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Scheduled Maintenance

horizonbcbsnj — Fri, 22 Jun 2018 15:20:30 +0000

Scheduled Maintenance Fri, 06/22/2018 - 11:20

Horizon BCBSNJ's Member Portal will undergo scheduled maintenance beginning at 6 p.m. Friday June 22, 2018 until 8 a.m. Monday June 25, 2018. During this time you may experience intermittent issues with some transactions. We apologize for the inconvenience and appreciate your patience.

Claims Issue Identified: Pay Percent for Multiple Services Rules

horizonbcbsnj — Thu, 21 Jun 2018 21:14:37 +0000

Claims Issue Identified: Pay Percent for Multiple Services Rules Thu, 06/21/2018 - 17:14

On June 3, 2018, Horizon Blue Cross Blue Shield of New Jersey implemented reimbursement policy guidelines that changed the way we reimburse claims for certain multiple services (i.e., diagnostic cardiovascular services, diagnostic ophthalmology services and professional therapy services¹) when rendered by the same health care professional on the same date of service.

We are aware of a claim processing system issue that is resulting in the inappropriate application of these guidelines to claims for services rendered between February 4, 2018 and June 2, 2018. As previously announced, the application of these guidelines should be effective for services rendered on and after June 3, 2018.

We are currently addressing this issue and expect to have it corrected on or around July 1, 2018.

We will temporarily suspend the application of these reimbursement guidelines to claims while we address this issue. We will not carry out bulk adjustments of claims finalized during the time that these rules are suspended; however, if finalized claims are adjusted for other reasons, these reimbursement guidelines will be applied.

Following the system correction, Horizon BCBSNJ will identify and adjust impacted claims for services rendered between February 4, 2018 and June 2, 2018 to ensure appropriate reimbursement.

There is no need to submit claim appeals or to resubmit claims.

Thank you for your patience as we work to correct this issue.

¹ Horizon BCBSNJ only applies Multiple Procedure Payment Reduction (MPPR) guidelines to therapy services rendered by nonparticipating practitioners. MPPR guidelines on therapy services will NOT apply to therapy services rendered by participating practitioners.

Claim Editing Issue Update: Claims to be Adjusted

horizonbcbsnj — Thu, 14 Jun 2018 17:35:42 +0000

Claim Editing Issue Update: Claims to be Adjusted Thu, 06/14/2018 - 13:35

As previously announced, a claim processing system issue resulted in the inappropriate application of claim editing rules to codes included on certain professional claims processed between March 1, 2018 and April 17, 2018.

Beginning on July 16, 2018, Horizon BCBSNJ will begin to adjust claims impacted by this system issue to either:

Appropriately apply claim editing rules to codes included on certain professional claims where they were not originally applied, or
Remove the application of claim editing rules to codes included on certain professional claims where they should not have been originally applied.

Changes to reimbursement and to patients’ financial responsibility for these impacted claims will be documented in the Explanation of Payment (EOP) statements you will receive following the completion of each claim adjustment as well as in the revised members’ Explanation of Benefits (EOB) statements.

Any reimbursement recoveries that may result from claim adjustments will establish Accounts Receivables (A/Rs) in our claim system. A/Rs are inactive for a period of 45 days to allow time for the return of overpayments to us or for an appeal to be filed with us. After 45 days, pending A/Rs will be activated and begin applying against future payments toward satisfying the A/R amount.

We apologize for any inconvenience.

Medical Policy Revision: Myoelectric Prosthetic Components for the Upper Limb

horizonbcbsnj — Tue, 12 Jun 2018 18:26:57 +0000

Medical Policy Revision: Myoelectric Prosthetic Components for the Upper Limb Tue, 06/12/2018 - 14:26

Effective September 11, 2018, Horizon Blue Cross Blue Shield of New Jersey will implement revisions to our medical policy, Myoelectric Prosthetic Components for the Upper Limb.

The revised policy guidelines may result in changes to the way we consider certain claims for services/supplies provided to your Horizon BCBSNJ patients.

We encourage you to visit our Medical Policy Manual to review the guidelines of this revised policy.

Based on the guidelines or our medical policy, Myoelectric Prosthetic Components for the Upper Limb, claims for services/supplies provided on and after September 11, 2018 will be processed as follows.

HCPCS code L6026 will be denied, regardless of the submitted diagnosis code(s), as an experimental/investigational, non-covered service/supply.

Unless Horizon BCBSNJ gives written notice that all or part of the above changes have been cancelled or postponed, the changes will be applied to claims for dates of service on and after September 11, 2018.

