and narrative explaining why the claim is being adjusted. For example, the adjustment reason could be “number of units” and additional narrative could be “units billed incorrectly, changed units from 010 to 001.”
Original reference number: Claim number of the originally adjudicated claim found on remittance advice (the ICN/DCN of the claim to be adjusted).

Share this information with your vendor or clearinghouse to ensure that electronic transactions are submitted correctly.

ERROR REPORT 999 OR 277CA

If a claim is rejected, you will receive an error report, either the 999 or the 277CA Claims Acknowledgement Report that explains why the claim was rejected.

What the reports show

The 999 report shows:

Claims with incomplete information
Invalid codes
Non-compliance with the 837 implementation guide

The 277CA report will show:

Claims with invalid ID/member not found
Dependent coverage rejections
Duplicate claims

When you receive an error report you must:

Review the report to see why your claim(s) was rejected
Work with your clearinghouse to resolve any errors
Correct the claim and resubmit for processing

Submitting claims

To be sure a claim is accepted when submitted, always include the patient and insured’s names and addresses, and the ICD-10 diagnosis codes.

If you must submit a professional claim on paper, please use the standard, government approved red-lined CMS 1500 claim form. To help expedite your hard copy claim submissions:

Do not use black and white, or photocopies of the CMS 1500 claim form.
Do not handwrite your claims.
Use a laser printer instead of a dot-matrix type printer to ensure better quality.

You will receive a letter for any paper claims that are unable to be entered into the claims processing system. Please review the letter carefully and submit a new claim with all of the required fields necessary for processing.

It’s important to review the claim report, or the Horizon BCBSNJ-issued letter, with your clearinghouse first before calling.

CORRECTED CLAIMS AND INQUIRIES

Corrected or adjusted claims may be submitted electronically in most cases. Physician Service Representatives can also accept missing or corrected claim information over the phone. ITS and Fund Accounts must submit corrected claims using Form 579, Inquiry Request and Adjustment Form.

For corrected claims processed by eviCore healthcare for radiology services, use Form 579 to add multiple bill lines not included in the original claim submission.

If there are circumstances that prevent an electronic claim submission, please complete Form 579 or risk denial of your paper claim submission as a duplicate claim. Ensure the following is included:

Identification of the corrected claim at the top of the page (“Request for…”)
The original claim # (“Claim #” within the Subscriber/ Patient Information section)
All pertinent information requiring data correction (“Details of Request” within the Subscriber/ Patient information section)

If the form is not received with the corrected claim submission, the claim may not be processed as a corrected claim and may be identified as a duplicate. Form 579 is on HorizonBlue.com/form579.

OBSERVATION CARE AND PLACE OF SERVICE CODES

Horizon BCBSNJ recognizes that either place of service code 23 (ER hospital) or place of service code 22 (outpatient hospital) meets the requirements for billing the appropriate place of service when submitting professional claims for services provided to members in an observation care status.

Please note the following:

Consistent with our current policies and procedures, services billed with place of service code 23 do not require a prior authorization.

Horizon BCBSNJ’s prior authorization requirements remain unchanged for specific services rendered in the outpatient setting and billed with place of service code 22. As a reminder, it is the ordering physician’s responsibility to obtain this prior authorization.

CHIROPRACTIC CLAIMS

Please use the Chiropractic Manipulative Treatment (CMT) codes listed below when submitting chiropractic claims to us. 98940 CMT; spinal, one or two regions. 98941 CMT; spinal, three or four regions. 98942 CMT; spinal, five regions. 98943 CMT; extra spinal, one or more regions.

Include Rendering/Referring NPI Info Chiropractic claims must include rendering and referring practitioner NPI information on all claim submissions as appropriate.

E&M Services and PT Modalities

In compliance with New Jersey Department of Banking and Insurance (DOBI) Order A09-113, Horizon BCBSNJ considers Evaluation and Management (E&M) services and physical therapy (PT) modalities for reimbursement separate from the reimbursement of CMT codes.

This impacts all participating and nonparticipating New Jersey chiropractors.

Chiropractic Order Number A09-113 does not apply to Federal Employee Program® (FEP®) members, Horizon Medicare Advantage members or Medigap members.

Evaluation of E&M services and PT modalities may require the submission of medical records to support the appropriateness of the services being billed.

The eligible CPT-4 codes are listed below. However, reimbursement of codes is subject to Horizon BCBSNJ policies and the member’s benefits.

Evaluation and Management Codes
For initial patient – 99201 through 99205.
For established patient – 99211 through 99215.
Physical Therapy Modality Codes
97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, 97110, 97112, 97113, 97116, 97124, 07139, 97140, 97530, 97550, G0283
Chiropractic Manipulative Therapy Codes 98940 through 98943.

Benefit Maximums

A common standard benefit is to cover a maximum of 30 visits per benefit year. However, some groups have other benefit maximums or elect not to cover chiropractic services.

Depending on the member’s contract, maximums may also apply to physical therapy modalities.

Please call the service number on your patient’s ID card to verify chiropractic and physical therapy modality benefits.

CLAIMS FOR HOT OR COLD PACKS

Horizon BCBSNJ does not provide reimbursement for CPT® code 97010.¹

The denial of this service as not eligible for reimbursement aligns our approach to 97010 with the Centers for Medicare & Medicaid Services (CMS) and standard business practice.

According to the terms of your participating Agreements with us, you may not bill or seek reimbursement from a Horizon BCBSNJ member for these denied services whether billed in conjunction with other medical services or alone.

1 Administrative Services Only (ASO) plans and self-funded employer groups may or may not provide this benefit to their covered employees.

PHYSICAL THERAPY AND OCCUPATIONAL THERAPY CLAIMS

Reimbursement for physical therapy and occupational therapy services is made on a maximum per-visit basis and covers all medically necessary treatment provided to a patient in a single visit.

Significant, separately identifiable Evaluation & Management (E&M) services may be eligible for separate reimbursement if:

The appropriate level of E&M service is billed.
The appropriate modifier is appended to the E&M service, which is above and beyond the other services provided.
The reason for the E&M service is clearly documented in the member’s medical record and this documentation supports that the member’s condition required the significantly, separate E&M service.
The services in question have not been specifically identified as part of an impacted code pair combination in our claim processing logic that prevent separate reimbursement (even if the E&M code is appended with a modifier).

Include Rendering/Referring NPI Info

PT/OT practitioner claims must include rendering and referring practitioner NPI information on all claim submissions as appropriate.

Online Authorizations

Participating health care professionals can use NaviNet to obtain online authorizations for short-term outpatient physical therapy and occupational therapy services for enrolled Horizon BCBSNJ members.

The online Utilization Management Request Tool should be used to submit submit and/or check the status of authorization and predetermination requests, access the online Utilization Management Request Tool.

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.

Online Training

Online training tutorials are available. Log on to NaviNet and select Horizon BCBSNJ from the My Health Plans menu, mouse over References and Resources and click Provider Reference Materials. Mouse over Resources, click Training, and then click Education.

Helpful Hints for Physical Therapy Claims

Standard benefit is to cover a maximum of 30 visits per benefit year. However, some large groups can elect other benefit maximums.
Call the Member Services phone number on the patient’s ID card to verify his or her physical therapy benefits.
Submit all claims using current CPT-4 codes that accurately reflect your services.
Certain groups may require services to be reviewed for medical necessity at specific intervals.
Medical records may be requested to confirm the medical necessity for care.

Note: Reimbursement may vary by county.

CLINICAL LABORATORY CLAIMS

You are required, according to their Physician Agreement(s), to refer Horizon BCBSNJ patients and/or send Horizon BCBSNJ patients’ testing samples to participating clinical laboratories. Failure to comply with the terms of your Physician Agreement(s) may result in your termination from the Horizon BCBSNJ networks.

Horizon BCBSNJ’s Managed Care laboratory network expanded to include Quest Diagnostics in addition to Laboratory Corporation of America® (LabCorp®). LabCorp and Quest provide national in-network clinical laboratory services to your Horizon BCBSNJ managed care patients (i.e., members enrolled in Horizon HMO, Horizon EPO, Horizon Direct Access, Horizon POS, OMNIA Health Plans, NJ DIRECT or Horizon Medicare Advantage plans).

You may refer members enrolled in Horizon PPO and Indemnity plans (and/or send their testing samples to one of our participating clinical laboratories including LabCorp, Quest and BioReference Laboratories, Inc. or to hospital outpatient laboratories at network hospitals).

As a reminder, our networks include a number of participating laboratories that can provide a variety of specialized laboratory services. Please visit our Online Doctor & Hospital Finder to locate participating laboratories.

To view a list of our participating clinical laboratories, visit HorizonBlue.com/doctorfinder. Within the Other Healthcare Services tab, select Laboratory – Patient Centers or Laboratory – (Physician Access Only) under the Service Type dropdown menu and click Search.

ELECTRONIC FUNDS TRANSFER

Horizon BCBSNJ requires all participating physicians and other health care professionals to register for Electronic Funds Transfer (EFT) upon joining our networks.

Horizon BCBSNJ reserves the right to re-evaluate the participation status of physicians and other health care professionals who do not comply with this requirement.

The benefits of EFT include:

Elimination of paper checks to track and deposit.
Reduction in paperwork and administrative costs.
Reduction in the opportunity for error/theft.
Quicker reimbursement into one or more designated bank accounts.
Improved cash flow by eliminating mail time and check float.
Elimination of bank fees for check deposits.

Note: EFT will only be used by Horizon BCBSNJ to make deposits into your designated accounts. We will not withdraw any amounts from these designated accounts.

Enrolling in EFT requires that you receive online Explanation of Payments (EOPs) in place of paper statements.

Reimbursements generated from our dental claim processing system will still be made via paper check, even for those who sign up for EFT. We will keep you apprised of our progress toward generating EFTs from our dental claim processing system in our Blue Review newsletter.

Changes in 2020

In 2020, Horizon BCBSNJ will no longer make payments using checks. If providers are not already registered for EFT, future payments will default to a single use card (known as a SUA card) payable in the exact amount owed.

The SUA cards include a high level of security: a unique 16-digit SUA card number created for each payment, receipt of an image of a SUA card (which will be sent by mail) and more.

Registering for EFT

To sign up for EFT, registered users of NaviNet may:

Log on to NaviNet.net and select Horizon BCBSNJ from the My Health Plans menu.
Select Claim Management.
Select EFT Registration.

We will perform two test deposits into the bank account you indicate. Once you confirm that the two test deposits were received, it takes only two to four business days before EFTs begin.

Questions about EFT

If you have questions about EFT or EFT registration, call our e-Service Helpdesk at 1-888-777-5075. You can also email questions to the e-Service Helpdesk at Provider_Portal@HorizonBlue.com.

If you have questions about NaviNet registration, call NaviNet Customer Care at 1-888-482-8057.

PROMPT PAY

All New Jersey insurance companies, health, hospital, medical and dental services corporations, HMOs and dental provider organizations and their agents for payment (all known as payers) must process claims in a timely manner, as required by New Jersey law (Prompt Pay Law).

Prompt Pay Law also requires that carriers pay clean claims within 30 calendar days of receipt for electronic claims and 40 calendar days of receipt for paper claims. Claims that are not paid must be denied or disputed within the same 30- or 40-day time frames.

Note: According to CMS guidelines, a Medicare health plan must pay clean claims from noncontract providers within 30 calendar days of the request, and pay or deny all other claims within 60 calendar days of the request.

In addition, the Health Claims Authorization, Processing and Payment Act (HCAPPA), where it applies, requires any claim paid beyond the above time frames to be paid with interest at the rate of 12 percent per annum. As such, interest calculation begins on the 31st day for electronic claims and the 41st day for paper claims (when applicable).

Prompt Pay requirements do not apply to certain lines of business, for example, self-funded businesses we work with as Administrative Services Only (ASO) accounts.

If you have questions about identifying the members to whom Prompt Pay applies, call 1-800-624-1110.

Additional Interest Payments

Horizon BCBSNJ issues additional interest payments on claims (for certain lines of business) to MDs and DOs. Interest will be paid at a rate of 8 percent per annum on balances due from the 20th calendar day after Horizon BCBSNJ receives a complete, electronically submitted claim to the earlier of the date that:

Horizon BCBSNJ directs issuance of payment, or
Interest becomes payable under New Jersey law.

These additional interest payments will be noted on your Explanation of Payment (EOP), which will separately identify interest payments required by New Jersey law and interest payments resulting from the settlement.

Claims eligible for this additional interest are limited to certain lines of business and exclude, for example, claims of members enrolled in the Federal Employee Program® (FEP®), certain national account groups managed outside of New Jersey and Medicare or Medicaid programs.

Other limitations include:

Duplicate claims submitted within 30 days of the original claim submission.
Claims that include a defect or error that prevents them from being systemically processed.
Claims from a physician who balance bills a Horizon BCBSNJ member in violation of their network participation Agreement.
Claims reimbursed to a member.
Claims payable during a major disruption in services for which claims processing is excused or delayed as a result of that event.

REIMBURSEMENT REQUESTS FOR UNDER- AND OVERPAYMENTS

The Health Claims Authorization, Processing and Payment Act (HCAPPA) affects physicians, other health care professionals and facilities. This law applies to all insured New Jersey group and individual business. HCAPPA requirements do not apply to certain lines of business, such as self- funded business, including Administrative Services Only (ASO) accounts such as the New Jersey State Health Benefits Program (SHBP) and School Employees’ Health Benefits Program (SEHBP).

Overpayment

Health insurers may only seek reimbursement for overpayment of a claim from a physician or health care professional within 18 months after the date the first payment on the claim was made. There can only be one reimbursement sought for overpayment of a particular claim. However, recapture of an overpayment, beyond the 18-month period, is permitted if there is evidence of fraud, if a physician or health care professional with a pattern of inappropriate billing submits the claim, or if the claim is subject to COB.

Recapture of overpayments by a health insurer may be offset against a physician’s future claims if notice of account receivable is provided at least 45 calendar days in advance of the recapture, and all appeal rights under HCAPPA are exhausted.

An offset will be stayed pending an internal appeal and state-sponsored binding arbitration. However, with prior written consent, Horizon BCBSNJ will honor requests for the recapture prior to the expiration of the 45-day period. If a physician or health care professional prefers to make payment directly to Horizon BCBSNJ rather than permit an offset against future claims, the 45-day notice letter will include an address to remit payment.

Horizon BCBSNJ may extend the notice period up to 90 days. The decision to offer an extended notice period is made on a case-by-case basis.

Note: Horizon BCBSNJ will not recapture an overpayment made on claims processed for members enrolled in insured group and individual plans covered under HCAPPA until the expiration of the 45-day notice period (except with a physician’s or health care professional’s prior written consent, or if a physician or health care professional remits payment directly to Horizon BCBSNJ). Both the paper voucher and the electronic (HIPAA standard 835 transaction) version of the voucher, if applicable, will reflect the adjustment as soon as it is recorded.¹

In the event that Horizon BCBSNJ has determined that an overpayment is the result of fraud and has reported the matter to the Office of the Insurance Fraud Prosecutor, HCAPPA allows a recapture of that overpayment to occur without the 45-day notice period.

1 The overpayment recapture guidelines noted above do not pertain to overpayments made on claims processed through the BlueCard program for members enrolled in other Blue Cross and/or Blue Shield Plans or for members enrolled in the Federal Employee Program®(FEP®).

Underpayment

Under HCAPPA, no physician or other health care professional may seek reimbursement from a member/patient or health insurer for underpayment of a claim submitted later than 18 months from the date the first payment on the claim was made, except if the claim is the subject of an HCAPPA appeal submitted or the claim is subject to continual claims submission.

No physician or other health care professional may seek more than one reimbursement for underpayment of a particular claim.

QUALIFIED MEDICARE BENEFICIARIES’ COST SHARING RESPONSIBILITIES

According to CMS guidelines, Qualified Medicare Beneficiaries (QMB) program members are not responsible for copayments or other cost sharing for Medicare-covered services and items. These enrollees include members who are enrolled in both a Horizon BCBSNJ Medicare Advantage (MA) plan and the New Jersey state Medicaid program.

You may bill the appropriate state source for those amounts. We encourage you to establish processes to identify the Medicaid status of your Horizon BCBSNJ MA plan or Medicare patients prior to billing for items and services.

Reference:

Centers for Medicare & Medicaid Services. (2017, February). Dual Eligible Beneficiaries under the Medicare and Medicaid Programs.Retrieved October 11, 2017, from https://www.cms.gov/ Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/ Medicare_Beneficiaries_Dual_Eligibles_At_a_Glance.pdf

CAPITATION

Capitation is a predetermined monthly rate paid to the physician for each member enrolled on a physician's panel regardless of the actual services rendered to members in certain Horizon BCBSNJ managed care plans. The payment is reviewed periodically to reflect changes in utilization, medical technology or the cost of medical goods and services.

Horizon Managed Care Network Primary Care Physicians (PCPs) who have a capitated payment arrangement will be reimbursed monthly as such for members enrolled in Horizon HMO, Horizon POS, Horizon Medicare Blue Value (HMO), Horizon Medicare Blue Access Group (HMO-POS), Horizon Medicare Blue Advantage (HMO), Horizon Medicare Blue Select (HMO POS), and Horizon Medicare Blue Choice w/Rx (HMO) plans.

Reimbursements for Horizon HMO Access members are through capitation only if the member has made a valid preselection of the treating PCP. If not, fee-for-service reimbursement applies.

Requests to amend your current reimbursement methodology may be made, in writing, to your Network Specialist. Please include:

Your practice name and address.
Your tax ID number and NPI.
A detailed explanation of your request.

Your request will be reviewed by a Network Management Representative and a notification of the implementation date of your new reimbursement methodology will be sent to your office. Allow 60 days from the date of your request for notification.

Base Monthly Capitation

The Base Monthly Capitation amount is defined as the amount of dollars prepaid to you or your group for all members on your or your group’s panel who are considered active with your office as recorded in Horizon BCBSNJ’s enrollment system when the monthly capitation is generated.

The Base Monthly Capitation is sent directly to the PCP by the 15th day of each month. Group practices receive a single capitation check.

If you are paid on a capitation basis, capitation payments for additions to your panel will be made as follows:

You will receive 100 percent capitation amount for persons covered by a plan requiring PCPs to be paid on a capitation basis who are added to your panel on or before the 15th day of the month.
You will receive 50 percent of the capitation amount for persons covered by a plan requiring PCPs to be paid on a capitation basis who are added to your panel after the 15th day of the month.

Capitation Liaison

A Horizon BCBSNJ Capitation Liaison is available at capitation_liaison@HorizonBlue.comto respond to your capitation-related issues, including concerns and questions about:

Your Horizon BCBSNJ capitation payment.
The members of your Horizon BCBSNJ patient panel.
The services that are included in the capitation payment.
The correct application of copayments on your capitation report.

To expedite our investigation and response, please include the following information in your email:

Name of your practice.
Office address.
Tax ID Number (TIN) and/or NPI.
Detailed description of the issue.
Any applicable member ID numbers.

Capitation Adjustment Request Forms Capitation adjustment request forms are available online. To access this information:

Visit HorizonBlue.com/Providers.
Mouse over Forms.
Select Forms by Type, then Inquiry/Request and select Request Form – Adjustment to Capitation for Multiple People or Request Form – Adjustment to Capitation for One Person.

Fax completed capitation adjustment request forms to 1-973-274-4530.

