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Medical Policy Revision: Electromyography and Nerve Conduction Studies

horizonbcbsnj — Mon, 15 Jul 2019 14:02:01 +0000

Medical Policy Revision: Electromyography and Nerve Conduction Studies Mon, 07/15/2019 - 10:02

Effective October 15, 2019, Horizon BCBSNJ will change the way we consider certain professional claims based on revisions to our medical policy Electromyography and Nerve Conduction Studies.

Access our Medical Policy Manual to review this medical policy content.

Based on the submitted diagnosis code(s), claims submitted for services provided on and after October 15, 2019 to patients enrolled in Horizon BCBSNJ commercial and Administrative Services Only (ASO) plans will be processed as follows.

The services represented by CPT® codes 95912 or 95913 may be denied as experimental/investigational, non-covered services.

Information may be requested to help us determine the medical appropriateness of the services represented by CPT codes 95912 or 95913. Following our review of medical record information, these codes may be denied as experimental/investigational, non-covered services.

Unless Horizon BCBSNJ gives written notice that all or part of the above changes have been canceled or postponed, the changes will be applied to claims for dates of service on and after October 15, 2019.

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

Additional Member Plans to be Included as part of our Surgical and Implantable Device Management Program for Orthopedic Surgeries

horizonbcbsnj — Mon, 15 Jul 2019 07:25:35 +0000

Additional Member Plans to be Included as part of our Surgical and Implantable Device Management Program for Orthopedic Surgeries Mon, 07/15/2019 - 03:25

Beginning on July 15, 2019, the Surgical and Implantable Device Management program for orthopedic surgery services will expand to also apply to members enrolled in Horizon BCBSNJ Medicare Advantage plans.

Through this program, TurningPoint Healthcare Solutions LLC (TurningPoint) conducts Prior Authorization & Medical Necessity Determination (PA/MND) reviews for certain orthopedic surgery services that are requested by participating and nonparticipating physicians when rendered in the following settings¹:

Inpatient
Outpatient
Ambulatory Surgical Center
Physician’s Office

Initially, this program only applied to Horizon BCBSNJ members enrolled in fully insured plans/products and in fully insured plans/products that include BlueCard® benefits for care received outside of Horizon BCBSNJ’s local service area. To determine member eligibility and benefits, your or your can call the phone number on the back to your member ID card.² ³

Some of the most common services reviewed as part of this program include:

Joint Reconstructive & Fusion Surgeries
(Including all associated revision surgeries)

Knee Arthroplasty
Hip Arthroplasty
Shoulder Arthroplasty
Elbow Arthroplasty
Ankle Arthroplasty
Wrist Arthroplasty
Hip Resurfacing
Shoulder Fusion
Elbow Fusion
Ankle Fusion
Wrist Fusion

Sports Medicine Surgeries

ACL Repair
Acromioplasty & Rotator Cuff Repair
Femoroacetabular Arthroscopy
Knee Arthroscopy
Hip Arthroscopy
Meniscal Repair (with or w/o Allograft)
Osteochondral Defect Repair

Your doctor can request a PA/MND for necessary orthopedic surgery services by calling TurningPoint at 1-833-436-4083 Monday through Friday between 8 a.m. and 5 p.m., Eastern Time. They may also find more details at HorizonBlue.com/turningpoint.

You or your doctor may request copies of the medical policy criteria and guidelines that TurningPoint uses to conduct PA/MND reviews as part of this program by calling TurningPoint at 1-833-436-4083.

As always, we encourage you to speak with your doctor about the orthopedic care that might be right for you. Horizon BCBSNJ remains committed to helping you access the care you need when you need it and reducing your out-of-pocket costs.

¹Services rendered in the observation setting and the Emergency Room (ER) are not reviewed by TurningPoint as part of this program.
² Horizon BCBSNJ members enrolled in plans that include BlueCard benefits who receive care outside of Horizon BCBSNJ’s service area which includes the State of New Jersey, contiguous counties in DE, NY and PA (as well as Lehigh County, PA).
³ For BlueCard benefit inquiries call 1-800-676-2583

CPT® is a registered trademark of the American Medical Association.
NaviNet® is a registered trademark of NaviNet, Inc.
TurningPoint Healthcare Solutions, LLC supports Horizon Blue Cross Blue Shield of New Jersey in the administration and utilization management review of certain surgical services that require an implantable device for coverage. TurningPoint Healthcare Solutions, LLC is independent from, and not affiliated with Horizon Blue Cross Blue Shield of New Jersey or the Blue Cross and Blue Shield Association.

Electromyography and Nerve Conduction Studies

horizonbcbsnj — Fri, 12 Jul 2019 13:14:22 +0000

Electromyography and Nerve Conduction Studies Fri, 07/12/2019 - 09:14

Medical policy type

Revised

Third Party URL

https://services3.horizon-bcbsnj.com/hcm/MedPol2.nsf/MedicalPolicies/RFMI-9NLN5A

Member Portal Maintenance

horizonbcbsnj — Fri, 12 Jul 2019 12:36:10 +0000

Member Portal Maintenance Fri, 07/12/2019 - 08:36

Horizon BCBSNJ's Member Portal will undergo scheduled maintenance beginning at 8 p.m. July 12, 2019 until 8 a.m. July 15, 2019. During this time you may experience intermittent issues with some transactions. We apologize for the inconvenience and appreciate your patience.

Member Portal Maintenance

horizonbcbsnj — Thu, 11 Jul 2019 14:47:02 +0000

Member Portal Maintenance Thu, 07/11/2019 - 10:47

Horizon BCBSNJ's Member Portal will undergo scheduled maintenance beginning at 8 p.m. July 11, 2019 until 8:20 p.m. July 11, 2019. We apologize for the inconvenience and appreciate your patience.

Taking Care of Your Health

horizonbcbsnj — Wed, 10 Jul 2019 07:35:30 +0000

Taking Care of Your Health Wed, 07/10/2019 - 03:35

Learn more about how to get and stay well.