Myoelectric Prosthetic and Orthotic Components for the Upper Limb

horizonbcbsnj — Tue, 12 Jun 2018 15:41:26 +0000

Myoelectric Prosthetic and Orthotic Components for the Upper Limb Tue, 06/12/2018 - 11:41

Medical policy type

Revised

Third Party URL

https://services3.horizon-bcbsnj.com/hcm/MedPol2.nsf/MedicalPolicies/HNBE-882NN7

Blue Review June 2018

horizonbcbsnj — Tue, 12 Jun 2018 06:20:55 +0000

Blue Review June 2018 Tue, 06/12/2018 - 02:20

Blue_Review_June_2018.pdf

Small Employer Common Ownership Certification

horizonbcbsnj — Mon, 11 Jun 2018 10:06:17 +0000

Small Employer Common Ownership Certification Mon, 06/11/2018 - 06:06

Attachment

SE_Common_Ownership_Certification.pdf

Small Employer Common Ownership Certification

horizonbcbsnj — Mon, 11 Jun 2018 09:54:56 +0000

Small Employer Common Ownership Certification Mon, 06/11/2018 - 05:54

Attachment

SE_Common_Ownership_Certification.pdf

Sanitas medical centers

horizonbcbsnj — Fri, 08 Jun 2018 11:23:12 +0000

Sanitas medical centers Fri, 06/08/2018 - 07:23

Another way Horizon Blue Cross Blue Shield of New Jersey is helping members get the care they need is by working with Sanitas, a multinational health care provider, to bring comprehensive primary and specialty care in a multicultural setting that offers both English and Spanish-speaking health care professionals in Essex and Hudson counties.

Sanitas medical centers offer:

same-week appointments
same-day lab tests and diagnostic imaging
walk-in appointments for urgent care

The medical centers focus on family medicine, internal medicine and pediatric services, and will also offer urgent care, preventive care, chronic disease care, gynecology, laboratory services, diagnostic imaging and wellness programs.

The Sanitas medical centers are located at:

1 Clara Maass Drive, Belleville, NJ 07109
3196 Kennedy Blvd., Union City, NJ
350 Montgomery St., Jersey City, NJ 07032 (Coming Soon)

The Sanitas medical centers are available to:

All members covered by Horizon BCBSNJ plans, including Medicare Advantage, Horizon NJ Health (NJ FamilyCare/Medicaid) and Horizon NJ TotalCare (HMO SNP)
Members who are covered by other Blue Cross and/or Blue Shield Plans through BlueCard®
Original Medicare enrollees
Patients who pay for care out of their pocket

Complete family care is an appointment away!

Learn more or call 1-833-617-0501 to make an appointment.

Taytulla Recall

horizonbcbsnj — Wed, 06 Jun 2018 19:11:57 +0000

Taytulla Recall Wed, 06/06/2018 - 15:11

Allergan recently identified that capsules were placed out of order in a sample pack of Taytulla, an oral-contraceptive. The first four days of therapy had non-hormonal placebo capsules instead of active oral contraceptives.

As a result of this packaging error, women who take oral contraceptive capsules as packaged may be at risk for contraceptive failure and unintended pregnancy.

Horizon Blue Cross Blue Shield of New Jersey is committed to helping members get the care and information they need, when they need it. Members who have the sample pack product with the lot #5620706 and an expiration date of May 2019 should notify their health care professional to arrange the return of the contraceptives or contact them if they have any questions. Allergan is available to answer any questions regarding this recall at 1-800-678-1605, Monday through Friday, from 8 a.m. to 8 p.m.

Learn more.

Grandmothering Extended Into 2019 for Pre-ACA Plans

horizonbcbsnj — Tue, 05 Jun 2018 10:46:47 +0000

Grandmothering Extended Into 2019 for Pre-ACA Plans Tue, 06/05/2018 - 06:46

May 31, 2018

Applies to: Pre-ACA Small Group plans with 4th quarter 2018 renewals

Horizon Blue Cross Blue Shield of New Jersey is pleased to advise that groups with health plans that preceded the Affordable Care Act (“pre-ACA plans”) and that renew between December 31, 2018, will be permitted to renew within those pre-ACA plans. With the fourth quarter representing our highest volume of renewing membership, our decision to grandmother pre-ACA plans will facilitate a smooth renewal process.

If a group opts to leave its pre-ACA plan, it will need to move to an ACA-compliant policy with stand-alone pediatric dental (SAPD) coverage. Popular ACA-compliant options include our OMNIA SM Health Plans.

Horizon BCBSNJ will communicate to you and your impacted groups the important details and dates regarding the renewal process. Below is an outline of the communications.

Broker Communications

October, November and December pre-ACA and ACA renewals will be available to the Broker of Record via the FTP secure site. An email notification will be sent once a renewal is available.
Renewals will be released according to the following schedule:
October renewals – no later than July 31
November renewals – no later than August 31
December renewals – no later than September 30

Group Communications

October ACA renewals: Renewals will include recommended ACA plans to which each group can be mapped.
October, November and December pre-ACA renewals: Renewals will include a pre-ACA renewal indicating that they may renew as is, as well as a suggested ACA plan to which each group can be mapped. A CMS Model Notice will also be included.
Renewals will be released according to the following schedule:
October renewals – no later than July 31
November renewals – no later than August 31
December renewals – no later than September 30

Please note:

If a group does not actively select an ACA plan, it will automatically renew as is with its existing pre-ACA product.
For all groups that select an ACA plan, please submit the ACA conversion via Broker Online Services.