Bulk Move of Members

We will initiate a bulk move of members for a terminating PCP to another PCP affiliated with the same tax identification number (TIN). The PCP must be terminating from our network(s) due to death, retirement or leaving the service area. The request to move members must be submitted in writing along with the termination request.

Reconciliation of Additions and Deletions to Panel

Horizon BCBSNJ will make periodic adjustments to the Base Monthly Capitation due to changes in your panel, but will not honor requests for adjustments that date more than 12 months back from the date Horizon BCBSNJ receives the initial request. Changes to your panel may occur for the following reasons:

Newborn enrollment (ADD) – Most of our members’ accounts require applications for newborns to be received by the employer group within 30 days from the date of birth. The application must then be forwarded to Horizon BCBSNJ for enrollment processing.
Retroactive enrollment, change of an employer group to the plan or individual member to an employer group (ADD/DELETE).
PCP changes made or processed after capitation checks have been generated (ADD/DELETE).
Change in PCP group practice affiliation (ADD/DELETE) – Horizon BCBSNJ must be notified in writing within 10 business days of such changes.

Positive adjustments processed by Horizon BCBSNJ prior to the generation of the current Base Monthly Capitation will generate extra payments to you or your group and will be paid in the current month’s Base Monthly Capitation payment. Those adjustments processed after the generation of the current Base Monthly Capitation cycle will be included in the subsequent month’s Base Monthly Capitation payment.

Likewise, negative adjustments processed by Horizon BCBSNJ prior to the generation of the current Base Monthly Capitation will be an offset against other adjustments or against your Base Monthly Capitation amount in the current month’s Base Monthly Capitation payment. Those negative adjustments processed after the generation of the current Base Monthly Capitation will be applied to the subsequent month’s Base Monthly Capitation payments.

All adjustments are reflected on the monthly Capitation Report within the guidelines mentioned on the previous page and will be indicated as an ADD or DELETE next to the member’s name.

All adjustments, offsets or payments are made by the end of the 12-month period.

Under no circumstances will adjustments be made beyond 12 months for members who join or leave your panel. If eligible claims incurred on a date of service more than 12 months prior to Horizon BCBSNJ’s receipt of request for addition of that individual to a panel, the claims will be reimbursed

on a fee-for-service basis and not through an adjustment or reconciliation to a capitation payment, unless we have agreed otherwise with the employer group.

Services reimbursed to you or your group which should have been considered under capitation may be netted against future claim payments.

Lastly, Horizon BCBSNJ will not make adjustments to panels beyond the 12 months when notification for a physician group affiliation change is not sent timely to Horizon BCBSNJ. However, timely filed claims for eligible billable services, as listed, will be considered for fee-for-service reimbursement.

Under no circumstances will Horizon BCBSNJ reimburse claims incurred beyond 12 months from the date of the initial request.

CAPITATED SERVICES

Services in the following categories are included in capitation:

Evaluation and Management Services1
Physicals and Routine Office Visits
Consultations with Your Own Patient
Routine Hospital Care, excluding ICU
Electrocardiogram (EKG) and/or Rhythm Strip
Urinalysis, Routine only
Hemoglobin and Hematocrit
Spirometry
Tympanograms/Hearing/Speech/Vision Screens²

1 Special services are billable under Billable Services for Capitated PCPs

2 Additional testing should be referred to the appropriate specialist.

BILLABLE SERVICES FOR CAPITATED PCPS

In addition to capitation, PCPs may bill for some special services. You will receive fee-for-service reimbursement for these services.

Primary Care Physicians (PCPs) may access a current list of billable services online. Our Billable Services for Capitated PCPs identifies the special services and immunizations that capitated PCPs may bill for and receive fee-for-service reimbursement, in addition to their capitation payment from HorizonBlue.com/pcplists.

If you have questions, contact your Network Specialist.

BILLABLE SERVICES FOR FEE-FOR-SERVICE PCPS

PCPs in solo or group practices who receive fee-for-service reimbursement for services provided to members enrolled in Horizon BCBSNJ managed care plans, may bill for and receive fee-for-service reimbursement for all current procedure codes appropriate for their specialty.

All reimbursements for services provided to Horizon BCBSNJ members are subject to the limits imposed by the physician’s contract and the member’s benefits.

This information may be subject to change. Physicians will be notified of any changes.

FEE INFORMATION AVAILABLE ONLINE

You can access our Fee Schedule information online. Our managed care and PPO fee schedules are based primarily on Resource-Based Relative Value Scale (RBRVS) methodology and the Centers for Medicare & Medicaid Services (CMS) fee schedule.

Please note that our Fee Schedule information is subject to change upon notice. Fee information is not a guarantee of the reimbursement amount for a particular service. Claim reimbursement is subject to member eligibility, the applicable fee schedule in effect when Horizon BCBSNJ processes the claim, and all member and group benefit limitations, conditions and exclusions. Payments are subject to contract limitations and can only be determined upon receipt of a claim.

To access our fee information – including Injectable Medication Fee Schedule information – registered NaviNet users should:

Log on to NaviNet.net and select Horizon BCBSNJ from the My Health Plans menu.
Mouse over Claim Management and select
Fee Schedule Inquiry.
On the Fee Schedule Inquiry page, select your Billing (Tax) ID number, County and Specialty.
Then, based on the information you’re seeking, you may either:
- View our fees for the most common CPT and HCPCS codes for that specialty; or
- Enter specific CPT and/or HCPCS codes for that specialty and view our allowances for those specific services.

Injectable Medication Fee Schedule Information Updates

Horizon BCBSNJ updates our Injectable Medication Fee Schedule information on a quarterly basis (on or around the first day of February, May, August and November).

Revised information will be available online following the implementation of each quarterly update.

ANESTHESIA REIMBURSEMENT GUIDELINES

Below are some reimbursement guidelines for eligible anesthesia services for participating and nonparticipating physicians. The overall anesthesia service(s) performed during a given procedure will not exceed 100 percent of the contracted benefit. Eligible anesthesia services provided by a physician or a Certified Registered Nurse Anesthetist (CRNA) will be reimbursed as follows:

Modifier	Description of service	Services are:
AA	Anesthesia services performed personally by the anesthesiologist.	Reimbursed at 100 percent of the applicable Horizon BCBSNJ fee schedule.
AD	Medical supervision by a physician for more than four concurrent anesthesia procedures.	Reimbursed at 50 percent of the applicable Horizon BCBSNJ fee schedule.
QK	Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals.	Reimbursed at 50 percent of the applicable Horizon BCBSNJ fee schedule.
QY	Medical direction of one CRNA by an anesthesiologist.	Reimbursed at 50 percent of the applicable Horizon BCBSNJ fee schedule.
QX	CRNA service with medical direction by a physician.	Reimbursed at 50 percent of the applicable Horizon BCBSNJ fee schedule.
QZ	CRNA service without medical direction by a physician.	Not eligible and will be denied. Some Medicare products are excluded from the QZ denial per CMS guidelines.

Include the above-listed modifiers in the first position to ensure correct reimbursement.

ANESTHESIA REIMBURSEMENT CALCULATION

Horizon BCBSNJ reimburses for anesthesia services based on the following formula:

Base Value Units + Time Units x Conversion Factor = Reimbursement

TIME AND ANESTHESIA CLAIMS

When submitting anesthesia claims electronically, please be sure to include the information in the table below.

Loop	Element	Description
2300	NTE02	ADD
2300	NTE03	Anesthesia start to stop time in military time separated by a dash with no spaces (e.g., HH:MM - HH:MM)
2400	SV104	Total number of minutes that anesthesia was provided
2400	SV103	MJ qualifier

When submitting anesthesia claims on a CMS 1500 form, be sure to include the anesthesia start-to-stop time in military time separated by a dash with no spaces (e.g., HH:MM - HH:MM) in the supplemental information section in Box 24 (shaded upper row).

TIME AND ANESTHESIA CLAIMS (continued)

Our claims processing system calculates time units based on the total time that anesthesia was provided. Time units are calculated in 15-minute intervals. Our system will round additional time greater than eight minutes up to the next unit. Our system will round down additional time seven and fewer minutes.

For example:

30 minutes of anesthesia is equal to two units (30=15+15)
38 minutes of anesthesia is rounded up to three units (38=15+15+8)
37 minutes of anesthesia is rounded down to two units (37=15+15+7)

ANESTHESIA FOR VAGINAL AND CESAREAN SECTION DELIVERIES

Anesthesia for deliveries may follow unique rules, based on the type of delivery performed.

Anesthesia for normal vaginal delivery is reimbursed based on a flat case rate (rates vary by geographic region).
Cesarean section delivery is reimbursed based on a time calculation.
A normal vaginal delivery that becomes a cesarean section delivery is reimbursed at a special rate that combines both a case rate plus a time calculation.

Horizon BCBSNJ reserves the right to change our obstetric reimbursement methodology.

CERTIFIED REGISTERED NURSE ANESTHETIST (CRNA)

Anesthesia services provided by a CRNA are eligible for reimbursement provided that the CRNA is employed by, or under the supervision of, an anesthesiologist.

When billing Horizon BCBSNJ for services rendered, submit your full charges for the applicable CPT-4 codes on both the CRNA claim line and the anesthesiologist claim line. Do not split the total charge between the CRNA and the anesthesiologist. Our systems will adjudicate the claim lines to calculate 50 percent of our allowance for both the CRNA and the supervising anesthesiologist for the service provided.

Please also append the claim lines with the appropriate modifier as indicated in the table below:

To view our anesthesia guidelines online, log in to NaviNet.net and:

Mouse over References and Resources and click Provider Reference Materials.
Click Reimbursement and Billing.
Click Reimbursement and Billing Guidelines for Anesthesia Claims.

Products

horizonbcbsnj — Mon, 30 Dec 2019 11:15:56 +0000

Products Mon, 12/30/2019 - 06:15

This section provides an overview of many of the products we offer and/or service.

Additional product information is available at HorizonBlue.com/providers-products.

Your Responsibilities

The following responsibilities apply to you as a participating physician or other health care professional:

You may collect copayment amounts as indicated on the member’s ID card.
You are expected to bill members for the appropriate member liability (deductible and/or coinsurance), as indicated on the Explanation of Payment (EOP) you receive.
You are required to accept our allowance for eligible services as payment in full.

Pre-existing Exclusions

The Affordable Care Act removed the pre-existing medical condition exclusion for both new employer-based health insurance plans and new individual health insurance plans. Health insurance companies cannot charge higher premiums for current and past health problems, gender and a person’s occupation. Also, insurers cannot refuse to sell coverage or renew coverage because of a

pre-existing medical condition and cannot deny claim payments because of a pre-existing medical condition.

The ACA does not require health insurers to remove the pre-existing condition exclusion from Medicare, Medigap and Medicaid plans. Horizon BCBSNJ currently only applies a pre-existing condition waiting period on Medigap coverage.

The effective date of the removal of the pre- existing condition exclusion will vary.

The State Health Benefits Program and Federal Employee Program® do not have pre-existing condition restrictions.

HORIZON MANAGED CARE NETWORK

If you are a participating Horizon Managed Care Network health care professional, members enrolled in the following plans use their in-network benefits when they receive care from you. Note that the Horizon Medicare Blue Advantage (HMO) uses a subset of the Managed Care Network.

HMO1

Horizon HMO
Horizon HMO Access
Horizon HMO Access Value
Horizon HMO Coinsurance
Horizon HMO Coinsurance Plus
Horizon HMO (SHBP and SEHBP)
Horizon HMO1525 (SEHBP)
Horizon HMO2030 (SEHBP)
Horizon HMO2035 (SEHBP)

Direct Access

Horizon Direct Access
Horizon Advantage Direct Access
Horizon Direct Access Value
NJ DIRECT ZERO (SHBP and SEHBP)
NJ DIRECT10 (SHBP and SEHBP)
NJ DIRECT15 (SHBP and SEHBP)
NJ DIRECT1525 (SHBP and SEHBP)
NJ DIRECT2030 (SHBP and SEHBP)
NJ DIRECT2035 (SHBP and SEHBP)

EPO1

OMNIA Health Plans
Horizon Advantage EPO
Horizon Patient-Centered Advantage EPO

Consumer-Directed Healthcare (CDH)

Horizon HMO Access HSA
Horizon HSA/HRA (Direct Access)
OMNIA HSA/HRA
NJ DIRECT HD1500 (SHBP and SEHBP)
NJ DIRECT HD4000 (SHBP)

POS

Horizon POS

Medicare Advantage

Horizon Medicare Blue Value (HMO)¹
Horizon Medicare Blue Value w/Rx (HMO)¹
Horizon Medicare Blue Choice w/Rx (HMO)1
Horizon Medicare Blue Advantage (HMO)1
Horizon Medicare Blue Select (HMO-POS)
Horizon Medicare Blue Access Group (HMO-POS)
Horizon Medicare Blue Access Group w/Rx (HMO-POS)
Horizon Medicare Blue Access Group w/Rx Value (HMO-POS)
Horizon Medicare Blue (PPO)
Horizon Medicare Blue Group (PPO)
Horizon Medicare Blue Group w/Rx (PPO)
Horizon Medicare Blue Group w/Rx Ideal (PPO)
Horizon Medicare Blue Group w/Rx Complete (PPO)

HORIZON MANAGED CARE NETWORK NJPA

Effective January 1, 2020, certain Individual and Small Group Market plans (HMO, POS and Advantage EPO plans without BlueCard benefits) will now be part of the Horizon Managed Care Network NJPA. Member ID cards for this plan will say “NJPA” along with the plan name.

HORIZON HMO

Horizon HMO members select a PCP who will either provide the necessary care or refer them to the appropriate specialist or facility. Members receive full benefit coverage, including coverage for preventive care, when services are provided or referred by their PCP.

Copayments

Horizon HMO offers various office visit copayments. Carefully check the member’s ID card for the copayment amount due for an office visit.

Coinsurance

Some Horizon HMO members are required to pay a coinsurance payment for most services that are not performed in an office setting.

Well Care

Well care, such as routine adult physicals and well child care, are covered under capitation. If you are a fee-for-service PCP, well care is also covered and billable. Immunizations are billable for capitated and fee-for-service PCPs (subject to plan limitations).

Obstetrical/Gynecological Care

Horizon HMO members may go directly to participating Ob/Gyns for obstetrical and gynecological-related care. They do not require a referral from their PCP for these services. However, certain infertility services require prior authorization.

Most members do not need a referral from their PCP or Ob/Gyn for routine mammography services (CPT Codes 76090, 76091 and 76092). Give these members a prescription to present to the radiology center.

Annual Vision Exam

If included in their contract, members are eligible for one routine vision exam per year by a participating physician or other health care professional. This service does not require a referral from the PCP. Members are also eligible for a vision hardware reimbursement every two years.

Most members who have diabetes may go directly to a participating eye care physician for a dilated retinal exam without a referral from their PCP. Advise the member to check their Horizon HMO member handbook or Evidence of Coverage for specific details.

Chiropractic Coverage

Most Horizon HMO members may go directly to participating chiropractors. This means they may not require a referral from their PCP to visit a participating chiropractor (subject to plan limitations).

Behavioral Health/Substance Use Disorder Care Physicians may contact Horizon Behavioral Health to refer most patients for behavioral health or substance use disorder care.

HORIZON HMO ACCESS AND HORIZON HMO ACCESS VALUE

Under Horizon HMO Access plans, members may receive care from Horizon Managed Care Network specialists without a referral.

Members enjoy both the benefits of working with a selected PCP and the freedom to coordinate their needs without a referral. Members may not

self-refer to PCP-type providers; they must use their preselected PCP.

Split Copayments

Horizon HMO Access plans include split copayments for physician services. A lower office visit copayment applies to visits to preselected PCPs. A higher office visit copayment applies to office visits to non-preselected PCPs, all other participating PCP-type physicians and other health care professionals, and to participating specialist office visits.

Other Copayments

Horizon HMO Access includes various inpatient and outpatient facility copayments and other professional health care services.

Coinsurance

Some Horizon HMO Access members are required to pay a coinsurance payment for most services not performed in an office setting, including Durable Medical Equipment.

Referrals

Horizon HMO Access members may visit participating specialists without a referral. Preapproval is required for some services.

Out-of-Network Benefits

Horizon HMO Access members have no out-of-network benefits.

Prescriptions

Member charges for prescription drug services do not accumulate to the maximum out of pocket (MOOP).

Well Care

Well care such as routine adult physicals, annual Ob/Gyn exams, well child care and immunizations are covered and billable. Coverage limitations exist and vary per contract.

Annual Vision Exam

Some Horizon HMO Access members are eligible for an annual vision exam or vision hardware reimbursement. Since this program does not use referrals, they are not needed. Coverage limitations exist and vary per contract.

Horizon HMO Access Value

The Horizon HMO Access and the Horizon HMO Access Value plans are identical except that Horizon HMO Access Value includes:

A higher specialist copayment amount
A lower maximum out-of-pocket amount
A higher hospital inpatient copayment amount

HORIZON HMO COINSURANCE AND HORIZON HMO COINSURANCE PLUS

The Horizon HMO Coinsurance and Horizon HMO Coinsurance Plus plans are managed care products. They require PCP selection, use of the Horizon Managed Care Network and referrals/ precertification to receive benefits. Out-of-network services are not covered under these plans.

These plans offer 100 percent coverage after office visit copayment for all services received in a network practitioner’s office. For all other network services, coverage is subject to deductible and coinsurance.

The deductible applies to all services rendered outside of the physician’s office except for:

Diagnostic lab work and X-ray
Emergency Room care
Prescription drugs

HORIZON HMO (SHBP AND SEHBP) HORIZON HMO1525 (SEHBP)

HORIZON HMO2030 (SHBP AND SEHBP)

Horizon BCBSNJ offers members of the State Health Benefits Program (SHBP) and School Employees’ Health Benefits Program (SEHBP) access to the following HMO options:

Horizon HMO10
Horizon HMO15
Horizon HMO1525
Horizon HMO2030
Horizon HMO2035

These plans provide safe and effective care through physicians, health care professionals and facilities that participate in the Horizon Managed Care Network.

Horizon HMO members must select a Primary Care Physician (PCP) and referrals are required.

The numbers in the health plan names reflect the physician office visit copayment levels:

Horizon HMO10 and Horizon HMO15 feature a $10 and $15 physician (PCP and specialist) office visit copayment, respectively.
Horizon HMO1525, Horizon HMO2030 and Horizon HMO2035 plan options feature split copayment levels. The lower copayment level in each of these plans ($15 and $20) applies to office visits to PCPs. The higher copayment level and the in each of these plans ($25 and

$35) applies to office visits to specialists.

These plans also offer:

100% coverage for preventive services (physical exams, well-child care, immunizations) in network. All SHBP and SEHBP plans offer preventive care services, as defined by the Patient Protection and Affordable Care Act (PPACA) with no member cost share (no copayment, not subject to deductible) when provided by a participating practitioner.
Access to specialty care with a referral from your PCP. (Referrals are not required for chiropractic care).
Guest Membership in our “Away from Home” care program if you or a covered family member will be traveling or out of the area for a longer period.

HORIZON DIRECT ACCESS

Our Horizon Direct Access products allow members to visit participating specialists without a referral from a PCP. Horizon Direct Access is similar to a POS product by offering two levels of benefits: in network and out of network.

Members are encouraged to select a PCP to help them access the appropriate medical care,

however, it is not required. PCPs are encouraged to refer members to participating physicians and other health care professionals.

Members are responsible for sharing the cost of their health care. For in-network care, this can amount to a basic office copayment, a deductible or coinsurance. Patients who receive care out of network, pay a higher share of the costs, sometimes including higher deductibles, coinsurance and/or copayment amounts.