Preventive Screenings

Managing your health includes preventive care, even when you’re not feeling sick. Preventive screenings are an important part of staying healthy.Talk to your doctor about which screenings are right for you.

Breast Cancer Screening
Did you know that three out of four women who get breast cancer have no family history of the illness? The best protection is early detection. Routine mammograms are covered by your health plan, at no cost to you, so talk to your doctor about when and how often you should be getting a mammogram. All you need is a prescription from your doctor.

A mammogram can:
- Detect symptoms years before you can feel a lump
- Find cancer early, when it’s most treatable, but only if you have the screening every year
- Take as little as 20 minutes with minimal discomfort for most women
Plus, you can receive a $50 CVS gift card when you complete your mammogram. Learn more about earning rewards by completing your preventive health screenings through the Horizon Healthy Journey Program. The program is available to members who have a Horizon Medicare Advantage plan (HMO or PPO).

Top 5 Things to Talk About at Your Annual Wellness Visit
When you have your Annual Wellness Visit with your Primary Care Physician (PCP), be sure to have an open discussion and remember to ask questions. Your PCP will create a personalized care plan that treats all your conditions, so being honest about your health concerns helps your doctor help you.

Talk about:
1. Falls: Certain health issues or living conditions may increase your chance of falling and these risk factors increase as you age. Always tell your doctor about any falls you have had in the past. Ask about taking a falls risk assessment.
1. Blood pressure: Make sure your doctor checks your blood pressure at every visit. If it’s high, ask how you can lower your blood pressure to avoid health issues like a stroke, heart disease and kidney failure.
1. Preventive care: If you had a fracture (broke a bone) in the last six months, you should get a DEXA scan to assess your bone health. Other important screenings to discuss are breast cancer, colorectal cancer and diabetes.
1. How you are feeling: Let your doctor know if you’re feeling sad or depressed. You may benefit from talking with a behavioral health professional who can help you learn skills to cope with negative feelings or prescribe medication to manage depression.
1. Medications: Follow the directions on your medicine bottles and don’t forget to take them even if you feel like they aren’t working. If you have side effects, let your doctor know right away. You must take your medication correctly for it to work properly. Not taking your medication correctly can cause serious damage to your health.
Plus, you can receive a $25 CVS gift card when you complete your Annual Wellness Visit. Learn more about earning rewards by completing your preventive health screenings through the Horizon Healthy Journey Program. The program is available to members who have a Horizon Medicare Advantage plan (HMO or PPO).

Health and Wellness

Staying healthy helps keep your body and mind strong, and can help prevent illness. Regular visits to your doctor, along with other tests and screenings, can help prevent certain health conditions, such as heart disease, stroke and high blood pressure. Taking care of yourself today can help keep you healthy tomorrow.

Falls Risk Assessment
Did you know that falling once doubles your chances of falling again? If you fall and injure yourself, you may lose the ability to live independently. Factors that can increase your risk include weakness in your legs, low levels of vitamin D, certain medications, vision problems, foot pain, poorly fitted shoes, uneven steps, throw rugs and items left on the ground.

Ask yourself:
- Have you fallen or tripped in the past year?
- Do you ever feel unsteady when walking?
- Do you need to push with your hands to stand up from a chair?
- Do you take medicine that makes you tired or dizzy?
- Have you ever lost feeling in your feet?
- Do you have weakness in your legs?
If you answered “yes” to any of these questions, schedule your annual checkup with your Primary Care Physician and ask for a Falls Risk Assessment.

Sometimes making simple changes to your home or lifestyle can help keep you from falling.

Consider:
- Asking for help to bring in the groceries
- Cleaning up clutter in hallways and on staircases
- Installing handrails in hallways and on staircases, and in bathrooms
- Repairing or removing tripping hazards like as loose carpeting, throw rugs or floorboards
Use our Doctor & Hospital Finder to find a doctor, or any other specialist, hospital or lab.

High blood pressure: Do you know your numbers?
High blood pressure, also known as hypertension, is often called a “silent killer.” Many people don’t know that they have it because it often has no warning signs or symptoms. The only way to know if you have hypertension is to measure your blood pressure. If you have high blood pressure, your doctor may prescribe medications for you to take.

Blood pressure is measured using two numbers – systolic and diastolic:
- Normal:
  - Systolic: <120 mmHg
  - Diastolic: <80 mmHg
- At risk:
  - Systolic: 120-139 mmHg
  - Diastolic: 80-89 mmHg
- High:
  - Systolic: 140+ mmHg
  - Diastolic: 90+ mmHg
Check with your doctor to know if your blood pressure is within a safe range.

Use our Doctor & Hospital Finder to find a doctor, or any other specialist, hospital or lab.

Staying Healthy and Saving Money

horizonbcbsnj — Wed, 10 Jul 2019 07:33:27 +0000

Staying Healthy and Saving Money Wed, 07/10/2019 - 03:33

Learn more about how you can earn and save, and take care of your health.

Horizon Healthy Journey

Learn how to take care of your health and earn rewards with the Horizon Healthy Journey Program.

The Horizon Healthy Journey Program is here to help you get the information you need to take care of your health. We focus on the importance of preventive health screenings through education and engagement. The Horizon Healthy Journey Program offers:

Personal Touch: Our care team makes one-on-one calls for health screening reminders, health education and chronic disease management.
All Stages of Life: You can count on us for support through all stages of life.
Awareness: Our educational materials and health screening reminders are tailored to your needs.
Rewards and Incentive: We make it easy for you to earn rewards just for being active in your wellness journey. You may be eligible to earn rewards when you complete certain preventive health screenings.

Your journey to better health begins here!

Getting the right care starts with an annual wellness visit with your Primary Care Physician (PCP). During this visit, your PCP will talk to you about your:

Blood pressure
Cholesterol
Body mass index (BMI)
Risk of falling
Needed preventive health screenings and vaccinations

An annual wellness visit is a covered benefit, at no cost to you.