Pre-ACA to ACA Plan Conversions

It is important to familiarize yourself with the process and paperwork requirements for groups that are converting from a pre-ACA plan to an ACA plan. All groups are required to send in, with the conversion form, new certification paperwork including applicable tax documentation, as noted below, and waivers. This applies to all pre-ACA to ACA conversions regardless of whether they previously sent in their certification to Horizon BCBSNJ and were advised by Horizon BCBSNJ Small Group Certification they could renew as is. Conversion paperwork should be sent to our Conversions department at Conversion@HorizonBlue.com , not to Horizon BCBSNJ’s Certification department

Mandatory Tax Documentation for Groups with two to five or 45+ Eligible Employees
Group Structure	Form	Additional Documentation
Single Owner/Sole Proprietor	Schedule C	Q3 2018 WR-30 for employees
Partnership (must be 100% ownership)	K-1(s)	Q3 2018 WR-30 for employees
Corporate Entities (C- and S-corps)	Schedule G for 2017	Q3 2018 WR-30 for employees
All Groups		NJ State WR-30: Most recent completed quarter for all employees¹

WR-30 = Quarterly Wage Report

¹Effective October 1, 2018 and after, third quarter WR-30s will be required for fourth quarter 2018 conversions.

Groups of six to 44 eligible employees do not need to submit tax documents, but rather the Certification with Conversion form and waivers.

View PDF version

Member Incentive for Completing an In-Home Health Assessment

horizonbcbsnj — Tue, 05 Jun 2018 08:34:07 +0000

Member Incentive for Completing an In-Home Health Assessment Tue, 06/05/2018 - 04:34

May 30, 2018

Applies to: Individual and Small Group markets

Horizon Blue Cross Blue Shield of New Jersey is committed to helping our members get the care and information they need, when and where they need it. That’s why we offer members enrolled in Individual or Small Group plans a $40 CVS Pharmacy® gift card for completing a comprehensive health assessment in the comfort of their own home. Gift cards are not offered as the result of a member receiving a physical or health assessment from his or her doctor.

Horizon BCBSNJ works with Matrix Medical Network to provide these members with a fully licensed and qualified nurse practitioner to evaluate their health.

This assessment is part of the member’s current coverage and is provided at no additional cost. It does not replace appointments or care provided by the member’s primary care or personal doctor. Participation in the assessment is strictly voluntary. No medicines, treatments or tests are ordered during the assessment.

What’s included

During the assessment, the nurse practitioner will:

Go over the member’s health history.
Listen to the member’s health concerns.
Answer the member’s health-related questions.
Review any medicines the member takes.
Suggest screenings or other tests.

Results of the assessment are shared with the member, his or her primary care or personal doctor and Horizon BCBSNJ to help ensure the member receives the best care possible and stays on top of any health conditions. Horizon BCBSNJ may also use the information to help identify members for our Care Management programs. The results of the assessment are also submitted to the Centers for Medicare & Medicaid Services (CMS) for Risk Adjustment purposes for Individual and Small Group members. The results also support Healthcare Effectiveness Data and Information Set (HEDIS) measurements with the National Committee for Quality Assurance (NCQA).

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

View Pdf Version

Summertime Safety

horizonbcbsnj — Mon, 04 Jun 2018 13:11:10 +0000

Summertime Safety Mon, 06/04/2018 - 09:11

You can have fun in the sun – and the water – this summer while still taking steps to stay safe.

In the sun…

Avoid alcoholic and caffeinated drinks, which can dehydrate you.
Avoid hot, heavy meals, which add heat to your body.
Don’t leave children or pets in cars, even if windows are open.
Drink water before, during and after exercise.
Keep children, pets and anyone in your care shaded and hydrated.
Know the warning signs of heat stroke: headache; leg cramps; red, hot, dry skin; lightheadedness/dizziness; nausea.
Know your limits during exercise; stop if you have trouble breathing.
Limit outdoor activity to cooler times, such as morning and evening.
Stay in the shade or in air-conditioned rooms as much as possible. A cool shower can help in a pinch.
Stay informed about extreme heat alerts, and have a plan if you need to use a cooling shelter in your area.
Wear light clothing, a hat and sunglasses.
Wear sunscreen, and reapply often. Be aware that having a sunburn can dehydrate you and affects your body’s ability to cool down.

In the water…

Don’t dive into shallow water.
Don’t go in the water if you can’t swim. Make sure children with you can swim, too. Everyone should swim with a buddy.
In a rip current, swim with it; don’t fight it.
Never leave children alone in or near water. Swim near a lifeguard.
Wear a life jacket when appropriate.

Horizon BCBSNJ wants to help you get the care you need. In a medical emergency, always call 911 or your local emergency services number.