No Referrals

This product does not require referrals for

in-network professional services. PCPs do not need to complete referrals for the member to receive care from a specialist or facility.

Prior Authorization

Please obtain prior authorization when referring a Horizon Direct Access member to an in-network or out-of-network facility for inpatient and outpatient care.

By obtaining the authorization, your patient may incur lower out-of-pocket expenses.

In-Network Benefits

To receive the highest level of benefits, members must access care from a participating physician, other health care professional or facility in the Horizon Managed Care Network. When a Horizon Direct Access member receives care from a participating physician, other health care professional or network facility, they are covered at the in-network level of benefits and incur lower out- of-pocket costs.

Out-of-Network Benefits

Out-of-network benefits apply when members do not use a Horizon Managed Care Network physician, health care professional or facility.

Members pay a higher share of the costs for out-of- network care, usually including deductible and/or coinsurance amounts.

Help your Horizon Direct Access members save money by encouraging them to receive all medical care and services from our large, comprehensive network of participating physicians, facilities and other health care professionals. This can significantly reduce their out-of-pocket costs and paperwork submissions and may also increase their satisfaction with your services.

We recognize that there may be instances in which a service is not available in network. If a member’s care is coordinated by their PCP and the proper authorization is obtained, eligible and medically necessary out-of-network services may be covered at the in-network level of benefits.

Horizon Direct Access and BlueCard

Horizon Direct Access is a managed care product. These ID cards display the PPO-in-the-suitcase logo indicating that these members have access to PPO physicians and health care professionals when receiving services outside of New Jersey.

Well Care

Well care, such as routine adult physicals, annual Ob/Gyn exams, well child care and immunizations, is covered and billable. Coverage limitations exist and vary per plan.

Annual Vision Exam

Some Horizon Direct Access members are eligible for an annual vision exam or vision hardware reimbursement. Since this plan does not use referrals, they are not needed. Coverage limitations exist and vary per benefit plan.

Chiropractic Coverage

Horizon Direct Access members are eligible for chiropractic care from a participating chiropractor. Referrals are not needed. Coverage limitations exist and vary per benefit plan.

HORIZON ADVANTAGE DIRECT ACCESS

Horizon Advantage Direct Access plan are similar to Horizon Direct Access plans but include:

Split copayments: Lower office visit copayments for PCP visits and higher office visit copayments for all other physicians. Members are not required to select a PCP; however, the lower copayment for PCP services is only available for a PCP-type doctor (a participating physician specializing in family practice, general practice, internal medicine or pediatrics).
Separate (and higher) out-of-network deductible amounts and maximum out-of- pocket (MOOP) levels to help discourage out-of-network utilization. The deductible and MOOP do not cross accumulate between the in-network and out-of-network benefits.
These plans also include a $2,000 benefit maximum for out-of-network ambulatory surgery centers.

NJ DIRECT

Horizon BCBSNJ administers seven direct access plans on behalf of the New Jersey State Health Benefits Program (SHBP) and School Employees’ Health Benefits Program (SEHBP).

All NJ DIRECT plans:

Do not require PCP selection or referrals.
Allow members to receive care in or out of network.
Require prior authorization for certain services (refer to the online prior authorization list).
Use the Horizon Managed Care Network in New Jersey and the national BlueCard PPO network outside of New Jersey.
Cover eligible preventive care services, as outlined in the federal health care reform law, the Patient Protection and Affordable Care Act (PPACA), with no member cost share when rendered in network.

NJ DIRECT copayment plans

SHBP/SEHBP members may select one of four copayment plans:

NJ DIRECT ZERO

NJ DIRECT10
NJ DIRECT15
NJ DIRECT1525
NJ DIRECT2030
NJ DIRECT2035

For these plans, NJ DIRECT will pay the full cost of in-network services (based on contracted rate), in most cases, after appropriate member copayment per visit. Services rendered out of network are subject to deductible and a percentage of coinsurance based on plan allowance.

The number in the plan name (ZERO, 10, 15, 1525, 2030 or 2035) refers to the primary and specialty provider office visit copayment.

NJ DIRECT ZERO has $0 copay for primary and specialty office visit copayments.
NJ DIRECT10 and NJ DIRECT15 have primary and specialty office visit copayments of $10 or $15.
NJ DIRECT1525 has a primary office visit copayment of $15; specialty office visit copayment is $25.
NJ DIRECT2030 has a primary office visit copayment of $20; specialty office visit copayment is $30 for adults, but $20 for children. A child is defined as eligible until the end of the year in which age 26 is reached. Once the 26th year is completed, the member is considered an adult (including disabled dependents who have extended coverage).
NJ DIRECT2035 has a primary office visit copayment of $20; specialty office visit copayment is $35/20 percent after deductible at an outpatient facility.
Primary office visit copayments apply to primary care physicians (internists, general practitioners, family practitioners, pediatricians, PAs, APRNs.)
Specialty office visit copayments apply to in-network specialist visits including non-routine Ob/Gyn services, short-term therapist visits (occupational therapy, speech therapy, physical therapy, respiratory therapy, and cognitive therapy) and chiropractic visits.
The Emergency Room copayment (waived if admitted) varies by plan.
The appropriate copayment amounts are indicated on the member’s ID card.
Nonbiologically based mental illness behavioral health services (in-network) are subject to in-network office visit copayment.

High-Deductible (HD) Health Plans
SHBP/SEHBP members may select one of two high-deductible plans.

NJ DIRECT HD1500
NJ DIRECT HD4000

In the High-Deductible Health Plans, all eligible services (except for eligible preventive services) are subject to deductible, coinsurance and out-of- pocket maximums before services will be considered for benefit. No copayments apply.

The plan is combined with a Health Savings Account (HSA) that can be used to pay for qualified medical expenses.

The number in the plan’s name (1500, 4000) refers to the individual deductible, which is doubled for non-single contracts, and is combined for in- and out-of-network medical services and prescription drugs.
Members are responsible for expenses, in and out of network, up to the deductible.
After the annual deductible is met, the member is responsible for 80 percent of the contracted rate in network and 60 percent of the plan allowance out of network.
If eligible expenses reach the out-of-pocket maximum, eligible services will be covered at 100 percent, subject to all provisions of the plan.

For more information about NJ DIRECT, visit HorizonBlue.com/SHBP.

SHBP/SEHBP: Multiple coverages prohibited

A New Jersey state law enacted in 2010 prohibits multiple coverage under the State Health Benefits Program (SHBP) and/or the School Employees’ Health Benefits Program (SEHBP).

This means:

An employee or retiree cannot be enrolled for coverage as both a subscriber and a dependent under the SHBP and/or SEHBP.
An employee cannot be enrolled for coverage as an employee and as a retiree under the SHBP/SEHBP.
Children cannot be enrolled as dependents for coverage under both SHBP/SEHBP covered parents.
NJ DIRECT members who have coverage under a non-SHBP/SEHBP plan can maintain enrollment in NJ DIRECT and the non- SHBP/SEHBP plan.

OMNIASM HEALTH PLANS

Our OMNIA Health Plans give enrolled members the flexibility to visit any New Jersey health care professional in our broad Managed Care Network.

OMNIA Health Plan members incur lower

out-of-pocket costs when they use OMNIA Tier 1 doctors, hospitals and other health care professionals.

These products are offered to individual consumers purchasing coverage on and off the Health Insurance Marketplace (Exchange) as well as to employer groups of all sizes, including the

New Jersey SHBP.

OMNIA Health Plan Metallic Levels
OMNIA BRONZE

Our lowest premium Bronze plan offers members the lowest monthly premium but highest

out-of-pocket costs compared to other OMNIA Health Plans. Bronze plans, on average, pay for 60 percent of the covered medical expenses; members pay 40 percent.

OMNIA SILVER

Our Silver plan offers mid-level monthly premium and out-of-pocket costs compared to other OMNIA Health Plans. Silver plans, on average, pay for 70 percent of the covered medical expenses; members pay 30 percent. Cost-sharing subsidies may be available with this plan.

OMNIA SILVER HSA

Our Silver plan offered in conjunction with a Health Savings Account (HSA) includes mid-level monthly premium and out-of-pocket costs compared to other OMNIA Health Plans. Silver plans, on average, pay for 70 percent of the covered medical expenses; members pay 30 percent. Cost-sharing subsidies may be available with this plan.

OMNIA SILVER VALUE

Our lowest premium Silver plan offers mid-level monthly premium and out-of-pocket costs compared to other OMNIA Health Plans. Silver plans, on average, pay for 70 percent of the covered medical expenses; members pay 30 percent. Cost-sharing subsidies may be available with this plan.

OMNIA GOLD

Our lowest premium Gold plan offers higher monthly premium and lower out-of-pocket costs compared to other OMNIA Health Plans. Gold plans, on average, pay for 80 percent of the covered medical expenses; members pay 20 percent.

OMNIA PLATINUM

Our lowest premium Platinum plan offers highest monthly premium and lowest out-of-pocket costs compared to other OMNIA Health Plans. Platinum plans, on average, pay for 90 percent of the covered medical expenses; members pay 10 percent.

Other OMNIA Health Plans

Large group employers, National Accounts, ASOs, Labor Accounts and Public Sector Accounts that select OMNIA Health Plans will have the ability to customize their OMNIA Health Plan benefits programs to include a range of benefit options, including BlueCard coverage and variations in Tier 2 out-of-pocket costs.

OMNIA Tier Status

All Horizon Managed Care Network physicians, other health care professionals and in-network hospitals are participating with OMNIA Health Plans; however, OMNIA members will have lower cost sharing when they use physicians, health care professionals and hospitals with the OMNIA Tier 1 designation.

To make it easier for members to understand their cost-sharing responsibilities, all physicians and other health care professionals affiliated with, or who practice under or on behalf of a group practice, will participate with OMNIA Health Plans at the same tier when treating members under a particular Group Tax ID Number (TIN).

Ancillary facilities and ancillary professionals that participate in our Horizon Managed Care Network will be designated OMNIA Tier 1. Some exceptions apply.

Use our Online Doctor & Hospital Finder to review OMNIA tier status information.

OMNIA Tier Awareness Administrative Policy We encourage all participating managed care network physicians and other health care professionals to review our OMNIA Tier Awareness administrative policy.

This policy includes guidelines that participating physicians and other health care professionals are required to follow when they treat, help to coordinate the care of, refer, recommend or advise patients enrolled in OMNIA Health Plans to seek specialty care and/or treatment at a health care facility or hospital.

The guidelines of this policy are designed to help ensure that patients enrolled in OMNIA Health Plans understand the benefit and cost-sharing implications of using physicians, other health care professionals and facilities designated as OMNIA Tier 1 or Tier 2.

To access this policy, registered NaviNet users should log in to NaviNet.net, select Horizon BCBSNJ from the My Health Plans menu, and:

Mouse over References & Resources and select Provider Reference Materials.
Mouse over Policies & Procedures.
Select Policies, then Administrative Policies.
Select Tier Awareness Policy.

No Out-of-Network Benefits

Members enrolled in OMNIA Health Plans do not have ANY benefits for out-of-network services.

OMNIA Health Plan members must use physicians, other health care professionals and hospitals who participate in the Horizon Managed Care Network and Horizon Hospital Network*, except in cases of medical emergencies.

* OMNIA Health Plans offered to large group employers, National Accounts, ASOs, Labor

Accounts and Public Sector Accounts may be customized to include a range of benefit options, including BlueCard® coverage, that are not available in the individual consumer and small employer markets.

Primary Care Physician (PCP) Selection

OMNIA Health Plan members are NOT required to select a Primary Care Physician (PCP).

Referrals

Referrals are not required for OMNIA Health Plan members to see a participating Horizon Managed Care network specialist.

Prior Authorizations

Prior authorizations are required for certain services.

Preventive Care

Eligible preventive services (physical exams, well-child care, immunizations, etc.) are covered with no member cost-sharing when provided by a doctor or other health care professional participating in the Horizon Managed Care Network.

Cost Sharing

OMNIA Health Plan member cost sharing (copayments, deductibles and coinsurance amounts) will vary based on the type of plan, the place of service and the tier status of the provider of service. Carefully review the OMNIA Health Plan member’s Horizon BCBSNJ ID card for the appropriate cost sharing amount.

Laboratory Services

Members are required to use an in-network clinical laboratory provider. You or the member can use our Online Doctor & Hospital Finder to locate

in-network laboratories.

Pharmacy/Prescription Benefits

Each standard OMNIA Health Plan includes a pharmacy benefit.1 OMNIA Health Plan members must use a participating pharmacy. Cost sharing varies based on the plan.

1 Large group employers, National Accounts, ASOs, Labor Accounts and Public Sector Accounts have the option to include a pharmacy benefit in their OMNIA Health Plans.

BlueCard Benefits

Our standard OMNIA Health plans available on– and off the Health Insurance Marketplace (exchange) to consumers and small employer groups DO NOT include BlueCard Benefits.

OMNIA Health Plans offered to large group employers, National Accounts, ASOs, Labor Accounts and Public Sector Accounts may be customized to include a range of benefit options, including BlueCard® coverage.

The PPO-in-a-suitcase logo will be displayed on ID cards of any members enrolled in OMNIA Health Plans that include BlueCard benefits.

HORIZON ADVANTAGE EPO

Horizon Advantage Exclusive Provider Organization (EPO) plans provide in-network only benefits through the Horizon Managed Care Network.

PCP Selection

Members enrolled in Horizon Advantage EPO plans are NOT required to select a Primary Care Physician.

Referrals

Referrals are NOT required for members to see specialists who participate in the Horizon Managed Care Network.

No Out-of-Network Benefits

Members enrolled in Horizon Advantage EPO plans have NO benefits for out-of-network services. Members enrolled in Horizon Advantage EPO plans must use physicians who participate in our Horizon Managed Care Network (except in the case of medical emergencies).

Members enrolled in Horizon Advantage EPO plans have no benefits for services provided by physicians and other health care professionals participating in the Horizon PPO Network.

BlueCard Program Access

Certain employer groups may choose to provide their members with access to the BlueCard® PPO program.

If a member’s Horizon Advantage EPO ID card includes the: PPO-in-the-suitcase logo or the empty-suitcase logo, they have access to the BlueCard® PPO program for services provided outside our local service area.

The PPO-in-the-suitcase logo identifies a member who has benefits for medical services received outside Horizon BCBSNJ’s service area. It does not mean that these members can see a participating Horizon PPO Network physician or other health care professional.

Horizon Advantage EPO plans must use physicians who participate in our Horizon Managed Care Network (except in the case of medical emergencies).

HORIZON PATIENT-CENTERED ADVANTAGE EPO

The Horizon Patient-Centered Advantage EPO plan is offered to employer groups and provides in-network only benefits through the Horizon

Managed Care Network. This plans builds upon our patient-centered programs, which include our Patient-Centered Medical Home (PCMH) and Accountable Care Organization (ACO) programs.

Our Horizon Patient-Centered Advantage EPO plan is similar to our other Horizon Advantage EPO plans, except this plan uses different member cost-sharing levels to encourage enrolled members to select and use a Primary Care Physician (PCP) affiliated with one of our established PCMH and/or ACO practices. Horizon Patient-Centered Advantage EPO members incur a lower out-of-pocket expense when they select and use a PCP who participates in one of our patient-centered programs. No PCP selection is required. However, members pay less out of pocket when they select and use a PCP who participates in our patient-centered programs.

Referrals are not required for members to see specialists who participate in the Horizon Managed Care Network. Preventive services, screenings and immunizations are covered with no member cost sharing when services are received from an in-network provider. Except in the case of medical emergencies, members have no benefits for out-of-network services. Referrals are not required to see specialists. Members must use LabCorp or Quest Diagnostics for laboratory services.

Member cost sharing for primary care and specialist visits vary for each plan. Please confirm specific benefits for members enrolled in the Horizon Patient-Centered Advantage EPO plan.

CONSUMER-DIRECTED HEALTHCARE (CDH) PLANS

Horizon BCBSNJ offers innovative Consumer- Directed Healthcare (CDH) products that incorporate a Health Reimbursement Arrangement (HRA) or a Health Savings Account (HSA) with a high-deductible medical plan. In addition, Horizon BCBSNJ provides a wide variety of tools and resources to help your patients make their health care decisions.

Key Features of CDH Plans

Copayments – Physicians, other health care professionals and facilities should collect copayments during visits (if applicable).

Copayment information will appear on the member’s ID card.

No referrals required for specialists – This reduces the administrative process for you and members.

Individual spending accounts – Horizon MyWay plans are combined with individual spending accounts, such as Health Savings Accounts (HSAs), Health Reimbursement Arrangements (HRAs) and Flexible Spending Accounts (FSAs). Members can draw from these accounts to pay for medical expenses not covered by their health plan, including deductibles and coinsurance.

The member’s ID card will indicate whether a member has a HRA or HSA.

Members without a card can pay online or through the Horizon MyWay mobile app, which offers a range of tools to help them manage their health spending and supplemental accounts.

Preventive Care – Generally, to promote wellness, routine preventive care services that are coded as such are covered at 100 percent. This includes childhood immunizations.

The following services are examples of preventive care:

Periodic health evaluations, including tests and diagnostic procedures ordered in connection with routine examinations, such as annual physicals
Routine prenatal and well-child care
Child and adult immunizations
Tobacco cessation programs
Obesity/weight-loss programs
Age-specific screenings

Horizon MyWay – Direct Access Plan Design The Horizon MyWay Direct Access product combines a high-deductible Horizon Direct Access plan with a spending/savings account. This health plan offers in- and out-of-network benefits and covers preventive care at 100 percent in network. Members maximize benefits by using participating managed care physicians, other health care professionals and participating facilities.

You can identify Horizon MyWay HRA/HSA Direct Access members by the following ID card prefixes:

Horizon MyWay – PPO Plan Design

The Horizon MyWay PPO product combines a high-deductible PPO plan with a medical account. This health plan offers in- and out-of-network benefits and covers preventive care at 100 percent in network. Members can maximize benefits by using participating PPO physicians, health care professionals and participating facilities.

You can identify Horizon MyWay HRA/HSA PPO members by the following ID card prefixes:

Horizon MyWay – HMO Access Plan Design The Horizon MyWay HMO Access product combines a high-deductible Horizon HMO Access plan with a spending/savings account. This health plan offers in network benefits only and covers preventive care at 100 percent. Members must use participating managed care physicians, other health care professionals and contracting facilities.

You can identify Horizon MyWay HSA HMO Access members by the following ID card prefix:

SHBP/SEHBP High-Deductible Plans

The New Jersey State Health Benefits Program (SHBP) and the School Employees’ Health Benefits Program (SEHBP) committees offer enrolled members access to two high-deductible plans designs: NJ DIRECT HD1500 and NJ DIRECT HD4000. These plans offer in- and out-of-network benefits and include $0 copayments for preventive care services. Members maximize benefits by using participating managed care physicians, other health care professionals and participating facilities.

You can identify NJ DIRECT HD1500 and NJ DIRECT HD4000 members by the following ID card prefix:

Horizon Advantage EPO HSA/HRA

The Horizon Advantage EPO HSA/HRA plans combine our Exclusive Provider Organization plan with either a Health Savings Account (HSA) or Health Reimbursement Arrangement (HRA). These plans provide in-network only benefits through the Horizon Managed Care Network. Members enrolled in Horizon Advantage EPO plans are NOT required to select a Primary Care Physician and referrals are not required for members to see specialists who participate in the Horizon Managed Care Network.

