Blue Review March 2022
It's easy to confirm your patients' health information online. Their digital member ID information is just as accurate as their physical member ID card. To learn more about how to access this information, please visit our Digital ID Card website.
Members now have more options to get over-the-counter (OTC), at-home COVID-19 tests kits.
The Biden-Harris Administration launched a website where residential households in the U.S. can order one set of four free OTC, at-home tests. This option is available to all of our members, regardless of which health plan they have.
In addition, the Biden-Harris Administration announced that health insurance companies and group health plans must provide coverage for OTC, at-home COVID-19 tests purchased on or after January 15, 2022, and through the end of the federal Public Health Emergency (PHE). This new coverage requirement allows many of our members to obtain up to eight at-home tests every 30 days when the tests are for personal use to diagnose a COVID-19 infection. This option is not available to our Medicare Advantage members.
Horizon will administer the coverage for fully insured and self-insured health plans that have prescription drug benefits with us through our pharmacy benefits manager (PBM), Prime Therapeutics LLC.
Your patients can find out more here.
You can read answers to frequently asked questions about this new coverage requirement.
This new requirement does not affect existing coverage for diagnostic testing that is ordered by a doctor, and it does not require coverage for OTC, at-home tests that are used for public health surveillance. Testing for public health surveillance (for employment or school) and in preparation for travel, is not covered.
We recently announced that effective on or after May 1, 2022, CareCentrix, Inc. will manage post-acute care services and a community-based palliative care program for your patients enrolled in Horizon Medicare Advantage, Braven Health℠ Medicare Advantage and Horizon Commercial, fully insured plans.
Training will be available for impacted providers.
If you have questions, please contact your Network Hospital Specialist or Ancillary Contract Specialist.
Fraudsters will always try to identify loopholes and exploit weaknesses to cheat and steal from patients, as well as insurers and government programs. Government agencies report a variety of schemes related to COVID-19.
Criminals use a variety of scams and contact methods related to COVID-19 to steal identities including:
- COVID-19 and add-on diagnostic testing
- Treatments and cure-related scams
- Clinical and vaccine trials
- Phishing emails and texts with harmful links
- Sales of Personal Protective Equipment (PPE)/counterfeit supplies and products
- Charity scams
- Contact tracing fraud
The Public Health Emergency may have contributed to program vulnerabilities in laboratory and other diagnostic services including:
- Counterfeit or adulterated COVID-19 tests
- Laboratory certification concerns
- Poor quality and inaccurate tests
- Unnecessary medical tests
- False COVID-19 diagnosis
- Duplicate and add-on billing in conjunction with COVID-19 laboratory services
- Pass Through Billing by both legitimate and fraudulent providers
- Referral kickbacks
The increased use of telemedicine services during the public health emergency may be contributing to fraud schemes including:
- Criminal telemedicine schemes
- Unnecessary add-on services (such as genetic/diagnostic tests, and DME)
- Lax oversight of new/start-up telemedicine companies
- Billing concerns (such as provider misrepresentation, upcoding, billing for services and care not rendered)
- Remote Patient Monitoring (RPM) schemes (including fitness devices)
The Credit Balance Adjustment Request Form allows your facility to return any improper or additional claim reimbursements from patient billing or claims processing to us. All credit balances outstanding for 30 days or more should be reported using the Credit Balance Adjustment Request Form.
You must submit copies of payment vouchers, hospital bills and any other pertinent information with your completed Credit Balance Adjustment Request Form either by fax to 1-973-274-2336 or mail to:
Mail Station PP12P
3 Penn Plaza East
Newark, NJ 07105
As a reminder, Horizon is no longer offering services from MOBE to its members since January 1, 2022. MOBE is an independent company that previously offered select members personalized health services assistance and coaching at no additional cost.
Your patients who are impacted have been notified and received information on how to find or transition to other programs that can address their unique health goals and challenges.
Effective April 1, 2022, more than 200,000 Medicare-eligible City of New York retirees will transition to the NYC Medicare Advantage Plus plan. This is an update to the originally communicated effective date of January 1, 2022.