Always talk with your doctor before making any changes to your exercise or diet.

Sources: American Cancer Society, American Red Cross, Centers for Disease Control and Prevention, National Safety Council, WebMD®

Molecular and Genomic Testing Program Update for July 1, 2018

horizonbcbsnj — Wed, 30 May 2018 18:07:25 +0000

Molecular and Genomic Testing Program Update for July 1, 2018 Wed, 05/30/2018 - 14:07

Effective July 1, 2018, additional diagnostic tests will be included as part of our Molecular and Genomic Testing Program, administered by eviCore healthcare (eviCore) for members enrolled in Horizon BCBSNJ fully-insured products as well as administrative services only (ASO) accounts that have elected the Molecular and Genomic Testing Program.

Beginning with services to be provided on and after July 1, 2018, eviCore will conduct pre-service Medical Necessity Determination (MND) reviews of the following additional diagnostic testing services (CPT® codes for which were recently published by the American Medical Association) when rendered in a physician’s office or clinical laboratory:¹

0011M
0012M
0013M

Review the complete list of molecular and genomic diagnostic testing services that require pre-service MND reviews.

Further information about this specialty utilization management program is available on our Molecular and Genomic Testing Program web page. If you have questions, please contact your Network Specialist or Ancillary Contracting Specialist.

¹ MND requirements will not apply to molecular and genomic diagnostic testing services rendered to patients in a hospital Emergency Room, hospital outpatient or inpatient setting, or an Ambulatory Surgery Center (ASC).

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

Pre-service MND reviews

To obtain pre-service MND from eviCore (or to validate that a pre-service MND was requested and/or approved):

Visit eviCore.com; or
Call 1-844-224-0493, between 7 a.m. and 7 p.m., Eastern Time.

The guidelines eviCore uses to conduct MND reviews for the Molecular and Genomic Testing Program may be reviewed by visiting www.evicore.com/healthplan/Horizon_Lab.

2018 Broker Incentive Program for New Dental Sales

horizonbcbsnj — Tue, 29 May 2018 11:13:23 +0000

2018 Broker Incentive Program for New Dental Sales Tue, 05/29/2018 - 07:13

May 21, 2018

Applies to: Public Sector market

Horizon Blue Cross Blue Shield of New Jersey is offering a special broker incentive program1 for all new Horizon Dental sales within the Public Sector market with effective dates of July 1, 2018 through December 1, 2018.

For fully insured and self-funded business, this program rewards an incentive payment of $10 per enrolled member for a Horizon BCBSNJ Dental plan.²

Horizon BCBSNJ values the strong relationship we have with you. This incentive program is offered as a way to express our appreciation for your support in making us a leader in the marketplace.

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

View PDF Version

¹ To be eligible for this program, brokers must be licensed and contracted with Horizon BCBSNJ, and must be the Broker of Record on the effective date of the sale.

²Not to exceed $30,000 total for any single group.

FDA Drug Safety Communication: Dolutegravir (Juluca©, Tivicay©, Triumeq©)

horizonbcbsnj — Tue, 22 May 2018 17:24:05 +0000

FDA Drug Safety Communication: Dolutegravir (Juluca©, Tivicay©, Triumeq©) Tue, 05/22/2018 - 13:24

The U.S. Food and Drug Administration (FDA) is advising that serious cases of neural tube birth defects involving the brain, spine and spinal cord have been reported in babies born to women treated with dolutegravir, which is used to treat human immunodeficiency virus (HIV). Approved in 2013, dolutegravir has been on the market for five years, and is available as a single ingredient product under the brand name Tivicay, and as a fixed dose combination tablet with other HIV medicines under the brand names Juluca and Triumeq.

Preliminary results from an ongoing observational study found that women who received dolutegravir at the time of becoming pregnant or early in the first trimester appear to be at higher risk for these defects. To date, there are no reported cases of babies born with neural tube defects to women starting dolutegravir later in pregnancy. The FDA is investigating this new safety issue and will update the public when more information is available.

This document contains references to brand name prescription medicines that are trademarks or registered marks of pharmaceutical manufacturers that are not affiliated with Horizon Blue Cross Blue Shield of New Jersey or the Blue Cross and Blue Shield Association.

New Sanitas Medical Center Opens in Belleville

horizonbcbsnj — Tue, 22 May 2018 09:10:36 +0000

New Sanitas Medical Center Opens in Belleville Tue, 05/22/2018 - 05:10

May 16, 2018

Applies to: All Markets

To increase the availability of primary care services to the Hispanic community, Horizon Blue Cross Blue Shield of New Jersey is furthering its collaboration with Sanitas, a multinational health care provider, by bringing comprehensive, cost-effective patient-centered health care services to Belleville.

The Sanitas medical center, located at 1 Clara Maass Drive, Belleville, opened its doors on May 1. Sanitas previously opened a Union City location in December 2017 and plans to open a Jersey City location later this year.