You can identify Horizon Advantage EPO HSA/HRA members by the following ID card prefixes:

HORIZON POS

Horizon POS is a point-of-service program providing the advantages of a HMO, but incorporating patient cost sharing and an option for members to access care from any physician without a referral from their PCP, at a lower level of benefits.

Horizon POS has two levels of benefits: in network and out of network. To receive the highest level of benefits, members must access care through their PCP (and obtain referrals as appropriate).

When members’ care is not coordinated through their PCP, the lower, or out-of-network, benefits apply. Members are given the choice to seek services either in network or out of network at each point of service.

Members are responsible for sharing the cost of their health care. For in-network care, this can amount to a basic office visit copayment, a deductible and/or coinsurance. Patients who go out of network or see a specialist without a PCP referral pay a higher share of the costs, including higher deductibles, coinsurance and copayment amounts.

Employers or association groups select the level of cost sharing for their employees. Horizon POS is designed to encourage members to maximize their benefits by using their PCP.

When Horizon POS members who have not selected you as their PCP come to you without a referral, you should bill us first. We will provide you with an Explanation of Payment (EOP) advising you of our reimbursement and the amount you can collect from your patient.

Well Care

Well care, such as routine adult physicals and well child care, is covered under capitation. If you are a fee-for-service PCP, well care is also covered and billable. Immunizations are billable for capitated and fee-for-service PCPs (subject to plan limitations).

Obstetrical/Gynecological Care

Female Horizon POS members may go directly to participating Ob/Gyns for obstetrical and gynecological-related care. They do not require a referral from their PCP.

Most members do not need a referral from their PCP or Ob/Gyn for routine mammography services. However, give these members a prescription to present to the radiology center.

Annual Vision Exam

Some Horizon POS members are eligible for an annual vision exam or vision hardware reimbursement. This service does not require a referral. If the services are not covered, the member is responsible for these charges.

Certain Horizon POS members are eligible for annual exams only when the PCP issues a referral. You can identify these members by the YHG alpha prefix on their ID card. These groups cover annual eye exams (with a referral) for dependents 17 years or younger only.

Most members who have diabetes may go directly to a participating eye care physician or professional for a dilated retinal exam without a referral from their PCP.

Chiropractic Coverage

Most Horizon POS members are eligible for chiropractic care. Some members may require a referral from their PCP to visit a participating chiropractor. Call to verify chiropractic benefits since some accounts have varying limitations.

HORIZON PPO NETWORK

If you are a participating Horizon PPO Network health care professional, members enrolled in the following plans use their in-network benefits when they receive care from you.

PPO

BCBS Service Benefit Plan (FEP PPO)
BlueCard® PPO
Horizon Advantage PPO
Horizon High Deductible PPO Plan D
Horizon PPO

Indemnity

Basic Blue℠ Plan A
BlueCare®
Comprehensive Health Plan
Comprehensive Major Medical
Horizon Basic Health Plan A
Horizon Basic Plan A/50
Horizon Comprehensive Health Plan A
Horizon High Deductible Plan C
Horizon High Deductible Plan D
Horizon MSA Plan C
Horizon MSA Plan D
Horizon Traditional Plan B, C, D
Major Medical
Medallion
Network Comprehensive Major Medical
Wraparound

Fixed Fee

Medical/Surgical Fixed Fee 14/20 Series
Medical/Surgical Fixed Fee 500 Series
Medical/Surgical Fixed Fee 750 Series
Student Program

Consumer-Directed Healthcare (CDH)

Horizon MyWay HRA
Horizon MyWay HSA

HORIZON PPO

Horizon PPO plans provide members a choice of physicians and hospitals without having to select a Primary Care Physician (PCP).

Members incur lower out-of-pocket costs and higher plan benefits, and do not need to file claims, when they receive care from Horizon PPO Network physicians, other health care professionals or facilities.

Members may also choose to use their out-of- network benefits, which provide access to care from any physician or hospital outside the network in exchange for higher out-of-pocket costs.

Nationwide and worldwide access to medical care is available through the BlueCard PPO program. .

FEDERAL EMPLOYEE PROGRAM

The Federal Employee Program® (FEP®) is a fee-for-service plan (with standard and basic options) with a preferred provider organization that is sponsored and administered by the Blue Cross and Blue Shield Association and participating Blue Cross and/or Blue Shield Plans.

FEP® is a traditional type plan that encourages members to use Preferred or in-network physicians, other health care professionals and facilities to receive the highest level of benefits.

FEP® members may be identified by their unique ID card. Member ID numbers include an R prefix and 8 digits.

Plan highlights include:

PPO reimbursement levels
Referrals are not required
Some services may require prior authorization

Standard Option

Members have the freedom to receive covered services from both Preferred and Nonpreferred health care professionals, hospitals and facilities.

Members who have the Standard Option have a calendar year deductible, and services are subject to a copayment or coinsurance. The annual deductible is $350 per person/$700 per family.

Routine care provided by a preferred health care professional is covered in full.

Office visits for:

Primary Care Provider (PCP)/other health care professional preferred: $25 copayment. Specialist preferred: $35 copayment,
Specialist nonpreferred: Subject to deductible and 35 percent of plan allowance plus difference between plan allowance and billed charge.
Lab, X-ray and other diagnostic tests preferred: Subject to deductible and 15 percent coinsurance. Nonpreferred: Subject to deductible and 35 percent of plan allowance plus difference between plan allowance and billed charge.

Preventive Care adult and children preferred: No member liability. Non-Preferred: Subject to deductible and 35 percent coinsurance plus any difference between the allowance and the billed charge.
Maternity professional care preferred: No member liability. Nonpreferred: Subject to deductible and 35 percent coinsurance plus any difference between the allowance and the billed charge.
Physical, occupational, speech therapies
75-visit limit for any one or a combination of all three.
Preferred PCP/other health care professional:
$20 copayment per visit. Nonpreferred: Subject to deductible and 35 percent of plan allowance plus any difference between plan allowance and billed charge.
Surgery preferred: Subject to deductible then 15 percent of Plan allowance. Nonpreferred: Subject to deductible and 35 percent of plan allowance plus any difference between plan allowance and billed charge.
Inpatient hospital preferred: $250 per admission copayment, unlimited days. Nonpreferred: $350 per admission copayment, 35 percent of allowance and any difference between allowance and charge.
Outpatient hospital (medical/surgery) preferred: Subject to deductible and 15 percent coinsurance. Nonpreferred: Subject to deductible and 35 percent of plan allowance plus any difference between allowance and charge.

Basic Option

Member’s benefits are limited to care performed by Preferred health care professionals, hospitals and facilities, except in certain situations, such as emergency care.

With the Basic Option, members do not have a calendar year deductible; however, most care under the Basic Option is subject to a copayment amount. Routine care provided by a preferred health care professional is covered in full.

Office visits for:

PCP/other health care professional office visit: $30 copayment.
Specialist office visit: $40 copayment.
Blood tests, EKG, Lab tests, pathology services Preferred: $0.
EEG/Ultrasound/X-rays Preferred: $40 copayment.
Bone density, CT scans, MRI/Pet scans preferred: $100 copayment.
Preventive care adult and children preferred: $0.
Maternity professional care preferred: No member liability, inpatient $175 copayment.
Physical, occupational, speech therapies: 50 visit limit any one or combination of all three.
Preferred Primary Care Physician or other health care professional: $30 copayment per visit and for a specialist $40 copayment.
Surgery preferred: $150 in office, $200 in non-office setting per performing surgeon.
Inpatient hospital preferred: $175 per day copayment, up to $875 per admission for unlimited days.
Outpatient hospital (medical/surgery) preferred: $100 copayment per day, per facility.

If you are not already enrolled in our Chronic Care Program, call 1-888-334-9006, Monday through Friday, between 8 a.m. and 7 p.m., Eastern Time, or visit HorizonBlue.com/chronic-care.

Horizon Behavioral Health can also help you deal with the stress of everyday life. If your Horizon BCBSNJ health plan includes behavioral health coverage, you can call Horizon Behavioral Health at 1-800-626-2212, 24 hours a day, seven days a week. All calls are confidential.

For more information about FEP® plans, call 1-800-624-5078 or visit fepblue.org.

FEP Blue Focus

The Federal Employee Program® (FEP®) has announced a new product, Blue Focus, available for members, effective January 1, 2019. The product is designed for federal employees who are:

Low utilizers of health care services
Not planning any inpatient stays and/or major surgeries
Use mostly generic medications
Managing their chronic conditions

Federal employees who choose FEP Blue Focus must stay in-network and do not need referrals for specialty care.

Just as the Standard and Basic Options precertification of inpatient hospital stays is required.
Limited benefits and additional services that will require prior authorization such as high-tech radiology services (MRI, CT/PET scan)

Bariatric surgery must be performed at a facility designated as a Blue Distinction Center for Comprehensive Bariatric Surgery.

Enrollment codes

131 FEP Blue Focus - Self Only
133 FEP Blue Focus - Self Plus One
132 FEP Blue Focus - Self and Family

FEP Inquiry/Claim Submission:

Providers should submit claims electronically through NaviNet or through their vendor using Payer ID 22099. If necessary, mail inquiries/claims to:

Horizon BCBSNJ
Federal Employee Program PO Box 656
Newark, NJ 07101-0656

HORIZON INDEMNITY PLANS

These products combine hospital, medical/surgical and major medical-type benefits into one product. After a deductible, we will pay a percentage of our applicable allowance for eligible services. nThere are no office visit copayments; however, the patient is responsible to pay the deductible, coinsurance and any amount charged for ineligible services.

The following pages include brief benefit descriptions of:

Horizon Comprehensive Health Plans A, B, C, D, E
Horizon Traditional Plans B, C, D
Basic BlueSM Plan A
BlueCare®
Comprehensive Health Plan (CHP)
Comprehensive Major Medical (CMM)
Horizon Basic Health Plan A/50
Network Comprehensive Major Medical

HORIZON COMPREHENSIVE HEALTH PLAN A

These plans are available to employee groups of two to 50 employees under the Small Employer Insurance Reform Act.

HORIZON TRADITIONAL PLANS B, C, D

These plans are available to individuals under the Individual Health Insurance Reform Act.

Brief benefit description:

Deductible Ranges from $1,000 to $2,500 (Individual); $2,000 to $5,000(Family)
Coinsurance Varies 80/20%, 70/30%, 60/40%
Office Visits/ Medical Care: Covered after deductible
Well Child Care/ $300 annually pet covered person (except newborns). $500 maximum for newborns up to age 1 year. Not subject to deductible or coinsurance.
Lab and X-ray Covered after deductible

Maternity Related

Requires subscribers and/or physicians and other health care professionals to notify us within 12 weeks of medical confirmation of pregnancy. If we are not notified, payment of maternity claims will be reduced by 50 percent.

BASIC BLUE PLAN A

Basic Blue Plan A is no longer sold by Horizon BCBSNJ; however, we continue to serve those customers currently enrolled.

This limited hospitalization plan covers 30 days of inpatient care and some professional services. The plan does not provide benefits for behavioral health and substance use disorder care services.

Brief benefit description:

Deductible $100/Individual,$300/Family
Coinsurance 50/50%
Office Visits/Medical Care: Covered after deductible
Well Child Care/ Covered Adult Physicals
Lab and X-ray Covered after deductible

BLUECARE®

BlueCare is no longer sold by Horizon BCBSNJ; however, we continue to serve those customers currently enrolled.

Brief benefit description:

Deductible $500; two deductibles per family
Coinsurance 80/20%
Office Visits/Medical Care Covered after deductible

Well Child Care/ Not covered Adult Physicals
Lab and X-ray Covered after deductible

COMPREHENSIVE HEALTH PLAN (CHP)

This plan is no longer sold by Horizon BCBSNJ; however, we continue to serve those customers currently enrolled.

Brief benefit description:

Deductible $100 to $1,000
Coinsurance 80/20%
Office Visits/ Covered after deductible
Medical Care
Well Child Care/ Not covered Adult Physicals
Lab and X-ray Covered after deductible

COMPREHENSIVE MAJOR MEDICAL (CMM)

Brief benefit description:

Deductible Ranges from $100 to $1,000
Coinsurance Varies 80/20%, 70/30%
Office Visits/ Medical Care Covered after deductible
Well Child Care/ Call physician.
Adult Physicals Services for patient benefits if no indication appears on ID card.
Lab and X-ray Covered after deductible

HORIZON BASIC PLAN A/50

This plan is available to individual, nongroup customers.

Brief benefit description:

• Deductible $1,000, $2,500, $5,000 or $10,000 (Individual); $2,000, $5,000, $10,000 or $20,000 (Family)

Coinsurance 50/50%
Office Visits/ Covered after deductible Medical Care
Well Child Care/ Covered Adult Physicals
Lab and X-ray Covered after deductible

NETWORK COMPREHENSIVE MAJOR MEDICAL (NETWORK CMM)

Brief benefit description:

Deductible Ranges from $100 to $1,000
Coinsurance Varies 80/20%, 70/30%
Office Visits/ Covered after deductible Medical Care
Well Child Care/ Call Physician Adult Physicals Services for patient benefits if no indication appears on their ID card.
Lab and X-ray Covered after deductible

FIXED FEE CONTRACTS

Series 14/20 Student Program

These programs cover medical and surgical services performed at a hospital and in a physician’s office. Major medical types of service are not covered unless the patient has separate major medical coverage. The term Fixed Fee Contracts accurately describes these products because payment for an eligible service is fixed.

Service Benefits are paid-in-full benefits extended to certain individuals covered under a Fixed Fee Contract. Payments are not considered payment in full unless the subscriber meets specified income limits, which vary depending on whether the contract is for Single or Family coverage and the subscriber’s marital status.

Service Benefits Requirements

The patient must advise you within 120 days of the last day of rendering an eligible service that they qualify for Service Benefits. You may request proof of income by asking for a copy of the Federal Tax Form 1040 for the calendar year preceding the date of service. The subscriber must furnish proof within 45 days of your request.

Service Benefits Income Limits

If you are not notified of Service Benefits eligibility within 120 days of the last date of service, or proof of income is not furnished within 45 days of your request, the customer is disqualified from receiving Service Benefits. The Service Benefits feature described on this page is not related to, or part of, the BCBS Service Benefit Plan (a.k.a., the Federal Employee Program® [FEP®]). Income is defined as the gross annual income from all sources for the calendar year prior to the year services were rendered. The income limits are listed below.

Income limits for 14/20 Series

Single, unmarried:	$14,000
Single, married:	$20,000
Parent and child:	$20,000
Husband and wife:	$20,000
Family:	$20,000
Student:	N/A

Service Benefit Payments

If your covered patient is enrolled under a fee schedule contract, you must accept our payment for eligible services as payment in full if the subscriber’s income makes him or her eligible for paid-in-full Service Benefits.

If the patient is not eligible for Service Benefits, the combined payment from us, from the patient or from any other source, shall equal your usual or reasonable fee for the procedure performed. You will not submit a fee to us that is higher than the fee usually accepted by you as payment in full for services performed.

Student Program

Deductibles, copayments and/or coinsurance amounts are part of these contracts. Some groups incorporate cost containment and utilization review programs. For patient-specific information, we recommend reading the patient’s ID card for special benefit messages and phone numbers of dedicated service teams.

Major accounts have unique benefits. For patient-specific information, call Physician Services at 1-800-624-1110, Monday through Friday, between 8 a.m. and 5 p.m., ET.

MEDICARE PLANS

These plans provide safe and effective care through physicians, health care professionals and facilities that participate in the Horizon Managed Care Network (for Medicare Advantage plans) or that participate with Medicare (Medicare Supplemental plans).

HORIZON MEDICARE ADVANTAGE PRODUCTS

We are an approved Medicare Advantage (MA) Organization and offer several Medicare Advantage products to Medicare beneficiaries in place of Medicare Parts A and B:

Horizon Medicare Blue Value (HMO)
Horizon Medicare Blue Value w/Rx (HMO)
Horizon Medicare Blue Choice w/Rx (HMO)
Horizon Medicare Blue Advantage (HMO)
Horizon Medicare Blue Select (HMO-POS)
Horizon Medicare Blue Access Group (HMO-POS)
Horizon Medicare Blue Access Group w/Rx (HMO-POS)
Horizon Medicare Blue (PPO)
Horizon Medicare Blue Group (PPO)
Horizon Medicare Blue Group w/Rx (PPO)
Horizon Medicare Blue Group w/Rx Ideal (PPO)
Horizon Medicare Blue Group w/Rx Complete (PPO)

Members enrolled in these products use our extensive Horizon Managed Care Network and must go to providers who accept Medicare assignment. These products are offered to individuals and group account members.

Members enrolled in this plan use a subset of the Horizon Managed Care Network.

Horizon Medicare Blue Value (HMO)

This HMO plan requires members to choose a PCP. Members receive benefits at an in-network level only. Referrals are not required for enrolled members to seek specialty care from a Horizon Managed Care network physician, other health care professional or facility.

Members enrolled in this plan use the Horizon Managed Care Network.

Members can convert Medicare Advantage to Medicare Advantage with Prescription Drug coverage:

Horizon Medicare Blue Choice w/Rx (HMO).
Horizon Medicare Blue Value w/Rx (HMO).

Horizon Medicare Blue Choice w/Rx (HMO) These HMO plan require members to choose a PCP. Members receive benefits at an in-network level only. Referrals are not required for enrolled members to seek specialty care from a Horizon Managed Care network physician, other health care professional or facility.

Members enrolled in these plans use the Horizon Managed Care Network.

HORIZON MEDICARE BLUE ADVANTAGE (HMO)

The Horizon Medicare Blue Advantage (HMO) plan will be offered in 15 counties throughout New Jersey. It will not be offered to Medicare-eligible beneficiaries that reside in Burlington, Camden, Cape May, Gloucester, Passaic and Salem counties.

Members that choose the Horizon Medicare Blue Advantage (HMO) plan will have access to a subset of the physicians and other health care professionals, as well as a subset of facilities in the Horizon Hospital Network. Members will also have access to all ancillary providers in the Horizon Managed Care Network.

There are no out-of-network benefits for the Horizon Medicare Blue Advantage (HMO) plan, except in the event of an emergency. Therefore, members must receive services from doctors, health care professionals and hospitals that participate with this plan. Provider participation status for the Horizon Medicare Blue Advantage (HMO) plan will be published in the Online Doctor & Hospital Finder.

$0 plan premium in 12 counties; $75 plan premium in 3 counties.
$10 PCP copay, $25 Specialist copay.
Prescription drug coverage is included.

Members have access to a subset of the physicians and other health care professionals that participate in the Horizon Managed Care Network, as well as all in-network ancillary providers. Ancillary providers can be classified into three categories: diagnostic (e.g. laboratory tests, radiology, genetic testing) therapeutic (e.g. rehabilitation, physical and occupational therapy) and custodial (e.g. hospice care, long-term acute care, nursing facilities, urgent care).

Members will have access to a subset of facilities in the Horizon Hospital Network. Members do not have out-of-network benefits except in the case of an emergency. Any physicians, hospitals or other health care professionals not participating in the Horizon Medicare Blue Advantage (HMO) plan are considered out of network.

Members are required to select a Primary Care Physician (PCP) that participates in the Horizon Medicare Blue Advantage (HMO) plan. Members do not need referrals.

Horizon Medicare Blue Select (HMO-POS)

The Horizon Medicare Blue Select (HMO-POS) plan is offered to Medicare-eligible beneficiaries who reside in Union County.