The NYC Medicare Advantage Plus plan is a Medicare Advantage PPO group retiree offering through an alliance between Empire Blue Cross Blue Shield (Empire) and EmblemHealth. The plan allows retirees to visit any doctor nationally that accepts Medicare while ensuring the health care provider is paid their negotiated contractual rate or 100 percent of the Medicare allowed rate if non-contracted (less any member copay).
Please see our recent web announcement.
Since launching this self-service capability last August, we have processed over 30,000 successful transactions. We closely monitored the unsuccessful transactions, and are happy to report that we have made and will continue to make enhancements to improve your experience.
As a reminder:
The Member Eligibility and Cost Share Estimator is included in our monthly Horizon General Product webinars for new Professional Provider Onboarding. We also host specifically scheduled webinars/trainings, which include the Cost Estimator and would be happy to host a session for you. Please contact your Network Specialist to schedule a session.
The information we display on our Doctor & Hospital Finder must be current and accurate, so our members can easily locate you and access the care and services they need from you. We rely on you to inform us when updates need to be made to your practice's listing.
According to the Consolidated Appropriations Act, we must verify provider directory information every 90 days. As a reminder, the Centers for Medicare & Medicaid Services (CMS) also requires Horizon to contact its provider network on a quarterly basis to ensure the information on our Doctor & Hospital Finder is accurate.
You must notify Horizon immediately of any changes. Failure to respond to our outreach will result in your information no longer appearing within our Doctor & Hospital Finder. Repeated failure to comply with our outreach may result in your termination from the Horizon network(s).
We appreciate your ongoing cooperation.
Please visit our Demographic Updates page for more information and how to use our Provider Data Management tool. This page also includes instructions for submitting demographic updates to us.
We enhanced our Provider Data Maintenance Tool on NaviNet® to make it easier to update demographic information which displays online. You can now enter or update your practice®s website URL.
The tool can be used to quickly and conveniently make many other changes to your provider information, which we display to your Horizon and Horizon NJ Health patients, including:
- Add or delete office locations
- Add or update office email addresses
- Update phone and fax numbers
- Manage practice limitations
- Manage areas of expertise for behavioral health services
- Indicate if telemedicine services are offered
- Practitioner race/ethnicity
To learn more about how to access the tool, visit the Provider Data Maintenance Tool webpage.
Horizon maintains our Appointment Availability Access Standards for Primary Care-Type Providers, ObGyns, Specialists and Behavioral Health Providers administrative policy guidelines to help ensure that our members, including those in Braven Health℠ plans, receive care when they need it.
We encourage you to review this content and keep our standards in mind when offering your patients a first-available appointment, responding to after-hours calls for urgent or emergent care, or monitoring office-waiting time. Our goal is for all of our members to have access to timely appointments based on the clinical urgency of their physical and/or behavioral health needs.
Access Standard information is also available online to our members.
We appreciate your flexibility in continuing to provide telemedicine services to our members during the course of the ongoing COVID-19 Public Health Emergency.
We encourage you to access and review the guidelines of the following policies, which also include Temporary Policy Addenda Related to the COVID-19 Pandemic that have been in place since March 2020.
- Telemedicine Services reimbursement policy for services provided to your patients enrolled in insured commercial plans, Medicare Advantage (including Braven Health℠) plans and Administrative Services Only (ASO) plans that have opted in to the guidelines of this policy.
- Telemedicine and Telehealth reimbursement policy for services provided to your patients enrolled in Horizon NJ Health plans.
If you have questions about the guidelines of these policies, please contact your Network Specialist.
We are delaying the previously announced February 1, 2022 expansion of our Surgical and Implantable Device Management Program to include Spine Services for Horizon's commercial (including certain Administrative Services Only (ASO) employer groups) and Medicare Advantage plans, including Braven Health℠.
The new effective date of this program expansion is April 1, 2022.
Please continue to work with eviCore healthcare for PA/MND requests/reviews for impacted spine-related services until further notice.
The expansion of the TurningPoint program to include management of spine-related services is subject to the approval of the New Jersey Department of Banking and Insurance. If regulatory approval is not obtained by April 1, 2022, the TurningPoint expansion and the sunsetting of eviCore's management of spine-related services will be delayed, and further communications will be issued.