The public is invited to attend the Open House at Sanitas Medical Center Belleville on Saturday, May 19, from 10 a.m. to 1 p.m. The event will include free health screenings, giveaways, prizes, face painting and refreshments.

Sanitas medical centers are independently owned and operated by Sanitas of New Jersey LLC, and will provide care to any Horizon BCBSNJ member (Commercial, Administrative Services Only, Medicare Advantage [MA] and NJ FamilyCare), Original Medicare enrollees and patients who pay for care out of their pocket. Out-of-state Blue Plan members with BlueCard ® coverage can also get care at a Sanitas medical center.

These medical centers are located in primarily Hispanic and ethnically diverse neighborhoods and are easily accessible via public transportation. The centers will offer same-week appointments, same-day lab tests and diagnostic imaging, and walk-in appointments for urgent care. The centers may keep patients for observation for up to six hours.

Sanitas medical centers provide a one-stop solution to patients’ everyday health needs, including:

Primary care
Specialty care
Comprehensive urgent care
Lab and diagnostic imaging
Disease management and wellness programs

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

View PDF Version

Changes to Coverage of Oral-Combined Contraceptives Due to Wide Range of Generic Alternatives

horizonbcbsnj — Tue, 22 May 2018 07:45:38 +0000

Changes to Coverage of Oral-Combined Contraceptives Due to Wide Range of Generic Alternatives Tue, 05/22/2018 - 03:45

May 15, 2018

Applies to: All commercial market segments (excludes commercial plans utilizing the NetResults Formulary and public sector groups)

Horizon Blue Cross Blue Shield of New Jersey manages pharmacy benefits to encourage the safe and appropriate use of prescription medicines. We are changing the way that we provide coverage for brand name, oral-combined contraceptive pills.

Starting June 15, 2018, brand name, oral-combined contraceptive pills will no longer be covered at a $0 copayment. This change is due to the wide range of generic alternatives that are available in various dosage forms and strengths for contraception. These brand name contraceptives will continue to be covered under a member’s pharmacy benefit, but a corresponding copayment or coinsurance amount will apply based on the member’s pharmacy plan design.

Below are examples of commonly prescribed brand name, oral-combined contraceptive pills that will have the appropriate copayment or coinsurance applied to them:

Examples of brand name, oral-combined contraceptive pills:

Estrostep Fe
Lo Loestrin Fe
Loestrin 1/20-21
Loestrin Fe 1.5/30
Loestrin Fe 1/20
LoSeasonique
Minastrin 24 Fe
Mircette
Ortho Micronor
Ortho Tri-Cyclen
Ortho Tri-Cyclen Lo
Ortho-Cyclen
Ortho-Novum 1/35
Ortho-Novum 7/7/7
Seasonique
Taytulla
Tri-Norinyl 28
Yasmin 28
Yaz

Horizon BCBSNJ will continue to cover generic, oral-combined contraceptive pills at a $0 copayment.

If a health care professional feels the brand name, oral-combined contraceptive pills are medically necessary for their patient(s) at zero cost share rather than the generic alternatives, a Copay Waiver form may be submitted for clinical review.

Impacted members and their prescribers will receive a letter notifying them about this change prior to the June 15, 2018 effective date.

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

View PDF Version

Changes to Coverage of Oral-Combined Contraceptives Due to Wide Range of Generic Alternatives

horizonbcbsnj — Tue, 22 May 2018 05:36:55 +0000

Changes to Coverage of Oral-Combined Contraceptives Due to Wide Range of Generic Alternatives Tue, 05/22/2018 - 01:36

May 16, 2018

Applies to: All commercial market segments (excluding commercial plans that use the NetResults Formulary and public sector groups)

Starting June 15, 2018, brand name, oral-combined contraceptive pills will no longer be covered at a $0 copayment. This change is due to the wide range of generic alternatives that are available in various dosage forms and strengths for contraception. These brand name contraceptives will continue to be covered under a member’s pharmacy benefit, but a corresponding copayment or coinsurance amount will apply based on the member’s pharmacy plan design.

Below are examples of commonly prescribed brand name, oral-combined contraceptive pills that will have the appropriate copayment or coinsurance applied to them:

Examples of brand name, oral-combined contraceptive pills:

Estrostep Fe
Lo Loestrin Fe
Loestrin 1/20-21
Loestrin Fe 1.5/30
Loestrin Fe 1/20
LoSeasonique
Minastrin 24 Fe
Mircette
Ortho Micronor
Ortho Tri-Cyclen
Ortho Tri-Cyclen Lo
Ortho-Cyclen
Ortho-Novum 1/35
Ortho-Novum 7/7/7
Seasonique
Taytulla
Tri-Norinyl 28
Yasmin 28
Yaz

Horizon BCBSNJ will continue to cover generic, oral-combined contraceptive pills at a $0 copayment.

If a health care professional feels the brand name, oral-combined contraceptive pills are medically necessary for his or her patient(s), at zero cost share, rather than the generic alternatives, a Copay Waiver form may be submitted for clinical review.