Contact us: If you have any concerns that make it difficult for you to get your preventive health screenings, please call the Horizon Healthy Journey line 1-844-754-2451 (TTY 711), Monday to Friday, from 8:30 a.m. to 5 p.m., Eastern Time (ET).

For questions regarding your coverage, benefits or eligibility please contact Member Services at 1-800-365-2223 (TTY 711), Monday to Friday, from 8 a.m. to 8 p.m., ET.

Throughout the year, Horizon Healthy Journey will remind you when it’s time for your preventive health screenings. You may hear from us through live or automated calls, or we may send you reminders in the mail. Horizon Healthy Journey will let you know when you are due for any of the following:

Breast cancer screening – mammogram
Osteoporosis Management in Women – DEXA scan
Vaccines – Flu, pneumococcal and shingles vaccine
Diabetes screenings – Hemoglobin A1C, Microalbumin lab test, and diabetic eye exam.
Colorectal cancer screening
Annual wellness visit

Preventive health screenings are the best way to find and treat any problems early, when chances for successful treatment are best. If you have any questions about the screenings above, call us at 1-888-754-2451 (TTY 711), Monday to Friday from 8:30 a.m. to 5 p.m., ET.

The Rewards and Incentive Program promotes staying healthy by completing your preventive health screenings while earning rewards. It is available to members who have a Horizon Medicare Advantage plan (HMO or PPO).

It’s easy to participate in the Rewards and Incentive Program:

Visit your Primary Care Physician (PCP) for your annual visit and preventive health screenings in 2019.
Complete and submit the Gift Card Redemption Form.
Submit your Redemption Forms by the following deadlines:
- By August 31, 2019 for screenings completed from January 1, 2019 to June 30, 2019
- By January 31, 2020 for screenings completed from July 1, 2019 to December 31, 2019

All health screening(s) must be completed between January 1, 2019 and December 31, 2019. Screenings completed before 2019 are NOT EIGIBLE for gift card redemption.

You must be enrolled in an eligible Horizon Medicare Advantage plan at the time you complete your screening(s).

If you prefer to send your form via mail, please contact Horizon Healthy Journey at 1-844-754-2451 (TTY 711), Monday through Friday, from 8:30 a.m. to 5 p.m., Eastern Time (ET) to request a paper copy of the Gift Card Redemption Form or print the Gift Card Redemption Form.

Rewards and Incentive Program FAQs:

Am I required to participate?
- No, this program is voluntary and does not affect your enrollment or benefits.
How do I know which screenings I need?
- We will send you a letter along with the redemption form that lists all the screening(s) you may need. You should then talk to your doctor about which screening(s) is best for you.
How will Horizon BCBSNJ know that I completed my screenings?
- All screenings are validated with claims.
What kind of purchases can I make with the CVS gift card?
- The gift card can be used for in-store purchases, except for money orders, prepaid cards, online or in-app purchases.

How long does it take to receive the gift card(s)?
- When we receive your completed Gift Card Redemption Form, Horizon BCBSNJ will record your form and completed screenings for validation.
  - We will then wait to receive a claim from your doctor or facility where the test was completed. This process may take up to 90 days from the date you completed your screening.
  - Once the screening is verified, we will send the CVS gift card to the address provide on the form, within 4-6 weeks. Missing information on the form may delay the processing of your gift card.

Which health screenings are eligible for a reward?

Screening	Reward
Annual Wellness Visit	$25 CVS gift card
Mammogram	$50 CVS gift card
Colonoscopy or Sigmoidoscopy	$50 CVS gift card
Fecal Occult Blood Test (FOBT) kit or Stool DNA	$15 CVS gift card
DEXA scan	$50 CVS gift card
Diabetic eye exam (recommended for diabetics)	$25 CVS gift card

Horizon Blue Cross Blue Shield of New Jersey has partnered with certain vendors to help you get the screenings you need quickly and easily. You may be contacted by one of the vendors below on our behalf, if you are eligible for a certain screening(s). If you get a call or receive mail from one of our partnered vendors, we have given them permission to reach out to you.

Magellan Rx: A team of pharmacists that contact members for the following:
1. Osteoporosis Management in Women — Magellan Rx educates members about the risks of osteoporosis and the importance of completing a Bone Density Mineral test/DEXA scan. They will also contact women between the ages of 65-87 that had a fracture in the past six months.
2. Statin Therapy for Patients with Cardiovascular Disease — Magellan Rx educates members who are at risk for cardiovascular disease and may benefit from statin therapy.
Magellan Rx services are offered to members in the following Medicare Advantage HMO plans:
- Horizon Medicare Blue Value (HMO)
- Horizon Medicare Blue Value w/Rx (HMO)
- Horizon Medicare Blue Choice w/Rx (HMO)
- 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 Advantage (HMO)
- Horizon Medicare Blue Select (HMO-POS)
Mobile Medical Examination services, MedXm: A specialized team of licensed, credentialed and professional technicians that perform in-home screenings for:
- Colorectal cancer
- Diabetic retinal eye exam
- Hemoglobin A1c
- Microalbumin test
- DEXA scan

MedXm services are offered to members enrolled in either Medicare Advantage HMO or PPO plans.

Home Delivery Pharmacy Service

Understanding your pharmacy benefits through Horizon Blue Cross Blue Shield of New Jersey can help save you time and money. Horizon Medicare Advantage members use AllianceRx Walgreens Prime for convenient home delivery pharmacy service.

Home delivery pharmacy service is safe, convenient and could save you money:

No more waiting in line at the pharmacy
A record of your medications is always available
With 90-day supplies, you could have fewer copayments
Free standard shipping, refill reminders and an auto-refill program
Delivery anywhere in the United States, even when you’re away from home
Medicines shipped in tamper-evident containers and delivered in plain packaging for privacy

A licensed pharmacist always processes your order and you can speak with the pharmacy team any time.

To start using the home delivery pharmacy service, visit alliancerxwp.com/home-delivery and follow the instructions to create an account. Once you’ve created an account, you can ask your doctor to send your prescription electronically to AllianceRx Walgreens Prime, or fax a prescription request to 1-800-332-9581.