Our Utilization Management (UM) policy gives you the right to discuss any initial UM denial determination with the Horizon physician who issued the decision within 72 hours of the initial determination.
Each written UM denial determination includes the reviewing physician's name and instructions with a phone number. The Horizon UM Department may be reached at 1-800-664-BLUE (2583), weekdays, from 8 a.m. to 5 p.m., Eastern Time. For urgent determinations of UM inquiries, including those needed after business hours or on weekends, call our clinical operations on-call staff at 1-888-223-3072. The informal peer-to-peer discussions process does not replace the formal appeal rights of the physician/other health care professional or member.
For additional information about our UM processes and our criteria, visit HorizonBlue.com/umpolicy.
Member satisfaction is one of the most important components of any health plan's Star Rating. Many of the measures that are calculated to yield the Star Rating are directly derived from the results of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey.
CAHPS survey measures:
- Getting the flu vaccine
- Getting needed care without delays
- Getting appointments and care quickly
- Customer service
- Rating health care quality
- Rating the health plan
- Care coordination
- Rating of drug plan
- Getting needed prescriptions
Because at least half of our overall Star Rating is influenced by member experience, it is important for both Horizon and its network providers to create a positive experience.
The CAHPS survey is sent to a random sample of Horizon members between February and May every year. It asks respondents to – among other topics – rate their primary care provider, discuss their ease in filling prescriptions, rate their own overall health and more. It's important you work with your patients to ensure best possible response rates.
Proper communication skills play a key role in improving health care outcomes and ensuring patient satisfaction.
An important part of effective communication is how readily patients voice their concerns and questions to you. Establishing a strong and trusting relationship with your patients based on open communication makes it more likely that patients will adhere to your treatment plans and get the full benefit of your care.
Through focus group sessions, our members offered the following suggestions to help improve communication with their health care professionals:
- Before an appointment, become familiar with their medical history, including past tests, major illnesses, allergies, medications and family history.
- Actively listen to your patient's concerns and answer questions in a manner and language your patient can understand.
- Encourage your patient to participate in health care decision making and treatment options (to the extent possible).
- Ensure that your patient understands the medications you prescribe, how to use them and any possible side effects.
- Ensure that your patient understands all tests you prescribe. Explain the reason for a particular test, what is involved in conducting the test and any potential financial liability related to the test. Your patients may be responsible for the cost of any equipment, drugs, supplies, etc. They should be told if hospital/facility claims are being submitted in addition to physician claims.
- Summarize your plan of treatment, tests and any follow-up care you are recommending. Then ask your patient to sum up, in his or her own words, the information you conveyed to him or her.
- Before the patient leaves your office, schedule required follow-up appointments.
We appreciate all that you do to help your patients, our members, take a more active role in their health.
Your patients who are enrolled in Horizon health plans that include Horizon Pharmacy have a new way to get their prescriptions filled and delivered right to their door: Amazon Pharmacy.
Amazon Pharmacy is now a participating home delivery pharmacy for 90-day supplies of maintenance medicines. Please note that Amazon Pharmacy does not fill prescriptions for Schedule II controlled substances. Those prescriptions should be sent to a local in-network pharmacy of your patients' choice.
Horizon members (excluding those enrolled in Medicare Advantage; Medicare Prescription Drug and Braven Health℠ plans) also get a drug discount card called MedsYourWay™¹ built in to the Amazon Pharmacy experience. All covered and eligible purchases count toward the member's deductible or out-of-pocket costs whether they use their insurance or MedsYourWay.
You can submit prescriptions to Amazon Pharmacy by:
- Eprescribing: Amazon Pharmacy 001
- Fax: 1-512-884-5981
- Mail: 4500 S Pleasant Valley Rd, Suite 201 Austin, TX 78744
- Phone: 1-855-745-5725, then press 1
If you or your patients have questions about Amazon Pharmacy, please visit amazon.com/horizonblue or call Amazon Pharmacy Customer Care at 1-855-549-1760. Representatives are available 24/7.
If your patient has questions about their Pharmacy benefits, they should call the phone number listed on their member ID card.