Horizon Medicare Blue Select (HMO-POS) members who are in this individual plan will have access to a subset of the Horizon Managed Care Network in New Jersey. The plan offers in-network and out-of-network benefits and does require a PCP selection. Members do not need referrals.

In-network level of benefits are available when members obtain services from participating physicians and hospitals.

Horizon Medicare Blue Access Group (HMO-POS)

This point-of-service plan is a group offering giving members the option of selecting a PCP. If a PCP is not selected, the member incurs higher copayments. Members can receive benefits at in- and out-of-network levels. No referrals are needed for additional services.

Members enrolled in this plan use the Horizon Managed Care Network. Members can convert Medicare Advantage to Medicare Advantage with Prescription Drug coverage.

Horizon Medicare Blue (PPO), Horizon Medicare Blue Group (PPO)

Horizon Medicare Blue Group w/Rx (PPO) Horizon Medicare Blue Group w/Rx Ideal (PPO) Horizon Medicare Blue Group w/Rx Complete (PPO)

We offer Medicare Advantage plans to allow enrolled group and consumer members to obtain in-network benefits outside our local service area by leveraging a Blue Cross and Blue Shield Association (BCBSA) program that makes Blue Plans’ provider networks available to other Plans’ enrolled Medicare Advantage (MA) PPO members.

Similar to the BlueCard network arrangement, our MA PPO plans will allow members who travel to, or reside in another service area, to obtain in-network care as long as they use a practitioner or facility that participates in another Blue Plan’s MA PPO network.

You will be able to identify Horizon Medicare Blue (PPO) members – as well as other Plans’ MA PPO members– by the MA-in-the-suitcase logo included on the member’s ID card.

Horizon Medicare Advantage (PPO) offers in-network and out-of-network benefits and covers all Medicare Part A and Part B benefits, and additional supplemental benefits.

No PCP selection or referrals are required for members enrolled in Horizon Medicare Advantage (PPO) plans.

Like all of our Medicare Advantage plans, Horizon Medicare Advantage (PPO) members use the Horizon Managed Care Network to access the in-network level of benefits in New Jersey.

Members enrolled in these MA PPO plans who see participating PPO network physicians or other health care professionals (who do not also participate in the Horizon Managed Care Network) will access their out-of-network benefits.

Enrolled employer group members who reside or travel in another service area may receive care at the in-network level of benefits as long as they use a practitioner or facility that participates in that other Blue Plan’s MA PPO network. The member may only go to providers enrolled in Medicare.

Enrolled employer group members who reside in a state where there is no Blue Plan MA PPO Network will receive the in-network level of benefits in accordance with the CMS Employer Group Waiver Plan policy. They may only go to providers enrolled in Medicare.

Group members may convert their Medicare Advantage coverage to Medicare Advantage with Prescription Drug (MAPD) coverage – Horizon Medicare Blue Group w/Rx (PPO).

Well Care

Our Medicare Advantage products cover services coded as preventive, such as prostate screening and gynecological exams (subject to plan limitations). These services can be obtained without a referral from the PCP when provided by participating physicians and other health care professionals.

Chiropractic Care

Our Medicare Advantage members may go directly to participating chiropractors for manual manipulation of the spine to correct subluxation that can be demonstrated by X-ray. This means they do not require a referral from their PCP to visit a participating chiropractor. Members are also eligible for an unlimited amount of chiropractic visits per year. X-rays ordered by chiropractors are not covered.

Chiropractors should call Physician Services to verify copayment.

Case Management

New members are asked to complete and return a health assessment questionnaire within one month of enrolling in any of our Medicare Advantage products. Members identified as high risk are assigned a case manager to help you coordinate the member’s care.

Copayments and Coinsurance

Our Medicare Advantage plans offer various office visit copayments. In other health care settings, coinsurance may be required. Copayment amounts and coinsurance percentages, if applicable, are printed on the member’s ID card.

Audiology/Hearing Aid Benefits

Audiology Distribution, LLC, doing business as HearUSA, works with Horizon BCBSNJ to administer hearing benefits and provide related products and services through their HearUSA network of independently practicing audiologists, hearing care professionals and company-owned hearing centers.

Members enrolled in MA plans with NO out-of-network benefits

Members enrolled in Horizon Medicare Blue Value (HMO), Horizon Medicare Blue Value w/Rx (HMO), Horizon Medicare Blue Choice w/ Rx (HMO) and Horizon Medicare Blue Advantage (HMO) must use a HEARx Center for audiology services and hearing aids that are medically necessary, including batteries.

If these members reside in a New Jersey county without a HearUSA Center, they may request that their Primary Care Physician (PCP) refer them to a participating Horizon Managed Care Network audiologist. These same members who reside in a New Jersey county without a HearUSA Center will be reimbursed directly for hearing aids/batteries supplied by any non-HearUSA provider.

Members enrolled in MA plans with out-of-network benefits

Members enrolled in Horizon Medicare Blue Access Group (HMO-POS) and Horizon Medicare Blue Access Group w/Rx (HMO-POS) may use a HearUSA center for in-network audiology services and hearing aids, including batteries, that are medically necessary.

If these members choose to use their out-of- network benefits (understanding that they will incur more cost sharing), they may obtain services from a non-HearUSA provider.

If these members reside in a New Jersey county without a HearUSA Center, they may use any participating Horizon Managed Care Network audiologist on an in-network basis. These same members who reside in a New Jersey county without a HearUSA Center will be reimbursed directly for hearing aids/batteries supplied by any non-HearUSA provider.

Use our Online Doctor & Hospital Finder to find a HearUSA location If you are not already enrolled in our Chronic Care Program, call 1-888-334-9006, Monday through Friday, between 8 a.m. and 7 p.m., ET, or visit HorizonBlue.com/chronic-care.

Horizon Behavioral Health can also help you deal with the stress of everyday life. If your Horizon BCBSNJ health plan includes behavioral health coverage, you can call Horizon Behavioral Health at
1-800-626-2212, 24 hours a day, seven days a week. All calls are confidential.

Visit HorizonBlue.com/doctorfinder, select Other Health Services and:

Select Audiology within the Service Typemenu.
Enter your ZIP Code and indicate a Search Radius, or select your County.
Click Search.

Emergency and Urgent Care Definitions

For our Medicare Advantage products, a medical emergency is a medical condition manifesting itself by acute symptoms of sufficient severity (including, but not limited to, severe pain) such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:

Serious jeopardy to the health of the individual or, in the case of a pregnant woman, the health of the woman or her unborn child,
Serious impairment of bodily functions, or
Serious dysfunction of any bodily organ or part.

Emergency services include a medical screening examination and inpatient and outpatient services that are needed to stabilize an emergency medical condition.

For our Medicare Advantage products, urgently needed services are those services required to prevent a serious deterioration of a covered person’s health that results from an unforeseen illness, injury or condition that requires care within 24 hours.

MEDICAL RECORD STANDARDS FOR MEDICARE MEMBERS

According to the Centers for Medicare & Medicaid Services (CMS), all information included within a medical record must be legible for review by an approved CMS coder and must include the following information to document a face-to-face encounter.

The physician or other health care professional must authenticate the services provided or ordered by including either a handwritten or electronic signature along with his/her credentials. The following types of signatures are not acceptable:
- Stamp signatures
- Signature of a physician other than the treating physician
- Signature of a nurse or other office professional on the physician’s behalf
- Statements that indicate: Signed but not read; Dictated but not signed/read; etc.
The medical record should include sufficient information to ensure that a reviewer can determine the date on which a particular service was performed/ordered.
The medical record should include sufficient documentation to support the diagnoses billed.
Each page of a medical record must include the patient’s name.

The official instruction (Change Request 6698) may be accessed at cms.gov/transmittals/ downloads/R327PI.pdf.

Medical Record Retention

Physicians and other health care professionals are required to maintain medical records for a minimum of 10 years for all Medicare Advantage members.

Medical Necessity Determinations

The medical necessity review and determination process for Horizon Medicare Advantage products is different than that of other managed care products.

If you or the member disagrees with a coverage determination we have made, the decision may be appealed. We have up to 14 days to determine whether an initial request for a service is medically appropriate and covered. If additional clinical information is required, we may have up to an additional 14 days to make a determination.

In some cases, the standard pre-service review process could endanger the life or health of the member. As a participating physician or other health care professional, you may request an expedited 72-hour pre-service determination for a Medicare Advantage patient if, in your opinion, the health or the ability of your patient to function could be harmed by waiting for a medical necessity determination.

Expedited determinations may be requested by calling 1-800-664-BLUE (2583).

Non-expedited determinations may be requested in writing to:

Horizon BCBSNJ Utilization Management Appeals Department
210 Silvia Street, TT-02T
West Trenton, NJ 08628 Fax: 1-877-798-5903

Medicare Part D Prescription Drug Determinations

Requests for a coverage determination will be responded to within 24 hours for an expedited request (or sooner if the member’s health requires us to) or within 72 hours for a non-expedited coverage determination.

Part D drug coverage determinations include:

Prior authorization determinations for those drugs that require prior authorization.
Requests that we cover a Part D drug that is not on the plan’s List of Covered Drugs (Formulary).
Requests that we waive a restriction on the plan’s coverage for a drug, including:
- Being required to use the generic version of a drug instead of the brand name drug.
- Being required to try a different drug first before we will agree to cover the drug you are asking for. (This is sometimes called step therapy.)
- Quantity limits. For some drugs, there are restrictions on the amount of the drug patients can have.
Requests that we pay for a prescription drug the member already purchased (a coverage decision about payment).
Expedited Medicare Part D drug determinations may be requested by calling 1-800-693-6651.

Non-expedited Medicare Part D drug determinations may be requested in writing to:

Prime Therapeutics LLC
Attn: Medicare Appeals Department 1305 Corporate Center Drive
Bldg. N10
Eagan, MN 55121
Fax: 1-800-693-6703

HORIZON MEDICARE ADVANTAGE MEMBER APPEALS

Members have the right to appeal any decision regarding our reimbursement or our denial of coverage based on medical necessity. Appeals may be requested verbally or in writing.

Medical records and your professional opinion should be included to support the appeal.

Based on the medical circumstances of the case, a Horizon BCBSNJ physician reviewer will determine if the request qualifies as an expedited appeal.

However, the member, physician or other authorized representative acting on behalf of the member may request an expedited appeal based on the medical circumstances of the case.

If coverage of services is denied, you must inform your Medicare Advantage patient of their appeal rights. At each patient encounter with a Medicare Advantage enrollee, you must notify the enrollee of their right to receive, upon request, a detailed written notice from the Medicare Advantage organization regarding the enrollee’s benefits. You may issue the appeal rights directly to the member in your office at the time of the denial, or contact

Member Services and we will issue the appeal rights to the member.

Details about how to pursue various appeals and appeal levels will be communicated in writing as part of each coverage determination and/or appeal determination notification.

Medical Appeals for Medicare Services

Generally, we have 30 days to process an appeal pertaining to the denial of a requested service (pre-service appeal for service), and 60 days to process an appeal pertaining to post-service denial of claim payment (appeal for payment).

Expedited appeals are processed within 72 hours. To file an expedited appeal, the member may call Member Services at 1-800-365-2223.

Pre-service medical appeals may be faxed to

1-609-583-3021 or mailed to:

Horizon Medicare Advantage
Utilization Management Appeals Department
210 Silvia Street,TT-02T
West Trenton, NJ 08628

Post-service appeals may be faxed ton1-732-938-1340 or mailed to:

Horizon Medicare Advantage Appeals Coordinator
Three Penn Plaza East, PP-12L
Newark, NJ 07105-2200

A completed Appointment of Representative (AOR) form or other court-appointed document indicating the member’s consent may be required for a physician to pursue post-service appeals on behalf of the member.

Medicare Part D Prescription Appeals Generally, we have up to seven days to process an appeal pertaining to a post-service denial of coverage decision or claim for a Medicare Part D

prescription drug and up to 72 hours to process an appeal pertaining to a coverage decision of a Medicare Part D prescription drug the member has not yet received. Expedited appeals are processed within 24 hours.

To file an expedited Medicare Part D appeal, the member may call 1-800-693-6651.To request a Medicare Part D prescription drug appeal in writing, members may fax to 1-800-693-6703

or write to:

Prime Therapeutics LLC
Attn: Medicare Appeals Department
1305 Corporate Center Drive
Bldg. N10
Eagan, MN 55121

Subcontractors and Medicare

Participating offices that have entered into business arrangements with a subcontractor must ensure that all contracts with those entities include language that requires them to comply with all applicable Medicare laws and regulations.

Nine-Digit ZIP Codes Required for Claim Submissions

CMS requires the use of nine-digit ZIP codes on all Medicare Advantage claim submissions in certain locations where a five-digit ZIP code spans more than one pricing area.

The New Jersey, New York and Pennsylvania towns that require the use of nine-digit ZIP codes are listed below.

New Jersey

08512 – Cranbury

07726 – Englishtown

08827 – Hampton 18055

08525 – Hopewell 18951

07735 – Keyport 18077

08530 – Lambertville

07747 – Matawan

08540 – Princeton

08558 – Skillman

08560 – Titusville

Pennsylvania

18036 – Coopersburg

18042 – Easton

18055 – Hellertown

18951 – Quakertown

18077 – Riegelsville

18092 – Zionsville

New York

11208 – Brooklyn

10925 – Greenwood Lake

10964 – Palisades

10965 – Pearl River

10590 – South Salem

10983 – Tappan

To avoid delays in claim processing, we recommend that physicians and other health care professionals within these areas bill with the complete nine-digit ZIP code for all patients.

If you’re unsure of your nine-digit ZIP code, visit the United States Postal Service’s online Zip Code Lookup at usps.com/zip4.

For more information and for similar ZIP codes requiring +4 extension that are outside our service area, please visit the CMS Prospective Payment Systems - General Information web page at https://www.cms.gov/Medicare/Medicare-Fee- for-Service-Payment/ProspMedicareFeeSvcPmtG en/index.html.

MEDICARE SUPPLEMENTAL (MEDIGAP)

We offer a variety of Medicare Supplemental Products to our members who have Original Medicare as their primary insurance coverage.

Effective January 1, 2020:

Horizon Medicare Blue Supplement Plans C and F, which pay the Medicare Part B deductible, will no longer be sold to the following individuals:

Age 65+: individuals who turn age 65 on or after January 1, 2020.
Under Age 65: individuals whose Medicare Part B effective date is on or after Plan availability is now based on the following criteria:

In the Age 65+ market, whether the applicant turned 65 before January 1, 2020, or on/after January 1, 2020.
In the Under Age 65 market, whether the applicant’s Part B effective date is before January 1, 2020, or on/after January 1, 2020.

For the Age 65+ market, Horizon Medicare Blue Supplement Plan G is now available with any of the Guaranteed Issue Rights.
For the Under Age 65 market, the enrollment opportunities have been revised, with the most notable being that persons who have a Part B effective date on or after January 1, 2020 have 12 months from their Part B effective date (rather than 6 months) to enroll.

New Plan Introduced for 2020

Effective January 1, 2020, Horizon Medicare Blue Supplement Plan D will be available for the Age 65+, Age 50 to 64 and Under Age 50 markets.

These Medigap products supplement or fill the gaps of eligible services paid by Medicare and have also been referred to as complementary coverage in the past.

As required by the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), we offer a new set of standardized Medigap plans. The new plans, to distinguish them from the previously offered Medigap plans (which we continue to service, but no longer sell), are identified by a YHW prefix on their ID card and are referred to as Horizon Contemporary Medigap Plans.

We offer the following Horizon Contemporary Medigap Plans:

Plan A
Plan C – ages 50 to 64
Plan C – age 65+
Plan C – under age 50
Plan F
Plan G
Plan K
Plan N

For more information about Horizon Contemporary Medigap Plans, visit HorizonBlue.com/medicare.

Horizon Contemporary Medigap Plans are the only Medigap plans we offer for sale. For members enrolled in one of our existing Medigap plans (see below), there will be no change in benefits. However, members may choose to enroll in one of the new Horizon Contemporary Medigap Plans, as long as they meet the requirements for that new plan.

Horizon Medigap Plans A
Horizon Medigap Plan C
Horizon Medigap Plan F
Horizon Medigap Basic Plan I
Horizon Medigap Plan I with Rx
Horizon Medigap Plan J
BCBSNJ 65
BCBSNJ 65 Select
Super 65

Members enrolled in the above Medigap plans are identified by a YHR prefix on their ID card.

Pre-Existing Condition

Medigap plans include a pre-existing condition clause. Under this clause, claims for certain members, may be subject to review.

A pre-existing condition is an illness or injury, whether physical or mental, which manifests itself in the six months before a covered person’s enrollment date, and for which medical advice, diagnosis, care or treatment would have been recommended or received in the six months before his/her enrollment date.

The restriction could remain on the member’s policy as noted below unless a Certificate of Creditable Coverage (COCC) is provided. (A COCC, or a letter from a previous carrier on that carrier’s letterhead indicating the effective and terminating dates of coverage, will nullify or reduce the pre-existing wait period.)

For beneficiaries age 65 and over, the pre- existing condition limitation waiting period is six months from the date of enrollment.
For beneficiaries under age 65, the pre-existing condition limitation waiting period is three months from the date of enrollment.

Based on the member’s pre-existing limitation clause under the benefit plan, review of claims in excess of $10,000.00 will be conducted to determine if a pre-existing condition exists. If a pre-existing condition exists, the member will be responsible for payment of services rendered.

Medicare Part D

We also offer Medicare Part D Prescription Drug coverage to our members who have Original
Medicare as their primary insurance coverage.

Provider Responsibilities

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Provider Responsibilities Mon, 12/30/2019 - 06:06

The Role of the Primary Care Physician

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

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

Primary Care Physician (PCP)

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

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

The Role of the Participating Specialist

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

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

To search for taxonomy codes:

• Click Code Sets.

• Select Provider Taxonomy.

• Select Code Lookup.

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

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

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

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

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

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

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

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

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

COMMUNICATION IN THE HEALTH CARE PROCESS

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

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

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

ADVANCE DIRECTIVES

Advance directives allow patients to make sure their wishes are clearly known regarding the type of care a member would like to receive. They also allow the patient to appoint someone to make medical decisions for them if they are unable to speak for themselves.

Advance directives are legally recognized documents and are an important part of a member’s medical record. During an audit, Horizon BCBSNJ representatives look for documentation that the physician asked their patient if they either have an advance directive or would like to create one.

When treating your Medicare Advantage patients, ask them if they have completed their advance directives.

If the patient responds that he or she has an advance directive, that documentation (along with an actual copy of the advance directive document itself) should be included as a prominent part of the medical record. Also advise your patients who have advance directives already in place that they should make their designated health care proxy and their family members aware of the advance directive.
If the patient responds that he or she has no desire to create an advance directive, that documentation should also be included as a prominent part of the medical record.

There are three options available when patients are making an advance directive choice:

Proxy Directive – Proxy Directives, or durable power of attorney for health care, are used to designate a health care representative or health care proxy who is authorized to make medical decisions on the patient’s behalf, in the event he or she is unable to do so.
Instruction Directive – Instruction Directives, also known as living wills, specifically express in writing the patient’s desires or instructions for treatment and indicate treatments the patient is not willing to accept.
Combined Directive – A Combined Directive is a single document in which the patient names a proxy and documents specific treatment instructions used to guide treatment decisions.

The state of New Jersey has advance directive forms available online; however, no particular form is required. For an advance directive to be legally recognized, it must be documented in writing and signed by the patient in front of two adult (age 18 or older) witnesses or by a Notary Public.