Impacted members and their prescribers will receive a letter notifying them about this change prior to the June 15, 2018 effective date.

If you have questions, please contact me.

View Pdf Version

Reimbursement Policy Update: Telemedicine Services

horizonbcbsnj — Mon, 21 May 2018 16:07:08 +0000

Reimbursement Policy Update: Telemedicine Services Mon, 05/21/2018 - 12:07

Horizon Blue Cross Blue Shield of New Jersey recently revised our Telemedicine Services¹ reimbursement policy to reflect recent changes including those changes pursuant to New Jersey NJ Public Law 2017, Chapter 117.

We strongly encourage you to review the guidelines of our Telemedicine Services policy.

Per the guidelines of this policy¹, real time (synchronized) telemedicine services that meet all the requirements of a face-to-face consultation or contact between a health care professional and patient are considered for reimbursement.

Telemedicine service is limited to services involving the use of interactive, real-time, two-way audio-video communication technologies for the purpose of diagnosis, consultation or treatment. Telemedicine does not include the use (in isolation) of audio-only phone conversation, email, instant messaging, phone text or fax.

The revised guidelines of this policy reflect the updates noted below.

CPT® codes 90785, 96160, 96161 and HCPCS codes G0296, G0506 have been added to this policy’s list of codes eligible for reimbursement.

HCPCS codes G0436 and G0437 have been removed from this policy’s list of codes eligible for reimbursement.

Modifier 95 will be recognized (in addition to Modifier GT) when appropriately appended to procedure codes that ordinarily describe face-to-face services including but not limited to, office or other outpatient professional visits, inpatient professional visits, or individual psychotherapy services.

Please note that while we continue to use Modifier 95 and Modifier GT, we have NOT adopted the use of CMS’s 02 place of service code.

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

¹ This reimbursement policy was formerly titled Services on a Telemedicine Platform.

² The guidelines of this policy do not apply to patients enrolled in products where Horizon BCBSNJ is secondary to Medicare (e.g., Medigap) or to patients enrolled in Horizon BCBSNJ Medicare Advantage plans.

New Sanitas Medical Center Opens in Belleville

horizonbcbsnj — Mon, 21 May 2018 13:25:27 +0000

New Sanitas Medical Center Opens in Belleville Mon, 05/21/2018 - 09:25

Sanitas medical centers are independently owned and operated by Sanitas of New Jersey LLC, and will provide care to any Horizon BCBSNJ member (Commercial, Administrative Services Only, Medicare Advantage [MA] and NJ FamilyCare), Original Medicare enrollees and patients who pay for care out of their pocket. Out-of-state Blue Plan members with BlueCard® coverage can also get care at a Sanitas medical center.

Sanitas medical centers provide a one-stop solution to patients’ everyday health needs, including:

Primary care
Specialty care
Comprehensive urgent care
Lab and diagnostic imaging
Disease management and wellness programs

If you have questions, please contact me.

View PDF version

Sanitas Medical Centers are independently owned and operated by Sanitas of New Jersey LLC. Sanitas is independent from and not affiliated with Horizon Blue Cross Blue Shield of New Jersey. Sanitas Medical Centers serve people insured by Horizon Blue Cross Blue Shield of New Jersey, Original Medicare and self-paying for medical treatment. Horizon Insurance Company, Inc. (“HIC”) has contracts with CMS for HMO, PPO and Part D Medicare plans. Horizon Healthcare of New Jersey, Inc. (“HHNJ”) has contracts with both CMS and the State of New Jersey Medicaid Program to provide a HMO Medicare Advantage Dual Special Needs plan. Enrollment in Horizon NJ TotalCare (HMO SNP) and/or HIC Medicare products depends on contract renewal. Other providers are available in our network.

Maternity Health Coach

horizonbcbsnj — Mon, 21 May 2018 10:49:31 +0000

Maternity Health Coach Mon, 05/21/2018 - 06:49

The registered nurses of Horizon BCBSNJ’s Maternity Health Coach program provide one-on-one educational support to expectant parents. Our coaches can help eligible members feel more comfortable accessing the right care for themselves and their babies.

Coaches do not replace a doctor’s care, but they can discuss pregnancy, labor and delivery, and postpartum care, so you have the information you need when you need it.

Coaches can discuss your general pregnancy questions about topics like breastfeeding, travel, common physical and emotional changes and nutrition and exercise. They can also speak with you about your specific needs if you:

Need to find an in-network Ob/Gyn
Are carrying multiples
Have a medical condition that may impact your pregnancy
Have been diagnosed with a pregnancy-related health condition, such as gestational diabetes

How to Reach a Maternity Health Coach

Eligible members will have a 24/7 Nurse Line phone number printed on the back of their member ID card. Call this number and choose option 3 to reach a Maternity Health Coach Monday through Friday, 8 a.m. to 8 p.m., Eastern Time.

Outside of these hours, you can use option 1 of your 24/7 Nurse Line number to reach a nurse at any time.