Healthy Discounts

Learn more about Blue365®, a discount program administered by the Blue Cross Blue Shield Association that offers eligible Horizon BCBSNJ members savings on products and services for a well-balanced lifestyle. Blue365® deals can help members stay active, while saving money at popular retailers and companies nationwide. Blue365® deals are offered in addition to the benefits of a member’s health plan. Enroll today.

Getting to Know Medicare

horizonbcbsnj — Wed, 10 Jul 2019 07:01:29 +0000

Getting to Know Medicare Wed, 07/10/2019 - 03:01

Valuable guidance and important information for a better understanding of Medicare.

Learning More About Your Medicare Plan

When you enroll in Original Medicare, you get Part A Hospital coverage and Part B Medical coverage. But Original Medicare doesn’t cover all of your medical costs. If you want prescription drug coverage, you can buy a separate Part D plan. Or, you may decide to get all your coverage in one plan from a private insurance company, like Horizon BCBSNJ. Part C – Medicare Advantage – gives you all the benefits in one convenient plan, often including Part D, as well as other extra benefits like vision, hearing and dental.

Understanding How Medicare Works

After you’ve enrolled in the Medicare plan that best suits your needs, you’ll want to understand how it all works so get the most from your plan.

Learn more about the different parts of Medicare.

The A, B, C D’s of Medicare

Understand the difference between Original Medicare and Medicare Advantage.

Original Medicare or Medicare Advantage – What’s the difference?

Learn how to save money on your medicines.

Save Money on Your Prescription Medications

How does my other insurance work with Medicare?

When you have other insurance and Medicare, there are rules for whether Medicare or your other insurance pays first.

If you have retiree insurance (insurance from your or your spouse’s former employment): Medicare pays first.
If you’re 65 or older, have group health plan coverage based on your or your spouse’s current employment, and the employer has 20 or more employees: Your group health plan pays first.
If you’re 65 or older, have group health plan coverage based on your or your spouse’s current employment, and the employer has fewer than 20 employees: Medicare pays first.
If you’re under 65 and have a disability, have group health plan coverage based on your family member’s current employment, and the employer has 100 or more employees: Your group health plan pays first.
If you’re under 65 and have a disability, have group health plan coverage based on your or a family member’s current employment, and the employer has fewer than 100 employees: Medicare pays first.
If you have Medicare because of End-Stage Renal Disease (ESRD): Your group health plan will pay first for the first 30 months after you become eligible to enroll in Medicare. Medicare will pay first after this 30-month period.

Note: In some cases, your employer may join with other employers or unions to form or sponsor a multiple-employer plan. If this happens, the size of the largest employer/union determines whether Medicare pays first or second.

Here are some important facts to remember:

The insurance that pays first (primary payer) pays up to the limits of its coverage.
The insurance that pays second (secondary payer) only pays if there are costs the primary insurer didn’t cover.
The secondary payer (which may be Medicare) might not pay all of the uncovered costs.
If your employer insurance is the secondary payer, you might need to enroll in Part B before your insurance will pay.
Medicaid pays after Medicare.

Source: U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES; Centers for Medicare & Medicaid Services; CMS Product No. 10050; Revised November 2018

Medicare Advantage

horizonbcbsnj — Wed, 10 Jul 2019 06:38:25 +0000

Medicare Advantage Wed, 07/10/2019 - 02:38

Learn more about your Medicare Advantage plan to get the most from your benefits.

Get the Facts on Fiber

horizonbcbsnj — Tue, 02 Jul 2019 10:06:07 +0000

Get the Facts on Fiber Tue, 07/02/2019 - 06:06

Foods high in fiber are generally low in fat and calories, fill you up more, and keep you full longer. Plus, the same
foods that are high in fiber tend to be high in essential vitamins, minerals, antioxidants, and sometimes even protein.

As it moves through your digestive tract, fiber also absorbs cholesterol, cancer-causing toxins, and prevents constipation. Fiber can also protect against heart disease and diabetes.

Women should aim for at least 25 grams of fiber a day, and men should try get at least 30 grams a day.

Here are some fiber-rich foods to help you increase your intake.

Whole Grains: 6-8 ounces per day (18-40 grams of fiber)
Fruits: 2 cups per day (7-8 grams)
Vegetables: 2 1/2 cups per day (5-10 grams)
Seeds: A handful of chia, flax or sunflower seeds (3-4 grams)

Here are some ways to add more fiber to your diet:

Read food labels; look for items that have at least 2 1/2 grams of fiber per serving.
Eat whole fruit instead of drinking fruit juice, which has less fiber.
Add beans to dishes like soups, salad and chili.

To get all of fiber’s benefits, you need the soluble type, which can be found in nuts, beans and apples, and the insoluble type, which is in whole-wheat bread and fruit skins.

However, some gastrointestinal conditions, as well as cancer treatments, may require a low-fiber diet. To stay healthy without irritating your stomach, choose ripened fruit, like bananas and peaches, and well-cooked or canned vegetables.

Visit HorizonBlue.com/doctorfinder to find in-network doctors and hospitals so you can get the care you need when you need it.

Sources: Krames Patient Education, WebMD®

Need motivation to get moving?

horizonbcbsnj — Tue, 02 Jul 2019 06:24:31 +0000

Need motivation to get moving? Tue, 07/02/2019 - 02:24

We all know we need exercise. Most health organizations agree that to prevent heart attacks, strokes, diabetes and certain cancers, we need to exercise at least 30 minutes a day five days a week. But actually doing it is another story.