In addition, the patient should be encouraged to make his or her desires known, not only to his or her health care proxy and physician, but also to his or her family members.

For more information on advance directives, review the brochure Advance Directives for Health Care, published by the State of New Jersey Commission of Legal and Ethical Problems in the Delivery of Health Care. This brochure is available at www.state.nj.us/health.

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

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

LICENSE, CERTIFICATION OR REGISTRATION

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

OUT-OF-STATE BCBS PLANS

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

MEDICARE PARTICIPATION

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

CULTURAL COMPETENCY

Horizon BCBSNJ’s membership represents many cultural, ethnic, linguistic and racial backgrounds.

To meet the needs of our members, including those that have limited English proficiency or reading skills, you are required to ensure that all clinical and nonclinical services are accessible to all members in a manner that:

Honors and is compatible with their cultural health beliefs and practices,
Is sensitive to cultural diversity, and
Fosters respect for their cultural backgrounds.

We use the AT&T Language Line service to help our service representatives communicate with callers in more than 140 languages, 24 hours a day, seven days a week.

MEDICAL RECORDS

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

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

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

MEDICAL RECORDS FOR QUALITY-OF-CARE COMPLAINTS

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

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

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

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

NOTIFICATIONS

You must notify us in writing if:

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

Please mail notifications to:

Horizon BCBSNJ

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

Or fax: 1-973-274-4302

REFERRING A PATIENT

Horizon BCBSNJ is proud of our comprehensive network of participating physicians, other health care professionals and facilities. We remind participating physicians, other health care

professionals and facility staff in our Horizon Managed Care Network about the important role referrals play in helping to ensure that your patients receive the highest level of benefit coverage.

Referring physician responsibilities

All referrals for patients enrolled in managed care plans1 should be created electronically through either through NaviNet.net or our IVR system by calling 1-800-624-1110.
- Primary Care Physicians (PCPs) may create electronic Primary referrals to specialists or facilities.
Ob/Gyns may create Primary referrals for Ob/Gyn-related services only.
Participating specialists may create Refer- On referrals to radiology centers and ambulatory surgery centers.
All referrals for patients enrolled in managed care plans must be made to specialty care physicians, other health care professionals or facilities that participate in the Horizon Managed Care Network. Visit our Online Doctor & Hospital Finder at HorizonBlue.com/doctorfinder to confirm participation status.
We recommend that all referring physicians print a Referral Confirmation and:
- Include that information within the patient’s medical record.
- Provide a copy to the member to present when they visit the referred to practitioner or facility.

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

Referred to provider responsibility

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

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

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

MEMBER NONDISCRIMINATION

Neither Horizon BCBSNJ nor practitioner shall discriminate in the delivery of health care services based on race, color, creed, ethnicity, national origin, religion, sex, age, mental or physical disability, medical condition, sexual orientation, gender identity, marital status, claims experience, medical or mental health history or status, pre-existing medical/health conditions, need for or receipt of health care services, evidence of insurability, geography, disability, genetic information, actuarial class, source of payment or any other unlawful purpose.

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

HEALTH CARE FRAUD AND ABUSE INVESTIGATION

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

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

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

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

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.

For reports of suspected fraud related to behavioral health services, call Horizon Behavioral Health’s Special Investigations at 1-888-293-3027 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.

Quality Management

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Quality Management Mon, 12/30/2019 - 06:04

The Quality Management Program consists of two major components: clinical and service. The range of the clinical activities is extensive, encompassing preventive care, acute care, chronic care and care provided for special populations. It monitors credentialing and compliance, member education, screening, practice guidelines, delegation and medical record documentation. The service component of the program monitors accessibility of care, member satisfaction and member complaints and appeals. The applicability of a specific program element is determined by contract, regulatory requirements and accreditation standards.

The Quality Management Program monitors the availability, accessibility, continuity and quality of care on an ongoing basis. Indicators of quality care for evaluating the health care services provided by all participating health care professionals include:

A mechanism for monitoring patient appointments and triage procedures, discharge planning services, linkage between all modes and levels of care and appropriateness of specific diagnostic and therapeutic procedures, as selected by the Quality Improvement Committee;
A mechanism for evaluating all providers of care; and
A system to monitor physician and member access to utilization management services.

More specific program goals include:

Specifying standards of care, criteria and procedures for the assessment of the quality of services provided and the adequacy and appropriateness of health care resources used.
Monitoring member satisfaction and participating network physicians’ response and feedback on plan operations.
Empowering members to actively participate in and take responsibility for their own health through the provision of education, counseling and access to quality health care professionals.
Maximizing safety and quality of health care delivered to members through the continuous quality improvement process.
Evaluating and maintaining a high-quality participating network through a formalized credentialing and recredentialing process.
Establishing long-term collaborative relationships with individuals and organizations committed to continuously improving the quality of care and services that they provide.
Maintaining effective communications systems with members and health care professionals to evaluate performance with respect to their needs and expectations.
Monitoring the utilization of medical resources using medical management processes as defined in the Utilization Management Program Description.
Maintaining a structured, ongoing oversight process for quality improvement functions performed by independently contracted entities and/or delegates.
Fulfilling the quality-related reporting requirements of applicable state and federal statutes and regulations, as well as standards developed by private outside review and accreditation agencies that Horizon BCBSNJ chooses to adhere to.

To receive a more detailed plan, please call the Quality Management Department at 1-877-841-9629.

MEDICAL RECORDS STANDARDS
In accordance with the CMS, the National Committee for Quality Assurance (NCQA) and URAC guidelines on standards for medical record documentation, Horizon BCBSNJ requires participating physicians and other health care professionals to adhere to the following commonly accepted practices regarding medical record documentation. The items below are also used in our medical record audits:

Medical Record Organization – Medical records will be organized and maintained in a systematic and consistent manner that allows easy retrieval.
Medical Record Availability – The physician has a process to make records available to covering health care professionals and others, as needed. Physician communicates to staff guidelines relative to the dispersal/retrieval of confidential patient medical records within and/or outside the office, such as in the case of a covering health care professional requesting medical records.
Medical Record Confidentiality – Access to medical records is limited to appropriate office staff:
- All medical records are stored out of reach and view of unauthorized persons.
- All electronic medical records are maintained in a system that is secure and not accessible by unauthorized persons.
- Staff receives periodic training in member information confidentiality.
Dated Entries – Entries and updates to a medical record are dated with the applicable month, day and year.
Author Identification – Entries are initialed or signed by the author. Author identification may be a handwritten signature, unique electronic identifier, initials or any other unique identifier system the health care professional chooses.
Page Identification – Patient name or unique identifier is found on each page in the medical record.
Personal/Biographical Data – The medical record will contain patient personal/ biographical information, such as:
- Patient’s insurer.
- Patient’s home address.
- Patient’s home, work and/or cell phone number.
- Emergency contact name and phone number.
Legible Entries – Entries and updates are legible to a reader other than the author.
Medication Allergies and/or Adverse Reactions – Information on allergies and adverse reactions (or a notation that the patient has no known allergies or history of adverse reactions) are prominently displayed in the medical record.
Prescribed Medications – Maintain a list of prescribed medications which include dosages and dates of initial or refill prescriptions.
Updated Problem List – A dated problem list summarizing a patient’s significant illnesses, as well as medical and psychological conditions, will be maintained.
Presenting Complaints/Physical Examinations–
The medical record contains an entry for each patient visit stating the reason for the visit and the applicable diagnosis/treatment plan.
Follow-up Care – Entries are recorded stipulating when the patient should return for follow-up care.
Laboratory Results – Laboratory results are reviewed and initialed by the health care professional.
Tobacco, Alcohol and Substance Use Disorder – For patients age 14 and older, there are appropriate entries made concerning the use of cigarettes and alcohol, and substance use disorder (including anticipatory guidance and health education).
Medical History – Past medical history, including serious accidents, operations and illnesses are prominently documented for patients who have had three or more visits.
Immunization Records – Childhood immunization records are present for children under the age of 14 years.
Growth Chart – Create and maintain a growth chart for pediatric patients.
Advance Directives – Information on advance directives is noted in the medical record for all Medicare Advantage members, including a completed copy of the directive or member’s decision not to execute.
Provider List – Physicians and other health care professionals involved in the patient’s care can be easily identified in the patient’s chart.
Preventive Services/Risk Screening – Each patient record includes documentation that age-appropriate preventive services were ordered and performed or that the physician discussed age-appropriate preventive services with the patient and the patient chose to defer or refuse them. Physicians should document that a patient sought preventive services from another physician (e.g., Ob/Gyn, cardiologist, etc.) and include results of such services as reported by the patient.

Medicare Advantage Medical Record Retention Physicians and other health care professionals are required to maintain medical and business records for a minimum of 10 years for all Medicare Advantage members.

MEDICAL RECORDS FOR QUALITY-OF-CARE COMPLAINTS
Horizon BCBSNJ is required to investigate member complaints, including those that allege inadequate care was received from a participating physician, other health care professional or facility.

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

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

Failure to comply with a request for medical records and/or additional documentation required to investigate a medical quality-of-care complaint is a very serious issue and may result in termination for cause from Horizon BCBSNJ’s networks.

Physicians and other health care professionals who do not respond to such requests in a timely manner will have a notation placed in their credentialing file for consideration at the time of recredentialing.

We will also advise impacted members of any failures to comply with requests for medical records and make these members aware of their right to file a complaint with the New Jersey State Board of Medical Examiners.

We acknowledge and appreciate that the great majority of our medical record requests are responded to promptly and efficiently.

NCQA AND HEDIS®
The National Committee for Quality Assurance (NCQA) is an independent, not-for-profit organization dedicated to assessing and reporting on the quality of managed care plans, managed behavioral health care organizations, preferred provider organizations, new health plans, physician organizations, credentials verification organizations, disease management programs and other health- related programs.

NCQA Health Plan Accreditation evaluates how well a health plan manages all parts of its delivery system – physicians, other health care professionals, hospitals, ancillary providers and administrative services – to continuously improve the quality of care and services provided to its members.

HEDIS® (Healthcare Effectiveness Data and Information Set) is the measurement tool used by the nation’s health plans to evaluate their performance in terms of clinical quality and customer service. It is a set of standardized performance measures designed to ensure that purchasers and consumers have the information they need to reliably compare health care quality.

NCQA accreditation not only involves a rigorous review of a health plans’ consumer protection and quality improvement systems, but also requires health plans to submit audited data on key clinical and service measures (e.g., mammography screening rates, advising smokers to quit; consumer satisfaction).

As NCQA gathers data from health plans for its nationwide comparisons, health plans like Horizon BCBSNJ gather data from your medical offices. A physician’s diligence in ensuring his or her patients are appropriately treated (as in the beta blocker measure) or screened (as in the cervical cancer screening measure) will be reflected in the plan’s report card made available to the general public through the NCQA’s website, NCQA.org.

Note: You may not charge Horizon BCBSNJ for copies of medical records when they are requested for medical review, claim review or as part of a medical record or HEDIS audit.

The BlueCard® Program

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The BlueCard® Program Mon, 12/30/2019 - 06:01

The BlueCard® Program links you and independent Blue Cross and/or Blue Shield Plans, across the country and abroad, with a single electronic network for claims processing and reimbursement.

The BlueCard program eliminates the need to deal with multiple Blue Plans. Horizon BCBSNJ is your one point of contact1 for claims or claims-related questions.

The program allows you to submit almost all types of claims for out-of-state members directly to us, your local Blue Plan. We process your reimbursement and provide you with an Explanation of Payment (EOP).

Please treat BlueCard members the same as you would a local Horizon BCBSNJ member. Doing so will increase your patients’ satisfaction and improve their overall BlueCard experience. Billing charges in excess of the allowance is not permitted.

1 The exception to this is if your office participates directly with the plan in which a BlueCard member is enrolled. If you participate with the other Blue Plan, please submit claims directly to that other Blue Plan for processing.

IDENTIFYING BLUECARD MEMBERS

The key to identifying BlueCard members is their ID cards. There are three ID card elements you should look for to identify a BlueCard member:

Blue Plan Logo

The presence of another Blue Cross and/or Blue Shield Plan’s logo on the member’s ID card means a member may be eligible for BlueCard benefits.

Member ID Card Prefix

The prefix on the member’s ID card is the key element used to identify the Blue Plan to which the member belongs and to route claims correctly. It is critical to confirm membership, eligibility and coverage. Ask to see the member’s ID card at each visit.

If there is no prefix on a member’s ID card, review the member’s ID card for the phone number of the member’s Blue Plan or for other instructions.

Suitcase Logo

The suitcase logos are unique identifiers for BlueCard members.

Members whose ID cards display the PPO-in-a-suitcase logo are enrolled in PPO (Preferred Provider Organization) products. Benefits are delivered through the BlueCard program. Members traveling or living outside their Plan’s service area receive PPO-level benefits when they need services from participating physicians, other health care professionals, hospitals and other facilities.
Members whose ID cards display the PPO B-in-a-suitcase logo are enrolled in an exchange PPO product from a Blue Plan. The member has access to the exchange PPO network, referred to as BlueCard PPO Basic. BlueCard plans that use our Horizon Managed Care Network are also known as Alternate Network BlueCard (AltNet) plans.
Members whose ID cards display the empty suitcase logo are enrolled in a product other than PPO, for example, Traditional, POS or HMO. These members are also eligible for BlueCard processing. However, benefits for services obtained outside the member’s local service area may be limited to those related to a medical emergency. Please verify BlueCard benefits for members whose ID card display the empty suitcase logo.

Members whose ID cards do not display a suitcase logo are excluded from receiving benefits through the BlueCard program. Be sure to review the member’s ID card for phone numbers and claim filing addresses.

BLUECARDID CARDS

All Blue Cross and/or Blue Shield Plans are independent licensees of the Blue Cross and Blue Shield Association (BCBSA) and are required to follow specific ID card standards. ID cards must contain the following elements on the front of the card:

Member’s name.
ID number.
Group number, if applicable.
Blue Cross and/or Blue Shield Plan code, a numeric value identifying each Blue Plan. In New Jersey, our codes are 280 and 780.
Blue Cross and/or Blue Shield symbols. Some Plans are only a Blue Cross or a Blue Shield Plan. Their ID cards may only show one symbol rather than both the Cross and Shield. The BCBSA has licensed them in a state or given geographic area to offer only certain products or services under the Blue Cross or Blue Shield brand name and symbol.
Blue Cross and/or Blue Shield Plan name, which may be a Plan’s legal name or it may be a trade name. Our ID cards are issued with the Horizon BCBSNJ name.

PARTICIPATING PHYSICIAN INFORMATION

To obtain information about participating physicians and other health care professionals in another BCBS Plan service area, members may call BlueCard Access at 1-800-810-BLUE (2583).

BLUECARD ELIGIBILITY AND BENEFITS

You can obtain eligibility and benefits information for your BlueCard patients by phone or electronically. Remember to have the member’s ID card information handy.

Obtaining Information by Phone

You can call BlueCard Eligibility at 1-800-676-BLUE (2583). After providing the prefix from the member’s ID card, you’ll be connected to the Customer Service team at the member’s Blue Plan.

If the member’s ID card does not include a prefix, please call the phone number on the ID card.

Obtaining Information Electronically

You may submit a HIPAA 270 transaction to Horizon BCBSNJ to request the information you need. Most BlueCard electronic inquiries received Monday through Friday, during regular business hours, are answered within 48 hours.

PRIOR AUTHORIZATION AND UTILIZATION MANAGEMENT

Your patients who are enrolled through other Blue Cross and/or Blue Shield Plans and who have BlueCard benefits, are responsible for obtaining prior authorizations.

All hospital admission and/or concurrent reviews and discharge planning are completed by the patient’s Blue Plan.

You may choose to contact the Blue Cross and/or Blue Shield Plan in which your patient is enrolled to obtain the prior authorization or pre-authorization. Refer to your patient’s ID card for phone number information or call 1-800-676-BLUE (2583).

Inpatient Prior Authorization/Precertification

Network facilities are required to obtain prior authorization/precertification for inpatient facility services for BlueCard patients. This requirement only applies to inpatient facility services.

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, call BlueCard Eligibility at 1-800-676-BLUE (2583) or the appropriate phone number listed on the BlueCard member’s ID card, or submit an electronic 278 transaction.

If prior authorization/precertification is required and not obtained for inpatient facility services, the facility will be financially responsible and the member will be held harmless.

Note: The responsibilities and obligations outlined in this section are applicable to out-of-state

Blue Cross and/or Blue Shield members.

SUBMITTING BLUECARD CLAIMS

Submit BlueCard claims electronically with other Horizon BCBSNJ claims or send paper claims to:

Horizon BCBSNJ BlueCard Claims
PO Box 1301
Neptune, NJ07754-1301

Be sure to include the member’s complete ID number when you submit the claim. Claims with incorrect or missing prefixes and member ID numbers delay claims processing.

If the patient’s ID card does not include a prefix, check for a phone number on the card. Call the appropriate Blue Cross and/or Blue Shield Plan for claim submission instructions.

Do not send duplicate claims. Check a claim’s status through our Interactive Voice Response (IVR) system, NaviNet or through an electronic transaction before you resubmit a claim.

DME Claim Submissions

Claims for DME services must be sent to the Blue Plan in the state in which the equipment was delivered or purchased. The claim will process according to the DME provider’s contractual relationship with the Blue Plan.

For example, if the equipment is purchased from a New Jersey DME retail store or delivered to a New Jersey address, that claim must be sent to Horizon BCBSNJ and will process according to the DME provider’s contractual relationship with Horizon BCBSNJ.

However, if the equipment is purchased by or delivered to a Horizon BCBSNJ member in Pennsylvania, the claim must be sent to the Pennsylvania Blue Plan and will process based on the DME provider’s contractual relationship with that Pennsylvania Blue Plan and consistent with the member’s Home Plan benefits.

BLUECARD CLAIMS PROCESSING

Upon receipt, we will electronically route the claim information to the other Blue Cross and/or

Blue Shield Plan that will process the claim and approve reimbursement. The other plan will transmit the approval to us and we will issue reimbursement and an EOP to you.

BEHAVIORAL HEALTH AND SUBSTANCE USE DISORDER CLAIMS AND INQUIRIES

All behavioral health and substance use disorder claim submissions and inquiries for your BlueCard patients (those enrolled in another state’s Blue Cross and/or Blue Shield Plan) must be handled through the BlueCard program.

Claim Submissions

Claims should be submitted electronically using NaviNet or through your vendor using Payer ID 22099. If you have to mail your claims, use the following address:

Horizon BCBSNJ BlueCard Claims
PO Box 1301
Neptune, NJ07754-1301

Be sure to include the member’s complete ID number when you submit claims. Incorrect or missing prefixes and member ID numbers delay claims processing.

If your office participates directly with another Blue Cross and/or Blue Shield Plan, send claims for those enrolled patients directly to that Plan.

Claim Inquiries

Call Horizon BCBSNJ’s Dedicated BlueCard Unit at 1-888-435-4383 or visit NaviNet.net.

ELIGIBILITY/ENROLLMENT INQUIRIES

Call BlueCard Eligibility at 1-800-676-BLUE (2583) or visit NaviNet.net.

Note: This claims submission information pertains only to your patients enrolled through an

out-of-state Blue Cross and/or Blue Shield Plan. There is no change to how inquiries and claims should be handled for your patients enrolled through Horizon BCBSNJ.