YWCA Tribute to Women and Industry (TWIN) Honors Two Horizon Blue Cross Blue Shield of New Jersey Business Leaders

horizonbcbsnj — Fri, 18 May 2018 18:44:51 +0000

YWCA Tribute to Women and Industry (TWIN) Honors Two Horizon Blue Cross Blue Shield of New Jersey Business Leaders Fri, 05/18/2018 - 14:44

Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ) announced today that Lili Brillstein, Director of Horizon BCBSNJ’s Episodes of Care Program, and Ilene Wachs, President of company subsidiary Horizon Casualty Services, Inc., were selected by the YWCA of Union County as 2018 Tribute to Women and Industry (TWIN) award recipients.

The TWIN award honors outstanding businesswomen who excel in their fields and have made significant contributions to their workplace. The TWIN award also recognizes the companies that encourage high achievement by women and promote equal advancement opportunities for women with diverse backgrounds.

“Lili and Ilene are highly accomplished business leaders whose professional skills and abilities in their areas of responsibility are helping to improve the overall experiences of our 3.8 million members,” said Alison Banks-Moore, Chief Diversity Officer for Horizon BCBSNJ. “Both women exemplify excellence in how they perform on the job and in private life,” she said.

Lili Brillstein joined Horizon 2013 to lead and build the company’s value-based, Episodes of Care Program, which grew from two episodes when she arrived to cover more than 10 specialties and almost 20 different episodes of care at present. Horizon’s Episodes of Care efforts in Cancer Care have been modeled and considered by CMS as alternative payment approaches for Medicare reimbursement for Cancer Care. In outside activities, Ms. Brillstein is an advocate for women and victims of domestic violence, serving on the board of directors of the NJ Coalition to End Domestic Violence, and as a founding board member of the Sadie Nash Leadership Project, an organization that promotes leadership and activism among young women.

Ilene Wachs came to Horizon in the mid-1990s to lead Horizon Casualty Services, Inc. from start-up to full maturity. Today, the company is a market leader and manages over $1.5 billion in workers’ compensation and personal injury protection claims for multiple insurance companies in New Jersey. With a deep passion for entrepreneurship, Ms. Wachs led her team to create the most successful of Horizon’s subsidiary companies. Ms. Wachs previously served in large teaching hospital management leadership roles, both nationally and internationally including consulting work for the British National Health Service, Royal Free Hospital, London. In outside activities Ilene is President of the Education Fund of the Women’s Forum of New York, a not-for-profit organization that provides financial awards for women who have experienced extreme hardship and are now back on track to get their college degrees.

She also sits on the Advisory Board of the Feliciano Center for Entrepreneurship, Montclair State University. Ms. Wachs is a member of the Women’s Forum of New York and International Women’s Forum and is a Fellow in the American College of Healthcare Executives.
TWIN originated in New Jersey in 1975. Now a national and international award program of the YWCA, TWIN annually recognizes outstanding business women and their companies.

About Horizon BCBSNJ’s Diversity programs

Horizon BCBSNJ has instituted many programs aimed at promoting diversity within the company including: paid minority internships and manager development programs, as well as a Diversity Council and minority leadership programs. To learn more about Horizon BCBSNJ and its diversity efforts, visit: www.HorizonBlue.com/diversity

About Horizon Blue Cross Blue Shield of New Jersey

Horizon Blue Cross Blue Shield of New Jersey, the state’s oldest and largest health insurer is a tax-paying, not-for-profit health service corporation, providing a wide array of medical, dental, vision and prescription insurance products and services. Horizon BCBSNJ is leading the transformation of health care in New Jersey by working with doctors and hospitals to deliver innovative, patient-centered programs that reward the quality, not quantity, of care patients receive. Learn more at www.HorizonBlue.com. Horizon BCBSNJ is an independent licensee of the Blue Cross and Blue Shield Association serving more than 3.8 million members.

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International health organization reimagining health care in the U.S. is expanding in Belleville, NJ, in collaboration with Horizon Blue Cross Blue Shield of New Jersey

horizonbcbsnj — Fri, 18 May 2018 14:52:46 +0000

International health organization reimagining health care in the U.S. is expanding in Belleville, NJ, in collaboration with Horizon Blue Cross Blue Shield of New Jersey Fri, 05/18/2018 - 10:52

Sanitas opens its second medical center in New Jersey, bringing its family centered, culturally relevant and preventive focused primary care model to members of Horizon Blue Cross Blue Shield of New Jersey (BCBSNJ).

Belleville is home to a new multiservice Sanitas Medical Center. The center is the second of three new centers expected to be opened in New Jersey resulting from phase one of the collaboration between Sanitas and Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ). The first center opened in Union City in December 2017 and the third will open later this year in Jersey City. The medical centers are independently owned and operated by Sanitas and are a critical component of Horizon BCBSNJ’s effort to improve access to health care services for the state’s Spanish-speaking and Latino residents.