While we may make excuses to avoid exercise, the fact remains that not exercising will contribute to your risk of chronic disease. Here are some tips to make exercise goals attainable:

Set reasonable goals: Start small, especially if you are just starting out. Gradually work your way up to the recommended minimum.
Track your progress: Keep a record of your workouts using a mobile app or pen and paper. Seeing progress, such as running faster, can motivate you to keep improving.
Ban guilt: There may be days when you don’t meet your own goals and expectations. That’s ok. Just get back on track the next day.
Ban comparisons: There will always be someone fitter, faster or more flexible than you. Don’t let that deter you. Your workout is about you.
Find social support: Online communities can offer encouragement, and so can a friend who wants to work out with you. An hour on a treadmill can fly by when you have someone to talk to.
Find exercise you enjoy: Try different things, such as dancing, gardening, swimming, or playing a sport. Exercise does not need to happen in a gym. Even if you don’t like most forms of physical activity, find something you can live with. Your body needs it, and you may even start enjoying it once the activity becomes a habit and you start seeing some benefits.
Break it up: The recommended 50 minutes per week can be divided up any way you’d like. If smaller increments work better, go for it!
Reward yourself: Acknowledge your success with a treat that isn’t food based, such as a massage or ball game tickets.

Visit HorizonBlue.com/doctorfinder to find in-network doctors and hospitals so you can get the care you need when you need it.

Source: WebMD®

Reminder: Our Laboratory Network to Offer More Choice

horizonbcbsnj — Tue, 02 Jul 2019 05:55:21 +0000

Reminder: Our Laboratory Network to Offer More Choice Tue, 07/02/2019 - 01:55

As a reminder, Horizon BCBSNJ is expanding its laboratory network to help increase members’ access to quality care. Beginning January 1, 2019, Horizon BCBSNJ will provide more participating national clinical laboratory choices for you to refer your Horizon BCBSNJ patients and/or send their laboratory testing samples (based on member plan benefits).

How We’re Improving Access
Effective January 1, 2019, our laboratory network will be as follows:

Horizon PPO Network

If you are enrolled in a plan that uses the Horizon PPO Network (PPO, Indemnity, Horizon MyWay® and Federal Employee Program® [FEP®] plans) you will have
in-network access to the following national laboratories:
- BioReference Laboratories
- LabCorp
- Quest Diagnostics
Horizon Managed Care Network

If you are enrolled in a plan that uses the Horizon Managed Care Network¹ (Horizon HMO, Horizon Advantage EPO, OMNIASM Health Plans, Horizon Direct Access, Horizon POS, Horizon Medicare Advantage or NJ DIRECT plans), you will have in-network access to the following national laboratories:
- LabCorp
- Quest Diagnostics
Horizon NJ Health

LabCorp will continue to be the exclusive in-network laboratory for Horizon NJ Health members.

This expansion continues Horizon BCBSNJ’s commitment to improving access to care, lowering overall costs and improving the member experience.

You can help members reduce their out-of-pocket costs, and access the care and services they need by referring them to these in-network national laboratories. As a reminder, our networks include a number of participating laboratories that can provide a variety of specialized laboratory services. Please visit our Doctor & Hospital Finder to locate participating laboratories.

¹Pathology 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 LabCorp/Quest Diagnostics network use requirements.

LabCorp is the commonly used name for Laboratory Corporation of America Holdings®. Laboratory Corporation of America® is a registered mark of Laboratory Corporation of America Holdings. Federal Employee Program® and FEP® names are registered marks of the Blue Cross and Blue Shield Association NJ DIRECT is administered by Horizon Blue Cross Blue Shield of New Jersey, an independent licensee of the Blue Cross and Blue Shield Association. OMNIASM and Horizon MyWay are service marks of Horizon Blue Cross Blue Shield of New Jersey.

Romosozumab-aqqg (Evenity)

horizonbcbsnj — Mon, 01 Jul 2019 12:46:31 +0000

Romosozumab-aqqg (Evenity) Mon, 07/01/2019 - 08:46

Medical policy type

New

Third Party URL

https://services3.horizon-bcbsnj.com/hcm/MedPol2.nsf/MedicalPolicies/SSHH-BCZK7C

Medical Injectables Program Updates: August 2019

horizonbcbsnj — Mon, 01 Jul 2019 09:03:22 +0000

Medical Injectables Program Updates: August 2019 Mon, 07/01/2019 - 05:03

Please review the Medical Injectables Program (MIP) updates noted below.

MEDICATIONS TO BE ADDED

Effective August 1, 2019, additional injectable medications will be included as part of our MIP.

Beginning with services to be provided on and after August 1, 2019, Magellan Rx Management will conduct medical necessity and appropriateness reviews (MNARs) for the additional injectable medications listed below which were included as part of the Center for Medicare & Medicaid Services’ Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes - July 2019 Update.

Brand Name	Generic Name	HCPCS
Belrapzo	bendamustine hydrochloride	J9036
Herceptin Hylecta	trastuzumab-hyaluronidase-oysk	J9356
Herzuma	trastuzumab-pkrb	Q5113
Ogiviri	trastuzumab-dkst	Q5114
Ontruzant	trastuzumab-dttb	Q5112
Truxima	rituximab-abbs	Q5115

Coding for Rebinyn®

Earlier this year we announced that effective August 15, 2019, Magellan Rx ManagementSM (MRxM) will conduct medical necessity and appropriateness review (MNAR) for certain hemophilia drugs as part of our MIP.¹

Based on Centers for Medicare & Medicaid Services’ guidance, please use the HCPCS code noted below when submitting claims for Rebinyn (coagulation factor IX [recombinant], GlycoPEGylated).

Brand Name	Generic Name	HCPCS
Rebinyn®	coagulation factor IX (recombinant), GlycoPEGylated	J7203

Review the full list of injectable medications that require MNAR as part of the MIP, or learn more about our Medical Injectables Program.

If you have questions, please contact your Network Specialist.

¹ As part of our MIP, Magellan Rx Management conducts MNARs for injectable medications administered in a freestanding or hospital-based dialysis center, an outpatient facility, a patient’s home or a physician’s office. Magellan Rx Management does not conduct MNARs for injectable medications administered during an inpatient stay, or in an Emergency Room or Observation Room setting.

For medical Injectable services rendered in the patient’s home, call 1-855-243-3321 for participating Horizon Care@Home health care professionals to obtain pre-service determination.

REBINYN® is a registered trademark of Novo Nordisk A/S.