BLUECARD CLAIM SUBMISSIONS HELPFUL HINTS

Be sure to include the prefix and the complete ID number on all claim submissions. Incorrect or incomplete information may delay claims processing or cause the claim to deny, since we will be unable to identify the member.

Always include appropriate ICD-10, revenue and CPT-4 codes.

Ensure that section 1A of the CMS 1500 form is completed by entering either the requested information or the word Same, as appropriate, in boxes 4 and 7 for all BlueCard paper claim submissions.

BLUECARD EXCLUSIONS

BlueCard applies to most claims; however, the following types of claims currently are excluded from the program:

Coordination of Benefits situations when the Blue Cross and/or Blue Shield Plan is not the primary carrier
Workers’ compensation situations
Stand-alone dental coverage
Stand-alone prescription drug coverage
Vision care services
Hearing care services

HOW TO AVOID BLUECARD CLAIM REJECTIONS

Horizon BCBSNJ strives to process your BlueCard claims quickly and accurately, but claim rejections do occur.

Below are the most frequent BlueCard claim rejection messages. We offer suggestions for what you can do to avoid having your BlueCard claims rejected.

No Record of Membership

Validate the BlueCard member’s ID card at each visit to ensure that you have the member’s most current information.

Claim Submitted with an Incorrect ID Number

Be sure to include the member’s complete ID number when you submit the claim. Claims with incorrect or missing prefixes and member ID numbers delay claims processing.

If the patient’s ID card does not include a prefix, call the member’s Blue Cross and/or Blue Shield Plan for claim submission instructions.

Care After Coverage Termination Date

Verify the member’s BlueCard eligibility and coverage by:

Phone: Call BlueCard Eligibility at 1-800-676-BLUE (2583).

Follow the prompts and the automated system will ask you for the prefix on the member’s ID card. You will be connected to the Customer Service team at the member’s Blue Plan. If you are unable to locate a prefix on the member’s ID card, review the ID card for the phone number of the member’s Blue Plan and call the Plan directly for information.

Online: Log on to NaviNet.net and select Horizon BCBSNJ from the My Health Plans menu. Then,

Mouse over Eligibility & Benefits and click Eligibility & Benefits Inquiry.
Select Out Of Area – BlueExchange®/FEP® in the Inquiry Typesection.
Enter the required BlueCard member information.
Click Search.

Physician Contracts with Two Plans

If your office participates directly with Horizon BCBSNJ and another Blue Plan, and the Horizon BCBSNJ member lives or works in New Jersey, file the claim directly to Horizon BCBSNJ for processing.

If services are rendered in New Jersey and your office does not participate with the Plan through which the member is enrolled, submit claims to Horizon BCBSNJ.

HOW TO AVOID DUPLICATE CLAIM DENIALS

Based on a review of BlueCard claim denials, we found that the number one reason for BlueCard claim denials is that the claim in question is a duplicate of a previously processed claim.

Here are some of the duplicate claim trends we uncovered as part of this review:

Claim submissions received for patients who have Medicare as their primary insurance.
Claim resubmissions received within two weeks of the original claim.
Claim resubmissions received where the original claim was finalized without generating a reimbursement.

Review the guidelines here to help decrease the trends identified above. Following these guidelines will help reduce or eliminate the number of duplicate claim denials you receive.

Wait for MEOBs

If Medicare is your patient’s primary insurance, submit your claim to Medicare first. The Medicare Explanation of Benefits (MEOB) you receive will indicate if the claim was automatically routed to the patient’s secondary insurance carrier. If the MEOB indicates that the claim was sent to the secondary carrier, do not resubmit it. If the MEOB doesn’t indicate that the claim was sent to the secondary carrier, submit it with the MEOB to:

Horizon BCBSNJ BlueCard Claims
PO Box 1301
Neptune, NJ 07754-1301

Check Claim Status First

Before resubmitting a claim, check the status of your claim on NaviNet.net or call our Dedicated BlueCard Service Unit at 1-888-435-4383.

Submit Corrected Claims with a 579 Form

Ensure that corrected claim submissions are accompanied by a completed copy of our Inquiry Request and Adjustment Form (579).Be sure to specify the changes made relative to the original claim submission (revenue codes, late charges added, etc.) and include all required supporting documentation (Universal Bill [UB] form, other carrier/MEOBs, etc.).

The 579 form is on HorizonBlue.com/form579.

BLUECARD CLAIM APPEALS

Our BlueCard claim appeal process aims to resolve BlueCard claim appeals within 30 to 45 days of their receipt.

As part of our BlueCard claim appeal process, we developed a BlueCard Claim Appeal Form (5373). This form is available at HorizonBlue.com/form5373.

The process and form only support BlueCard-related claim appeals from hospitals on behalf of their patient.

Use of this form is not intended for non-BlueCard claim appeals or for routine BlueCard claim inquiries.

A BlueCard claim appeal is a formal request for reconsideration of a previously adjudicated BlueCard claim. The claim appeal may or may not include additional information. BlueCard claim appeals may involve, but are not limited to, inquiries about:

Payer allowance
Medical policy/medical necessity determinations (e.g., cosmetic or investigational services)
Incorrect payment or coding rules applied

The following are not considered a claim appeal and should not be submitted on the BlueCard Claim Appeal Form (5373):

Corrected claim submissions.
General claim inquiries or questions.
Claim denial requiring additional information.

Completed forms, along with necessary supporting documentation, may be mailed to:

Horizon BCBSNJ BlueCard Claim Appeals
PO Box 1301
Neptune, NJ 07754-1301

For questions about the BlueCard claim appeal process, call our Dedicated BlueCard Unit at 1-888-435-4383.

To avoid delays, ensure that claim appeals submitted on behalf of your patient are accompanied by a completed Consent to Representation in Appeals Form (also available on our website).

SUBMITTING BLUECARD CLAIM APPEALS THROUGH NAVINET

Log on to NaviNet.net.
Select Horizon BCBSNJ from the My Health Plans menu.
Mouse over Claim Management and select Claim Status Inquiry.
Locate the claim in question and access the
Claim Status Details screen.
Click Submit Claim Appeal.¹
Complete the requested information and attach the appropriate documentation (the system can accept up to five attachments per appeal – not to exceed a total of 10 MB – in either a PDF, JPG or TIF format).
Click Submit.

Once an appeal is successfully submitted, a confirmation screen will display with an appeal confirmation number for your records. To help prevent duplicate claim appeal submissions, only one submission will be accepted within a 45-day period for a particular claim.

If you have questions about the BlueCard appeal process, call our Dedicated BlueCard Unit at
1-888-435-4383.

1 The Submit Claim Appeal function will only display if the BlueCard claim in question is finalized with a zero paid amount and includes a claim message. Claims that are partially paid (one line is approved for reimbursement but another line is denied) must be appealed by mail and accompanied by a completed BlueCard Claim Appeal Form (5373) available within the Forms section of our website.

BLUECARD HELPFUL HINTS

Send medical records when:

Requested in writing by Horizon BCBSNJ.
Requested by the BlueCard Home Plan.

Do not send medical records:

When a retrospective review is done by the Utilization Review Department via a phone call.
For a second level medical appeal.

OTHER BLUECARD COVERAGE TYPES ALTNET

Though most BlueCard members access their in-network level of benefits when they use participating providers within our Horizon PPO network, there are also a number of national account groups enrolled through out-of-area

Blue Cross and/or Blue Shield Plans whose members reside in New Jersey and who access their in-network level of benefits only when they use physicians, other health care professionals, hospitals or ancillary providers that participate in our Horizon Managed Care Network.

These BlueCard plans that use our Horizon Managed Care Network are also known as Alternate Network BlueCard (AltNet) plans.

Special features of these national account group plans include:

The option to select a Primary Care Physician (PCP)
No referrals
Fee-for-service reimbursement for eligible services at the Horizon Managed Care Network allowance

In-Network Benefit Level

To maximize their benefits, AltNet plan members must use physicians, other health care professionals or facilities that participate in the Horizon Managed Care Network. Reimbursement for eligible services will be calculated based on our Horizon Managed Care Network rates.

Out-of-Network Benefit Level

Out-of-network benefits apply to members who use other physicians, health care professionals or facilities, including physicians or health care professionals who participate only in our Horizon PPO Network. Reimbursement for eligible services will be calculated based on our Horizon PPO Network rates.

AltNet ID Cards

The member ID cards for AltNet plans include the PPO-in-a-suitcase logo. This logo indicates that these BlueCard members have access to in-network coverage when traveling outside New Jersey. Alt-Net ID cards will also include the words Horizon Managed Care Network adjacent to that PPO-in-a-suitcase logo.

AltNet Groups in Our Service Area

The list below will help you identify members enrolled in an AltNet plan.

Prefix Group Name

ANX Assisted Living

BVV, BVY, BWJ, BIQ, BIZ, BYX, BYE Bed, Bath & Beyond

CVP Omnicom

EYR Modelez International (Kraft)

EYZ Autozone

FIO Ford Motor Company

FJF Pepsico

FWJ Ferguson Enterprises

GJW John Wiley & Sons

GXX General Motors

GZD Penske Automotive

HTJ HSBC

HTP Crestline Hotels and Resorts, LLC

JBJ JB Hunt

JDU, JEE, JEJ Chubb

JNW Walgreens

LGV Local 53 Health Benefits Fund

LZU Novartis

MZT 3M

OZB ABC Supply Company

PUB, PYJ PSE&G Long Island

QGJ, SBU, SNA Silgan Containers

TPP NYC Transit

MTA TYN, TZF, TVV, TUL TD Bank

TQL, TUV, TQW, UAA,UGZ, UMW UAW Retiree Medical Benefits Trust (URMBT)

UGK Central Garden & Pet

VJS Sears Holdings Corporation

VWA Advance Auto Parts

WES Walmart

GEOBLUE®

GeoBlue, in partnership with Blue Cross and/or Blue Shield Plans, provides BlueCard coverage for internationally-based employees of large group employers.

GeoBlue members are enrolled in a Blue Cross and/or Blue Shield product and have full access to the BlueCard provider network. As with other BlueCard members, please treat patients with GeoBlue coverage the same as you would a local Horizon BCBSNJ member. Doing so will increase your patients’ satisfaction and improve their overall BlueCard experience.

GeoBlue ID Cards

GeoBlue member ID cards contain all BlueCard specifications and all BlueCard processes that apply for coverage and claims.

The GeoBlue ID card shows the member contract number, including the three-letter alpha prefix, and has the Blue Cross and Blue Shield symbols prominently displayed on the front.

GeoBlue Eligibility and Benefits

To verify eligibility and benefits of a GeoBlue member, call GeoBlue Customer Service at
1-855-282-3517.

You may also log in to NaviNet and use the BlueExchange® option within the Eligibility and Benefits Inquiry capability.

GeoBlue Claims

Claims for GeoBlue members should be submitted electronically using NaviNet or through your vendor using Payer ID 22099. If you have to mail your claims, please send to:

Horizon BCBSNJ BlueCard Claims
PO Box 1301
Neptune, NJ 07754-1301

Be sure to include the member’s complete ID number when you submit claims. Incorrect or missing prefixes and member ID numbers delay claims processing.

GeoBlue Claim Inquiries

For GeoBlue claim inquiries, call Horizon BCBSNJ’s Dedicated BlueCard Unit at1-888-435-4383 or visit NaviNet.net.

OUT-OF-STATE MEDICAID MEMBERS

The BlueCard® Program can also be used to submit most claims for certain out-of-state Medicaid members you may treat. Horizon NJ Health is your one point of contact for Medicaid claims or Medicaid claims-related questions.

Medicaid programs in the following states (and commonwealths)1 are administered by Blue Cross and Blue Shield Plans:

California
Delaware
Hawaii
Illinois
Indiana
Kentucky
Michigan
Minnesota
New Jersey
New Mexico
New York
Pennsylvania
Puerto Rico
South Carolina
Tennessee
Texas
Virginia
Wisconsin

If you see patients enrolled in one of these Medicaid programs, we remind you that claims should be handled as you would other BlueCard Program claims.

1 This information is accurate as of the posting date. Updated information, as it becomes available, will be included on Horizon NJ Health’s Resources page at HorizonNJHealth.com/for-providers/resources.

Identifying Medicaid Members to Determine Eligibility and Benefits

BCBS Plan ID cards may not always indicate that a member has a Medicaid product.

BCBS Plan ID cards for Medicaid members do not include the suitcase logo that you may have seen on most BCBS ID cards, but they do include a disclaimer on the back of the ID card providing information on benefit limitations. For members with such ID cards, you should obtain eligibility and benefit information and prior authorization for services using the same tools as you would for other BCBS members.

Submit an eligibility inquiry by calling the BlueCard Eligibility Line at 1-800-676-BLUE (2583).
Submit an eligibility inquiry using BlueExchange.
Obtain pre-service review using the Electronic Provider Access (EPA) tool.

Provider Enrollment Requirements

Because Medicaid programs are state-run programs, requirements vary for each state, and thus each BCBS Plan.

Some states require that out-of-state providers enroll in their state’s Medicaid program in order to be reimbursed. If you are required to enroll in another state’s Medicaid program, you should receive notification upon submitting an eligibility or benefit inquiry.

You should enroll in that state’s Medicaid program before submitting the claim. If you submit a claim without enrolling, your Medicaid claims will be denied and you will receive information from your local BCBS Plan regarding the Medicaid provider enrollment requirements.

Visit Horizon NJ Health’s Resources page on HorizonNJHealth.com/for-providers/resources to review enrollment requirements for BCBS Medicaid states.

Medicaid Billing Data Requirements

When billing for a Medicaid member, please remember to check the Medicaid website of the state where the member resides for information on Medicaid billing requirements.

Medicaid claims must include the following data elements:

Rendering Provider Identifier (NPI)
Billing Provider Identifier (NPI)
National Drug Code (as appropriate)

Medicaid Reimbursement and Billing

When you see a Medicaid member from another state and submit the claim, you must accept the Medicaid fee schedule that applies in the member’s home state. Remember that billing out-of-state Medicaid members for the amount between the Medicaid-allowed amount and charges for Medicaid-covered services is specifically prohibited by Federal regulations (42 CFR 447.15).

If you provide services that are not covered by Medicaid to a Medicaid member, you will not be reimbursed. You may only bill a Medicaid member for services not covered by Medicaid if you have obtained written approval from the member in advance of the services being rendered.

FOR MORE INFORMATION

Specific information on the BlueCard program is available at bcbs.com.

Quality Recognition Programs

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Quality Recognition Programs Mon, 12/30/2019 - 06:00

BLUE DISTINCTION DESIGNATION
Blue Distinction is national designation awarded by the Blue Cross and Blue Shield Association (BCBSA) to hospitals and provider entities that meet quality focused criteria that emphasize patient safety and outcomes in certain specialty care areas.

In addition to Blue Distinction Center designation, the BCBSA also awards Blue Distinction Center+ designation to hospitals and provider entities that meet the same quality-focused criteria as well as cost of care measures in certain specialty care areas.

Designation is based on rigorous, evidence-based, objective selection criteria established in collaboration with expert physicians’ and medical organizations’ recommendations. The criteria used to select Blue Distinction Centers® are made available to the public, allowing all involved to understand what’s behind the quality designation.

The goals of Blue Distinction designation are to:

Encourage health care professionals to improve the overall quality and delivery of health care, resulting in better overall outcomes for patients.
Support consumers as they identify the care and treatment that best meets their needs.

The Blue Distinction program recognizes hospitals and provider entities for their distinguished clinical care and processes in the areas of:

Bariatric Surgery
Cardiac Care
Cancer Care
Cellular Immunotherapy-CAR-T
Fertility Care
Gene Therapy-Ocular Disorders
Maternity Care
Knee and Hip Replacement
Spine Surgery
Transplants

This national program will continue to expand into additional specialty care areas which, when complete, will represent more than 30 percent of inpatient hospital expenditures.

A list of New Jersey hospitals and provider entities designated as a Blue Distinction Center or Blue Distinction Center+ is available online at HorizonBlue.com/BDC.

For more information about the Blue Distinction program, including a complete listing of designated facilities, visitbcbs.com/bluedistinction.

BLUE DISTINCTION CENTERS FOR TRANSPLANTS
The Blue Distinction Centers for Transplants® are a national comprehensive network of transplant centers for both solid organ and bone marrow transplants.

The Blue Distinction Centers for Transplants are designated facilities across the nation that meet stringent quality criteria established by national organizations and expert clinician panels. By meeting these requirements, the centers demonstrate better outcomes and consistency of care and provide greater value for many of our members. Blue Distinction Centers for Transplants are considered in network for all members with BlueCard access.

There are Blue Distinction Centers for Transplants for the following transplant types:

Heart
Lung
Liver (deceased and living donor)
Pancreas (adult transplants only)
Bone marrow/stem cell

Physicians referring a Horizon BCBSNJ member for a transplant, should call us for information about participating local and national transplant facilities.

Dedicated case management is available to help you and your patient. For more information, call
1-888-621-5894, extension 46404.

CMS requires that Medicare and Medicare Advantage members must receive transplant- related services only at Medicare-approved transplant facilities.

Visit cms.gov for more information on approved transplant programs.

Referrals

horizonbcbsnj — Mon, 30 Dec 2019 10:57:53 +0000

Referrals Mon, 12/30/2019 - 05:57

Horizon BCBSNJ has a comprehensive network of contracted physicians and other health care professionals throughout our region.

If a PCP determines a patient, who is enrolled in a Horizon BCBSNJ managed care plan that requires referrals, needs care from a specialist or facility, the PCP should refer the patient to a specialty care physician, other health care professional or facility participating in the Horizon Managed Care Network.

Referrals serve several purposes including:

Provide a mechanism to manage the appropriate use of specialty care services.
Expedite communication between the PCP, specialist, facility and Horizon BCBSNJ, allowing for efficient and prompt reimbursement of services.
Provide clinical information for data analysis and medical outcomes.

To help ensure that your patients receive the highest level of benefit coverage, it is important to make sure all referrals to a physician, other health care professional or hospital are obtained prior to services being rendered.

Horizon BCBSNJ requires that all referrals are created electronically through either NaviNet.net or our IVR system. We do not accept paper referrals.
Referrals must be completed before the specialist’s services are rendered.
Referrals are valid for 365 days from the date of issuance and must include the referring physician’s name, the name of the hospital and the approved number of visits.
Generally, the maximum number of visits per referral is 12. However, referrals for dialysis treatment may be created for up to 160 visits.
PCPs and Ob/Gyns in the Horizon Managed Care Network can submit initial referrals to specialists in the network. These are called Primary referrals. Ob/Gyns may issue Primary referrals for Ob/Gyn-related services only.
Specialists in the Horizon Managed Care Network can submit secondary referrals to network radiology centers or to ambulatory surgery centers or hospital outpatient departments for same day surgery. These are called Refer-On referrals.
Referrals are NOT required for members enrolled in any Horizon BCBSNJ Medicare Advantage HMO plans, including: Horizon Medicare Blue Value (HMO), Horizon Medicare Blue Value w/Rx (HMO), Horizon Medicare Blue Choice w/Rx (HMO) and Horizon Medicare Blue Advantage (HMO).
Referrals are not required for members enrolled in Horizon HMO Access, Horizon Direct Access, NJ DIRECT ZERO, NJ DIRECT10, NJ DIRECT15, NJ DIRECT1525, NJ DIRECT2030, Horizon Advantage EPO, OMNIA Health Plans, Horizon Medicare Blue Access Group (HMO-POS), Horizon Medicare Blue Access Group w/Rx (HMO POS), Horizon Medicare Blue (PPO), Horizon Medicare Blue Group, (PPO) or Horizon Medicare Blue Group w/Rx (PPO) plans when they use physicians, other health care professionals or facilities that participate in the Horizon Managed Care Network.
Referrals are not valid for out-of-network services.
Any referral to a non-participating physician or other health care professional for a member enrolled in a plan that does not include out-of- network benefits requires prior authorization from Horizon BCBSNJ.
Referrals are required for members enrolled in Horizon POS plans to receive the in-network benefit level.
Although referrals or approval from Horizon BCBSNJ are not required for members enrolled in managed care plans that include the option of receiving care from nonparticipating physicians, other health care professionals or facilities, these services are generally subject to higher out-of-pocket expense than in-network services.