The Belleville medical center is located at 1 Clara Maass Drive. The medical center provides primary care, urgent care, laboratory, diagnostic imaging services, and wellness and disease management programs. The center is open in the evenings and weekends to ensure that patients have convenient access to care in their local community. Additionally, Sanitas develops a culturally relevant experience tailored to each community including establishing a local diverse medical team of Spanish speaking doctors to address the needs of the growing Hispanic community.

Sanitas entered the U.S. market in November 2015 and has grown to more than 200,000 patients, improving the quality of care and the patient/member experience while significantly reducing total cost of care. Sanitas attributes these results mainly to its ability to engage patients in their health journey and a total health mindset. The other key success factor is the establishment of a customized approach in each community in close collaboration with the health insurance company.

Sanitas starts with a deep understanding of the clinical and non-clinical aspects that shape a patient’s ability to engage in healthy behaviors. Spending the time to truly know and support patients and jointly develop a care plan are critical aspects of Sanitas’ model. Sanitas also invests in developing and enabling diverse primary care teams with a mindset of delivering on ‘Total Patient Care’. This mindset focuses on prevention and screening at every step of the patient’s journey and handling most of the patient’s needs at the primary care setting—an approach that empowers primary care doctors to practice medicine as it should be and naturally reduces waste in the health system.

“Sanitas difference comes from a deep understanding of the unique needs of each patient’s health care journey and our proven ability to deliver a care experience that helps patients get healthier,” said Dr. Fernando Fonseca, Sanitas Chief Executive Officer. “We’re excited to work together with Horizon Blue Cross Blue Shield of New Jersey to tailor our primary care model to the needs of their members and integrate our services and programs to deliver a simpler and better health care experience.”

“Horizon is committed to serving New Jersey’s Latino communities and to delivering the multicultural health focus Sanitas provides,” said Allen J. Karp, Senior Vice President of Healthcare Management. “Horizon has been really successful helping Hispanic consumers navigate the healthcare system and get the care they need through intensive person-to-person contact, a culturally sensitive approach and grassroots, community-based outreach.”

About Sanitas

Sanitas is a leading multinational health organization serving more than 3 million people with presence in Spain, United States, Mexico, Colombia, Venezuela, Peru, Brazil, and the Philippines. Sanitas also includes educational and socially-focused organizations that complement its world of health mission. In the United States, Sanitas has 14 medical centers in Florida, Connecticut and New Jersey, serving more than 200,000 patients in collaboration with local leading health insurance organizations. Sanitas brings a unique integrated care model that improves access to quality and culturally relevant primary care while reducing total cost of care.
To learn more about Sanitas expansion in New Jersey visit mysanitas.com/nj

About Horizon Blue Cross Blue Shield of New Jersey

Horizon Blue Cross Blue Shield of New Jersey, the state’s oldest and largest health insurer is a tax-paying, not-for-profit health service corporation, providing a wide array of medical, dental, and prescription insurance products and services. Horizon BCBSNJ is leading the transformation of health care in New Jersey by working with doctors and hospitals to deliver innovative, patient-centered programs that reward the quality, not quantity, of care patients receive. Learn more at www.horizonblue.com. Horizon BCBSNJ is an independent licensee of the Blue Cross and Blue Shield Association serving more than 3.8 million members.

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Medical Policy Revision: Gait Trainers and Standing Frames

horizonbcbsnj — Thu, 17 May 2018 17:29:53 +0000

Medical Policy Revision: Gait Trainers and Standing Frames Thu, 05/17/2018 - 13:29

Effective August 16, 2018, Horizon Blue Cross Blue Shield of New Jersey will change the way we consider certain claims for standing devices and gait trainers.

We encourage you to review the guidelines of our revised medical policy, Gait Trainers and Standing Frames, in our Medical Policy Manual which identify when the use of standing devices and gait trainers are considered medically necessary.

Based on the guidelines of our revised medical policy, Gait Trainers and Standing Frames, claims for services/supplies provided on and after August 16, 2018 will be processed as noted below.

HCPCS codes E8000, E8001 and/or E8002 submitted on claims for supplies provided to members enrolled in Horizon BCBSNJ Medicare Advantage (MA) plans will be denied, regardless of the submitted diagnosis code(s), as experimental/investigational, non-covered services.
Claims that include HCPCS codes E8000, E8001, E8002 and/or E0638 submitted for supplies provided to members enrolled in plans other than Horizon BCBSNJ MA plans may, based on the submitted diagnosis code(s), pend while information required for us to determine medical appropriateness is requested and reviewed.

Unless Horizon BCBSNJ gives written notice that all or part of the above changes have been cancelled or postponed, the changes will be applied to claims on and after August 16, 2018.

As part of the Horizon Care@Home program, CareCentrix conducts review of requests for Durable Medical Equipment (including Medical Foods [Enteral], and Diabetic and Other Medical Supplies); Orthotics and Prosthetics and Home Infusion Therapy Services, including hemophilia.