Magellan Rx ManagementSM is a service mark of Magellan Health, Inc. Magellan Rx Management is an independent company that supports Horizon Blue Cross Blue Shield of New Jersey in the administration of conduct medical necessity and appropriateness review (MNAR) for certain medical injectable drugs. Magellan Rx Management is independent from and not associated with Horizon Blue Cross Blue Shield of New Jersey.

Changes to Management of the Horizon Behavioral Health Program

horizonbcbsnj — Fri, 28 Jun 2019 09:16:16 +0000

Changes to Management of the Horizon Behavioral Health Program Fri, 06/28/2019 - 05:16

June 28, 2019

Applies to: All Markets

Horizon Blue Cross Blue Shield of New Jersey will transition the administrative and clinical management of the Horizon Behavioral HealthSM Program – behavioral health services and benefits – from Beacon Health Options (formerly Value Options) to Horizon BCBSNJ internal operations.

Horizon Medicare Advantage plans will change on or about January 1, 2020. All other fully insured and self-insured (Administrative Services Only [ASO]) plans will change on or about April 1, 2020.

Throughout this transition, members will have uninterrupted access to the behavioral health services they are entitled to under their plan. Horizon BCBSNJ’s plan benefits and services will not change and members will continue to have access to the same network of behavioral health providers. In addition, health care information will remain safeguarded to protect our members’ privacy.

This change continues our commitment to providing better coordination of medical care and behavioral health care services when members access mental health and substance use disorder treatment. Care for the body and mind must be coordinated to help ensure the best outcomes. Our integrated strategy will help empower members to achieve their best physical health, mental and emotional wellbeing. Whether members and their families are dealing with everyday challenges or serious conditions, Horizon BCBSNJ will continue to be here to help them access the best overall care. This change will help provide a more connected, more complete approach to total wellness.

Horizon BCBSNJ remains committed to working with health care professionals throughout the state to improve the quality of care while lowering the cost of care and improving the experience for our members facing mental health issues and substance use disorders.

If you have questions, please contact your Horizon BCBSNJ sales executive or account manager.

Changes to Management of the Horizon Behavioral Health Program

horizonbcbsnj — Thu, 27 Jun 2019 12:30:14 +0000

Changes to Management of the Horizon Behavioral Health Program Thu, 06/27/2019 - 08:30

Beginning on or about January 1, 2020, Horizon BCBSNJ will move the administrative and clinical management of the Horizon Behavioral Health℠ Program – behavioral health services and benefits – from Beacon Health Options (formerly ValueOptions) to Horizon BCBSNJ’s internal operations.

Horizon Medicare Advantage plans will change on or about January 1, 2020.
Horizon BCBSNJ fully insured and self-insured plans will change on or about April 1, 2020

What does this mean?

Beginning in 2020, Horizon BCBSNJ will no longer use Beacon Health Options to manage the program. This change does not impact your plan benefits and services.

You will continue to have access to behavioral health services according to your plan. Current benefits will not be changing.
There will be no changes to the network of behavioral health care professionals that participate with your plan.
You don’t need a new member ID card.
You can still use the phone numbers that you currently use to access behavioral health care benefits and services.
Your health care information will remain safeguarded to protect your privacy.

Horizon BCBSNJ remains committed to working with health care professionals throughout the state to improve care for our members facing mental health issues and substance use disorders.

Navinet

horizonbcbsnj — Wed, 26 Jun 2019 12:57:11 +0000

Navinet Wed, 06/26/2019 - 08:57

Onasemnogene Abeparvovec (Zolgensma)

horizonbcbsnj — Tue, 25 Jun 2019 17:43:50 +0000

Onasemnogene Abeparvovec (Zolgensma) Tue, 06/25/2019 - 13:43

Medical policy type

New

Third Party URL

https://services3.horizon-bcbsnj.com/hcm/MedPol2.nsf/MedicalPolicies/SSHH-BCZJDN

Member ID Cards and Proof of Coverage Options Available Through App and Online

horizonbcbsnj — Tue, 25 Jun 2019 10:13:44 +0000

Member ID Cards and Proof of Coverage Options Available Through App and Online Tue, 06/25/2019 - 06:13

June 17, 2019

Applies to: All Markets

Members who need care but don't have their member ID handy can easily use the Horizon Blue app to access their card and show it to a health care professional.

Using the app, members can display and/or print a copy of their member ID card – as well as order a permanent replacement. Members just need to register for the app, sign in, choose ID Cards and follow the instructions. To download the Horizon Blue app, members can text GetApp to 422-272 or download it at the App Store® or Google Play™.

Members can also access their member ID card when signed in.

We encourage you to download and share our flyer on this topic with your group and individual clients so they know about these convenient options available to them.

If you have questions, please contact your Horizon BCBSNJ sales executive or account manager.

The App Store® is an online store and is a service mark of Apple, Inc. Google Play™ is a trademark of Google, Inc.There is no charge to download the Horizon Blue app, but wireless rates from your carrier may apply.

Reminder: Additional Member Plans to be Included as part of our Surgical and Implantable Device Management Program for Orthopedic Surgeries

horizonbcbsnj — Tue, 25 Jun 2019 09:37:02 +0000

Reminder: Additional Member Plans to be Included as part of our Surgical and Implantable Device Management Program for Orthopedic Surgeries Tue, 06/25/2019 - 05:37

As a reminder, beginning July 15, 2019, the Surgical and Implantable Device Management program for orthopedic services will also apply to members enrolled in Horizon BCBSNJ Medicare Advantage plans.

Through this specialty utilization management program, which Horizon BCBSNJ collaborates with TurningPoint Healthcare Solutions LLC (TurningPoint), TurningPoint conducts Prior Authorization & Medical Necessity Determination (PA/MND) reviews for certain orthopedic surgery services that are requested by participating and nonparticipating physicians when rendered in the following settings¹:

Inpatient
Outpatient
Ambulatory Surgical Center
Physician’s Office

Initially, this program only applied to services provided to Horizon BCBSNJ members enrolled in fully insured plans/products and to those members in fully insured plans/products that include BlueCard® benefits for care received outside of Horizon BCBSNJ’s local service area²,³.