Participating referring physicians are required to follow the guidelines set forth in our Out-of-Network Consent Policy.

REFERRING TO A SPECIALIST

If a PCP determines a patient needs care from a specialist, the PCP should refer the patient to a specialty care physician or other health care professional participating in the Horizon Managed Care Network.

Visit our Online Doctor & Hospital Finder on HorizonBlue.com/doctorfinder to confirm the participation status of specific physicians.

EXTENDED REFERRALS

A patient’s PCP may obtain authorization from our Utilization Management Department to allow the specialist to exercise authority and control care provided for a chronic condition (e.g., HIV, cancer, diabetes and transplants). This includes performing tests and treatment and referring to other specialists, hospitals and facilities, as necessary.

If the PCP determines the need to refer a member to a participating specialist for a chronic condition, the PCP must call Utilization Management for authorization at 1-800-664-BLUE (2583).

REFERRING TO A FACILITY FOR CHEMOTHERAPY

Chemotherapy services rendered at a facility require a referral only.

ELECTRONIC REFERRAL REQUIREMENT

Horizon BCBSNJ requires that all referrals are created electronically through either NaviNet.net or our Interactive Voice Response (IVR) system. We do not accept paper referrals.

Submitting Referrals through NaviNet Registered users of NaviNet may create, submit and review referrals with just a few clicks of the mouse.

Here are a few tips to help make using online referral submissions even easier:

After entering the subscriber ID number, select the name of the patient being referred. The subscriber information, along with the patient information will prepopulate the referral.
Search for the ETIN number, which will prepopulate the referred-to physician information.
You can create multiple consecutive referrals for the same patient without having to re-enter the patient’s information.
The system speeds up online referral submissions by saving the following frequently used information as favorites:
- ETIN or tax ID numbers
- Number of visits
Download/print a Referral Confirmation at any time.

Online Demo

Learn about creating online referral submissions by viewing the NaviNet tutorial:

Select Provider Reference Materials and mouse over Resources.
Select Training, then Education.
Select NaviNet Information Demo.

Submitting Referrals through the IVR System

Referrals may be submitted via our IVR system. To access our IVR system, call 1-800-624-1110.

After submitting a referral through our IVR system, you can request a fax copy of that referral through the IVR. Or, if you are a registered user of NaviNet, you can view and/or print the applicable Referral Confirmation Receipt(s) through NaviNet.net.

Before you submit a referral using IVR, you will need:

Either your provider ID number, tax identification number (TIN) or National Provider Identifier (NPI).
The ID number or Social Security Number of the patient being referred.
The birth date (month, day and year) of the patient being referred.
The electronic tax identification number (ETIN), TIN, NPI or Medicare ID of the specialist or facility the patient is being referred to.
Your fax number to receive a fax copy of the referral (optional).

Submitting a primary referral

From the IVR main menu, say referrals or press 4.
From the Referrals menu, say submit or press 1.
Say primary or press 1.
Say or enter the patient’s ID number or Social Security Number.
Say or enter the patient’s eight-digit date of birth (mm/dd/yyyy).
Say or enter the ETIN, TIN, NPI or Medicare ID of the specialist who you are referring the patient to.
Say or enter the number of visits. (The maximum number of visits, per referral,is 12. The maximum number of dialysis visits, per referral, is 160).
Confirm the information you have entered, when prompted.
Say or enter your fax number, when prompted.
Listen for and make note of the referral number.

Submitting a Secondary Referral

From the IVR Main menu, say referrals or press 4.
From the Referrals menu, say submit or press 1.
Say secondary or press 2.
Say the Referral Number for the applicable primary referral. You may enter it via touch-tone if it is all numeric digits.
Say or enter the ETIN, TIN, NPI or Medicare ID of the hospitals, radiology centers, or ambulatory surgical centers that you are referring to.
Follow steps 7 through 10 under Submitting a Primary Referral.

Checking Referral Status on the IVR

From the IVR main menu, say Referrals or press 4.
From the Referrals menu, say Status or press 2.
Enter the patient’s ID number or Social Security Number.
https://nanthealth.com/navinet-contact-us/
Enter the patient’s eight-digit date of birth (mm/dd/yyyy).
Listen for a list of referral status records.
Listen for your opportunity to provide your fax number to request a fax copy of the referral.

IVR System Tips

Here are a few tips to make it easier to submit referrals through the IVR:

Listen carefully to the prompts and speak your response in a clear voice.
Information containing letters should be spoken.
If you think you made a mistake in entering information, simply wait.
To return to the main menu at any time, say main menu.

To review other best practice hints for creating referrals through the IVR, visit HorizonBlue.com/ivr.

Viewing Referral Confirmations Online

After submitting a referral through our IVR system, you can view and/or print the applicable Referral Confirmation Receipt(s) through NaviNet.net.

A few minutes after submitting a referral through the IVR, log on to NaviNet.net.
Mouse over Referrals and Authorization and click Referral/Authorization Inquiry.
Search submitted referrals in the appropriate date range.
Click the appropriate referral confirmation number to see the details.

Service

horizonbcbsnj — Mon, 30 Dec 2019 10:54:26 +0000

Service Mon, 12/30/2019 - 05:54

We understand 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 practice.

INTERACTIVE VOICE RESPONSE (IVR) SYSTEM

The Interactive Voice Response (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, seven days a week, generally including weekends and holidays, and get instant answers to many questions previously handled only by our service representatives.

Our 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.

We encourage you to access the easy-to-use IVR system by calling 1-800-624-1110 and exploring all the information and services that it has to offer.

IVR

Use your natural voice or the touchtone keypad to enter the patient’s ID number or navigate through the call, whichever is right for the environment you’re in.

Here are some tips to help you navigate our IVR system:

Speak clearly in your natural tone.
If accessing the IVR from a noisy environment, please 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 reimbursement.

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 check the status of an authorization.

Referrals to refer a patient for a treatment or check the status of an existing referral (if needed).

Duplicate Vouchers to request a duplicate voucher.

Physician Services Representatives are available to help you and provide information that you may not be able to access through our IVR system. Call 1-800-624-1110, Monday through Friday, between 8 a.m. and 5 p.m., ET.

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 Horizon BCBSNJ managed care patients.

OTHER SERVICE AREAS

Horizon BCBSNJ has a number of more specialized service areas that provide more specific information and assistance with authorizations and prior authorizations. For the representative in these specialized service areas to perform their functions efficiently and effectively, it’s important that their time is not spent responding to basic benefits, enrollment and eligibility inquiries.

Please seek basic benefits, enrollment and eligibility information prior to contacting our Precertification Call Center for an authorization request. If you require documentation that a service does not require prior authorization, a Physician Services Representative can provide both the information you need and a service reference number that documents the information you were provided.

BlueCard® Dedicated Unit – phone: 1-888-435-4383
BlueCard/Out-of-state members (eligibility, benefits and prior authorizations) – phone: 1-800-676-BLUE (2583)
CareCentrix – phone: 1-855-243-3321
eviCore healthcare (prior authorization/medical necessity determinations) – phone: 1-866-496-6200 (radiology and cardiology): 1-866-241-6603
(pain management): 1-844-224-0493
(molecular and genomic testing): 1-866-241-6603 (musculoskeletal program for spine surgery services): 1-866-241-6603

fax: 1-800-637-5204 (radiology services)
- 1-888-785-2480 (cardiology services)
- 1-800-649-4548 (pain management)
- 1-800-649-4548 (musculoskeletal)
Dental inquiries – phone: 1-800-4-DENTAL (433-6825)
EDI Service Desk – e-Business (online capabilities inquiries and help) – Provider_Portal@HorizonBlue.comphone: 1-888-777-5075
EDI Service Desk - Electronic Data Interchange (EDI) (data feed issues) – HorizonEDI@HorizonBlue.comphone: 1-888-334-9242
Home care and/or Home IV infusion – fax: 1-800-492-2580
Magellan Rx Management (medical necessity and appropriateness reviews of specific injectable medications) – phone: 1-800-424-4508
National Provider Identifier (NPI) submission – fax: 1-973-274-4416
NaviNet® NaviNet.net – phone: 1-888-482-8057
Notices of admission for out-of-state and non-network facilities – phone: 1-888-621-5894
Physician profile changes – Provider_Portal@HorizonBlue.comfax: 1-973-274-4302

UTILIZATION MANAGEMENT CONTACT INFORMATION

If you need to obtain prior authorization for a Horizon BCBSNJ member, you can submit your request via the Utilization Management Request Tool on NaviNet or call 1-800-664-BLUE (2583).

To access our Utilization Management Department after business hours and on weekends, you should call our after-hours emergent clinical issues phone number, 1-888-223-3072.

BEHAVIORAL HEALTH AND SUBSTANCE USE DISORDER CARE

Please check your patient’s ID card for the name and phone number of the behavioral health and substance use disorder care administrator that administers benefits for your patient. Whether it is an emergency or a request for inpatient or outpatient services, either you or the member should call the appropriate behavioral health care administrator.

With few exceptions, Horizon Behavioral Health coordinates members’ behavioral health and substance misuse benefits. Call 1-800-626-2212 to speak with a Care Manager who can inform you of your patient’s treatment plan and progress. This service is available 24 hours a day, seven days a week.

You may call Horizon Behavioral Health to refer most patients for behavioral health or substance use disorder care.

If Horizon Behavioral Health does not administer your patient’s behavioral health and substance use disorder benefits, please contact the behavioral health and substance abuse administrator listed on the back of your patient’s ID card.

FAX INQUIRIES

If you have five or more inquiries for any of our Horizon BCBSNJ members, you may fax your inquiries to 1-973-274-4159.

You may download fax inquiry forms from the Forms section of HorizonBlue.com/providers. To receive a supply of fax inquiry forms, call 1-800-624-1110.

COPIES OF AGREEMENTS

As a participating physician or other health care professional, you may request a copy of your AGREEMENT WITH PARTICIPATING PHYSICIANS AND HEALTHCARE PROFESSIONALS or HORIZON HEALTHCARE OF NEW JERSEY, INC. AGREEMENT WITH PARTICIPATING PHYSICIANS AND OTHER HEALTHCARE PROFESSIONALS by faxing a request to 1-973-274-4302 or by mailing a request to:

Horizon BCBSNJ
Three Penn Plaza East, PP-14C
Newark, NJ 07105-2200

NETWORK SPECIALISTS

Your Network Specialist is your primary point of contact for Horizon BCBSNJ products and administrative policies and procedures. He or she is accessible to you when and where you need him or her by phone, email and visits to your office, upon request.

Each Network Specialist faces off to the participating physicians and other health care professionals our local service area (New Jersey and certain counties in New York, Pennsylvania and Delaware)

Network Specialist assignments are available by logging on to NaviNet.net. From My Health Plans menu, select Provider Reference Materials, then:

Mouse over Resources and select Network Specialists.

To speak with your Network Specialist, call 1-800-624-1110, and select More Options, then select Network Relations.

NAVINET.NET

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

Through NaviNet, a multi-payer web portal, your office 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 office 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, 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 SignUp.
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 billingagency?

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.

Following the receipt of a completed authorization form, 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, please ask them to forward a copy of the authorization form (see step 3 on the previous section) they originally received from NaviNet for you to sign. For help registering, call NaviNet Customer Care at 1-888-482-8057.

NaviNet Online Capabilities

The online capabilities you can access through NaviNet include:

Answers to Frequently Asked Questions
Capitation Reports
Claim Inquiry (local and out-of-state members)
Claim Submission (CMS 1500 and UB04)
Clear Claim Connection

COB Questionnaire Submission
EFT Registration
Eligibility and Benefits Inquiry (local and out-of-state members)
Fee Schedule Inquiry
Horizon Healthcare Innovations
ITS Host Claim Appeal Submission
Medical Attachment Submission
Payment Status Inquiry
PCP Panel Inquiry
Physical and Occupational Therapy Authorization
Pre-existing Condition Attachment Submission
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 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.

Capitation Reports

Registered NaviNet users may click Capitation Reports within the Eligibility & Benefits tab to access capitation reports.

This can help you better reconcile your rosters and quickly verify that a patient is, or is not, on your roster in real-time.

Primary Care Physicians (PCPs) and their office staff now have access to 12 months of practitioner or group capitation report information.
Capitation report information may be generated based on any of the following criteria:
- Health insurance plan/product
- Member
- Month
- Physician
Capitation report information may be downloaded in the format of your choice:
- HTML
- Microsoft® Excel
- PDF

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 physicians and 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 and:

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 your office 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 local (Horizon BCBSNJ) as well as BlueCard and FEP members.

The Eligibility & Benefits Detail screen displays:

Current Primary Care Provider Information (if applicable)
Plan information
Patient 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.

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.

Online Credentialing Application

If you’re adding health care professionals to your practice, you can use Horizon BCBSNJ’s online credentialing application.

To use the online credentialing application, log in to NaviNet.net, and select Horizon BCBSNJ on the My Health Plans menu. Select Provider Data Maintenance.

Our credentialing application is accessible to those registered NaviNet users who have Security Officer rights. If you don’t see Provider Data Maintenance within References and Resources, you may not be set up as the Security Officer for your practice. Call NaviNet Customer Care at 1-888-482-8057 for assistance.

To use our online credentialing application, the health care professional joining your practice must be recognized by our systems. This means that at least one claim must have been previously submitted to Horizon BCBSNJ for the health care professional joining your practice. If the health care professional joining your practice has never submitted a claim to us, visit HorizonBlue.com/whyjoin to print an application.

The online credentialing application:

Is integrated with the Council for Affordable Quality Healthcare’s online Universal Provider Datasource® to speed processing and eliminate input errors.
Will generate automated email messages to advise you:
- That your application was received and provides a confirmation number for easier follow up.
- When your application is approved.
Allows you to check the status of your credentialing application online.

Fee Schedule Inquiry Information Online Fee Schedule

Horizon BCBSNJ makes fee information (for most specialties) available to you online immediately. To access online fee schedule information, including Injectable Medication Fee Schedule Information, log in to NaviNet.net and select Horizon BCBSNJ from the My Health Plans menu and:

Mouse over Claim Management and select
Fee Schedule Inquiry.
On the Fee Schedule Inquiry page, select your Billing (Tax) ID number and your county.
- Select your specialty to view our fees for the most common CPT codes for that specialty, or
- Enter specific CPT codes to view our allowances for those specific services.
Then, based on the information you’re seeking, you may either:

Injectable Medication Fee Information is updated on a quarterly basis (on or around the first day of February, May, August and November).

Fee information for the following services/specialties is not yet available in this immediate electronic format:

Anesthesia services
Services provided by:
- Certified nurse specialists
- Nurse practitioners
- Physician assistants
- Registered nurse first assistants
To access the Fee Schedule Inquiry Form, log in to NaviNet.net, select Horizon BCBSNJ from the My Health Plans menu, mouse over Claim Management and select Fee Schedule Inquiry.

Complete the required fields and select Submit Request. The fee schedule information will be emailed to you within 15 days.

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, including the:
- W-9 Tax Form
- Fax Prior Authorization Request (8319) Form
- Capitation Adjustment Request (2801) Form
- Inquiry Request and Adjustment (579) Form
- 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 at HorizonBlue.com/provider. Then select Forms and form type.

You may also download a blank, printable W-9 form via our website and submit it by mail or fax.

Our forms are organized into the following sections:
- Forms by Plan Type
- Forms by Specialty Type
- Forms by Type
- Frequently Used Forms
- Miscellaneous
- W9 Form-Dental
- W9 Form-Medical
ONLINE EDUCATION RESOURCES

We now 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:
- Horizon BCBSNJ new physician orientation.
- A collection of online demos and webinars.
- Horizon BCBSNJ product knowledge courses and assessments.
- Online user guides, including physician office 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 Plansmenu.
- Select Provider Reference Materials.
Physician Training Webinars

Our Network Specialists will host online training webinars to introduce new products, reinforce existing product knowledge, highlight our self-service features and more. Visit our online educational resources to learn more.

Interactive Online Classes

Online courses are available to provide valuable information about Horizon BCBSNJ products, initiatives and other topics. Courses are available to all participating physicians, other health care professionals, their office managers and staff.

Courses include assessments to help validate and reinforce understanding of the material presented. We use the assessment data to help us improve the course content and direct other training and education efforts.

If you have questions, contact your Network Specialist.

ONLINE DOCTOR & HOSPITAL FINDER

Visit HorizonBlue.com/doctorfinder and Use our Online Doctor & Hospital Finder to locate participating physicians/other health care professionals, hospitals 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
In addition, the Online Doctor & Hospital Finder provides the NPI number for participating specialists, which is useful when submitting referrals online and via the IVR system.

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

You should check your details on our website to ensure your information is accurate. Updates to your demographic information may be performed online or by fax request.

Provider File Change Request Form

You may initiate changes to your demographic information by fax. Complete a copy of our Provider File Change Request Form (9093) and fax it, along with all necessary supporting documents (e.g., W-9, NPPES Letter, SS4, etc.) to 1-973-274-4302.

To access our Provider File Change Request Form (9093), visit HorizonBlue.com/filechangerequest.

ELECTRONIC DATA INTERCHANGE

Our EDI Service Desk supports all of the most common Electronic Data Interchange (EDI) transactions. All of our transactions are based on the nationally accepted American National Standard Institute (ANSI) 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
- Physician, Hospital and Dental Claims (837)
- Eligibility Inquiry and Response (270/271)
- Request for Authorization/Review (278)
- Referrals (278)
- Claim Status and Response (276/277)
- Benefit Enrollment and Maintenance (834)
- Claim Payment Advice (835)
- Premium Payment (820)
Benefits of EDI
- Faster exchange of information
- Improved accuracy
- Reduced postage cost
- Reduced administrative cost
- Elimination of paper documents
- Timely postings
- Reduced handling
- Reduced reimbursement cycle
- Tracking capabilities
- More efficient means of conducting business
- Minimize possibility of lost or misrouted documents
If you have questions about EDI transactions, or for more information, call the EDI Service Desk team at 1-888-334-9242, Monday through Friday, between 7 a.m. and 6 p.m., Eastern Time, or send an email to HorizonEDI@HorizonBlue.com.

RENDERING, REFERRING AND ATTENDING PHYSICIAN NPI REQUIREMENT

Horizon BCBSNJ captures National Provider Identifier (NPI) information for rendering, referring and attending physicians.

Submit NPI information on all appropriate electronic and paper copy claim submissions. Ensure that your claim submissions include rendering, referring and attending physician NPI information to avoid claim transaction rejections and/or delays in the processing of your claim submissions.

If you have technical questions about NPI or questions regarding electronic transactions, call our EDI Service Desk at 1-888-334-9242, Monday through Friday, between 7 a.m. and 6 p.m., ET. Or, email your inquiry to HorizonEDI@HorizonBlue.com.