¹MedsYourWay drug discount card, administered by Inside Rx LLC, is not insurance. Members are responsible for the cost of prescription(s) when using the card. Limitations apply.
Amazon Pharmacy is contracted by Horizon Blue Cross Blue Shield of New Jersey to provide pharmacy home delivery services.
Providing the right care at the right time is important to your patients. Horizon maintains appointment availability access standards for Primary Care Physicians (PCPs), obstetricians and gynecologists (Ob/Gyns), specialists and behavioral health care professionals to help ensure that our members receive care when they need it.
These standards should be kept in mind when offering your patients a first available appointment, responding to after-hours calls for urgent or emergent care, or monitoring office-waiting time.
This information, in addition to being available on our Administrative Policies page, may also be reviewed within our Participating Physician and Other Health Care Professional Office Manual. Access standard information is also made available to our members.
Jubril Oyeyemi, M.D., a Primary Care Physician in Camden, often treats patients who are dealing with life problems too big for a doctor alone to solve.
“The population we serve has some of the most complex daily living needs,” Dr. Oyeyemi says. “They're facing housing instability or homelessness. Transportation is another big problem. Social Determinants of Health (SDoH) shape health and wellness in a way that goes way beyond the walls of the primary care office.”
Dr. Oyeyemi is the Medical Director at the Camden Coalition of Healthcare Providers, which partnered with Horizon in April 2020 to launch the Horizon Neighbors in Health program in Camden. The program aims to address SDoH and reduce health disparities to help at-risk members achieve good health. Since it began, the program is bringing hope and practical solutions to people facing challenges they see as insurmountable.
“The Horizon Neighbors in Health program has been remarkable,” Dr. Oyeyemi says. “With the Camden Coalition and Horizon working together, we're able to identify the needs of high-risk members and walk alongside them using a coaching model, to show them how to help themselves and meet those needs in a way that's sustainable.”
It's important that the information we display within our Online Doctor & Hospital Finder is current and accurate so our members can easily locate you and access the care and services they need from you. We rely on you to inform us when updates need to be made to your practice's listing.
According to the Consolidated Appropriations Act, we must verify provider directory information every 90 days. As a reminder, the Centers for Medicare & Medicaid Services (CMS) also requires Horizon to contact its provider network on a quarterly basis to ensure the information in our Online Doctor & Hospital Finder is accurate.
You must notify Horizon immediately of any changes. Failure to respond to Horizon outreach will result in your information no longer appearing within our Online Doctor & Hospital Finder. Repeated failure to comply with Horizon outreach may result in your termination from the Horizon network(s).
We appreciate your ongoing cooperation.
Please visit our Demographic Updates page for more information and additional resources about this effort. This page also includes instructions for submitting demographic updates to us.
Reminder: You Can't Bill Medicaid Patients
We'd like to remind you that you should not directly bill Horizon NJ Health members for any balance due on medical claims for medically necessary, covered services. Providers enrolled in the NJ FamilyCare Fee-for-Service program or in Managed Care are required to accept the reimbursement rate established by these programs as payment in full.
Reimbursement rates are determined by your contract with us. However, if you wish to dispute the amount you received from us, please mail an HCAPPA claim appeal to:
Horizon NJ Health
PO Box 63000
Newark, NJ 07101-8064
Reminder: Horizon NJ Health is the Payor of Last Resort
If your patients that have Horizon NJ Health also carry other health insurance, these other plans should be billed first. Services our members receive should first be reviewed against benefits under their other carriers, such as Medicare, employee health plans or other third-party medical insurance. Please ask your patients for all of their health plan member ID cards and about all of their insurance coverage before providing services.
Please follow the primary insurer's administrative requirements and forms for claims submission. Providers should not file a claim with us until they receive an Explanation of Benefits (EOB) from the other insurance carrier(s).
After you receive payment from our members' primary insurer, submit the coordination of benefits claim, including the primary insurer's EOB, to us within 60 days of the date of the other carrier's correspondence or 180 days from the date of service, whichever is later.
Note that the total amount reimbursed by all parties will not exceed the lowest contractually agreed-upon amount and normal Horizon NJ Health benefits, which would have been payable had no other insurance existed. Thank you for your cooperation in providing care to our members.