Beginning July 1, 2019, TurningPoint will begin accepting PA/MND requests for orthopedic surgery services to be rendered on and after July 15, 2019 to members enrolled in Horizon BCBSNJ Medicare Advantage plans.

View more about this program, including a full listing of the procedures and CPT® codes that are subject to PA/MND review under this program. You can also review information about the PA/MND review process and medical policy guidelines TurningPoint uses to conduct their reviews.

Questions?

Horizon BCBSNJ values your participation in our network and the care you provide to our members. If you have any questions, call 1-833-436-4083 Monday through Friday between 8 a.m. and 5 p.m., Eastern Time.

¹Services rendered in the observation setting and the Emergency Room (ER) are not reviewed by TurningPoint as part of this program. ²Horizon BCBSNJ members enrolled in plans that include BlueCard benefits who receive care outside of Horizon BCBSNJ’s service area which includes the State of New Jersey, contiguous counties in DE, NY and PA (as well as Lehigh County, PA).

³To determine member eligibility and benefits, physicians can call the phone number on the back to the member’s ID card. For BlueCard benefit inquiries call 1-800-676-2583.

NaviNet® is a registered trademark of NaviNet, Inc.
TurningPoint Healthcare Solutions, LLC supports Horizon Blue Cross Blue Shield of New Jersey in the administration and utilization management review of certain surgical services that require an implantable device for coverage. TurningPoint Healthcare Solutions, LLC is independent from, and not affiliated with Horizon Blue Cross Blue Shield of New Jersey or the Blue Cross and Blue Shield Association.

Conscious Sedation

horizonbcbsnj — Mon, 24 Jun 2019 13:16:58 +0000

Conscious Sedation Mon, 06/24/2019 - 09:16

Reimbursement Policy:
Conscious Sedation

Effective Date:
June 1, 2006

Last Revised Date:
June 13, 2017

Purpose:
To provide guidelines for the reimbursement of conscious sedation

Scope:
All products are included, except

Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap)
COB

All Insured and Administrative Services Only (ASO) accounts are included.

Policy:
Procedure codes 99151, 99152, 99155, 99156, and G0500 are classified as medical codes. Only one (1) unit is considered for reimbursement per date of service.

Procedure codes 99153 and 99157, also classified as medical codes, may be used to report additional units. Multiple units of these codes are considered for reimbursement.

The CPT codes/nomenclature used in this policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the policy will continue to be in force, albeit applied to the new or amended coding so issued until this policy is revised to reflect new/amended coding.

Procedure:
Horizon BCBSNJ shall reimburse for conscious sedation at the applicable Horizon BCBSNJ fee schedule.

In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.

In instances where the provider is not participating, member liability shall be up to the provider’s charge.

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

Group or Individual benefit
Provider Participation Agreement
Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
Mandated or legislative required criteria will always supersede.

History:
04/11/2016: Policy approved
06/13/2017: Replaced deleted codes 99143, 99144, 99145, 99148, 99149, 99150 with revised codes

Policy003_v2.0_06132017

Reminder: Surgical and Implantable Device Program to Include Cardiac Services

horizonbcbsnj — Mon, 24 Jun 2019 13:04:59 +0000

Reminder: Surgical and Implantable Device Program to Include Cardiac Services Mon, 06/24/2019 - 09:04

As a reminder, effective July 15, 2019, Horizon BCBSNJ will expand our Surgical and Implantable Device Management Program, administered by TurningPoint Healthcare Solutions, LLC (TurningPoint), to include Prior Authorization & Medical Necessity Determination (PA/MND) reviews for certain cardiac services, many of which may require the use of an implantable device.

TurningPoint will conduct PA/MND reviews of certain cardiac services to:

Determine medical necessity of the services to be provided
Ensure appropriate conservative therapies are attempted prior to invasive procedures
Help to ensure that the most appropriate surgery is performed in the most appropriate setting using the most appropriate device(s)
Help to improve provider best practices

TurningPoint will accept requests for PA/MND starting on July 1, 2019, for any in-scope cardiac procedures to be performed on or after July 15, 2019.

Some of the most common cardiac surgical procedures subject to PA/MND review under this program include:

Implantable Cardioverter Defibrillators

Pacemaker (Single Chamber)

Pacemaker (Dual Chamber)

Pacemaker (Leadless)

Stent (Angioplasty & Endovascular)

Stent (Drug Eluting)

Places of service included in this program
TurningPoint will conduct PA/MND reviews for services rendered in the following settings:

Inpatient
Outpatient
Ambulatory Surgical Center
Office setting

TurningPoint will not conduct PA/MND reviews of services rendered in the Emergency Room or an observation setting.

Members included in this program
TurningPoint will conduct PA/MND reviews of services to be provided to members enrolled in Horizon BCBSNJ fully insured plans/products (including those fully insured plans/products plans that include BlueCard® benefits for care received outside of our local service area).¹ ²

TurningPoint will not conduct PA/MND reviews of services to be provided to members enrolled in self-insured Administrative Services Only (ASO) plans as part of this program.³

Submitting a PA/MND request to TurningPoint
There are three ways you can request a PA/MND for a cardiac service:

Log on to NaviNet®,select Horizon BCBSNJ from the My Health Plans menu, and:
- Mouse over Referrals & Authorization and select TurningPoint PA/MND Requests
- Select Requests within the TurningPoint menu bar or click the Add Request shortcut.

If you do not have access to NaviNet, you can submit a request via TurningPoint’s web portal at myturningpoint-healthcare.com. You must register to obtain access credentials by calling TurningPoint at 1-833-436-4083, Monday through Friday between 8 a.m. and 5 p.m., Eastern Time.
Call TurningPoint at 1-833-436-4083 during the hours noted above.

Review the information TurningPoint requires for a PA/MND request.

Provider responsibilities
Physicians
Physicians are responsible for requesting PA/MND review from TurningPoint.

Although some member benefits do not require prior authorization for services rendered in an outpatient setting or a physician’s office, physicians are strongly encouraged to obtain a pre-service MND from TurningPoint prior to providing cardiac services included in this program to ensure that services will be considered medically necessary.

Hospitals and Ambulatory Surgery Centers

Rendering hospitals and ambulatory surgical centers are encouraged to call TurningPoint at 1-833-436-4083 to confirm that a PA/MND has been obtained.

TurningPoint will provide authorization and pre-service PA/MND determination notifications to facilities if they made aware of the appropriate persons/departments to receive such notification. Please call TurningPoint at 1-833-436-4083 to provide contact information to receive PA/MND determination notifications.

Cardiac services submitted on professional and facility claims that are reviewed by TurningPoint on a post-service basis and deemed not medically necessary will not be eligible for coverage or payment by Horizon BCBSNJ. Claims for impacted services will also be processed and reimbursed in a manner consistent with TurningPoint’s guidelines in regard to frequency rules and service maximums.

Medical policy criteria and guidelines TurningPoint manages and maintains the medical policy criteria and guidelines used to conduct PA/MND reviews as part of this program expansion.

Program details and information
Information about this program including the following program resources are available.

Questions?

If you have any questions, call TurningPoint at 1-833-436-4083.

¹Horizon BCBSNJ members enrolled in plans that include BlueCard benefits who receive care outside of Horizon BCBSNJ’s service area which includes the State of New Jersey, contiguous counties in DE, NY and PA (as well as Lehigh County, PA).

²You can determine member eligibility and benefits by calling the phone number on the back to the member’s ID card. For BlueCard benefit inquiries call 1-800-676-2583.

³ The back of a self-insured ASO member ID card will state, “Horizon BCBSNJ provides administrative services only and does not assume any financial risk for claims.” A fully insured member’s ID card will not have that message. Please always verify member benefits, as it may be possible that the most current ID card is not presented at the time of service.

NaviNet® is a registered trademark of NaviNet, Inc.

TurningPoint Healthcare Solutions, LLC supports Horizon Blue Cross Blue Shield of New Jersey in the administration and utilization management review of certain surgical services requiring implantable devices for coverage. TurningPoint Healthcare Solutions, LLC is independent from, and not affiliated with Horizon Blue Cross Blue Shield of New Jersey or the Blue Cross and Blue Shield Association.

Implantable Device Management Program for Orthopedic Surgeries

horizonbcbsnj — Mon, 24 Jun 2019 12:21:35 +0000

Implantable Device Management Program for Orthopedic Surgeries Mon, 06/24/2019 - 08:21

As a reminder, beginning July 15, 2019, the Surgical and Implantable Device Management program for orthopedic services will also apply to members enrolled in Horizon BCBSNJ Medicare Advantage plans.

Inpatient
Outpatient
Ambulatory Surgical Center
Physician’s Office

View more about this program,including a full listing of the procedures and CPT® codes that are subject to PA/MND review under this program. You can also review information about the PA/MND review process and medical policy guidelines TurningPoint uses to conduct their reviews.

Questions?

Horizon BCBSNJ values your participation in our network and the care you provide to our members. If you have any questions, call <span class="class-bold">1-833-436-4083 </span>Monday through Friday between 8 a.m. and 5 p.m., Eastern Time.

¹Services rendered in the observation setting and the Emergency Room (ER) are not reviewed by TurningPoint as part of this program. ²Horizon BCBSNJ members enrolled in plans that include BlueCard benefits who receive care outside of Horizon BCBSNJ’s service area which includes the State of New Jersey, contiguous counties in DE, NY and PA (as well as Lehigh County, PA).

³To determine member eligibility and benefits, physicians can call the phone number on the back to the member’s ID card. For BlueCard benefit inquiries call 1-800-676-2583.

Ultrasound Services Program Will Not Be Implemented

horizonbcbsnj — Mon, 24 Jun 2019 12:00:00 +0000

Ultrasound Services Program Will Not Be Implemented Mon, 06/24/2019 - 08:00

We recently announced that we were delaying the implementation of Medical Necessity Determination (MND) review for certain obstetrical and non-obstetrical ultrasound procedures until further notice.

Horizon BCBSNJ will NOT implement this Ultrasound Services Program.

If you have questions, please contact your Network Specialist, Ancillary Contracting Specialist or Hospital Network Specialist.

Quarterly Claim Editing Update: Third Quarter 2019

horizonbcbsnj — Wed, 19 Jun 2019 19:37:17 +0000

Quarterly Claim Editing Update: Third Quarter 2019 Wed, 06/19/2019 - 15:37

On or about August 25, 2019, Horizon Blue Cross Blue Shield of New Jersey will implement an update to our claim editing rules and processes.

We encourage you to review details of this update in our Quarterly Claim Editing Update Report.

The changes noted in this report will be implemented on or about July 1, 2019.

The effective date of the changes noted in this report will be July 1, 2019 (unless otherwise specified in the report). Changes noted in this report will apply to all claims finalized on and after our implementation date.¹

Read more about our Claim Editing Policies

If you have questions, call a Physician Services representative at 1-800-624-1110 or an Institutional Services representative at 1-888-666-2535, Monday through Friday, between 8 a.m. and 5 p.m., Eastern Time.

¹Claims finalized before this update is implemented will not be adjusted following the implementation for the sole purpose of ensuring conformity with these claim editing rules. If a claim originally finalized before the implementation is adjusted after the implementation for other reasons, the claim editing rules noted here will be applied.

Clear Claim Connection™

Participating physicians, other health care professionals and facilities can review how updated claim editing rules impact reimbursement for certain code combinations by using the Clear Claim Connection available via NaviNet®.

To access Clear Claim Connection, log in to NaviNet.net and:

Select Horizon BCBSNJ from the My Health Plans menu.
Mouse over Claim Management.
Click Clear Claim Connection.

NaviNet® is a registered trademark of NaviNet, Inc.