Here is a brief overview of the products we offer and/or service. You can always verify member benefits by searching their information, or by using our Eligibility and Benefits Cost Share Estimator on NaviNet®. This tool provides medical and behavioral health claim-level member eligibility, benefits and out-of-pocket costs. It is for patients enrolled in our Commercial and Braven Health plans.
Additional product information is available.
The following responsibilities apply to you:
You may collect copayment amounts as indicated on the member’s ID card.
You are expected to bill members for the appropriate member liability (deductible and/or coinsurance), as indicated on the Explanation of Payment (EOP) you receive.
You are required to accept our allowance for eligible services as payment in full.
The Affordable Care Act removed the pre-existing medical condition exclusion for both new employer-based health insurance plans and new individual health insurance plans. Health insurance companies cannot charge higher premiums for current and past health problems, gender and a person’s occupation. Also, insurers cannot refuse to sell coverage or renew coverage because of a pre-existing medical condition and cannot deny claim payments because of a pre-existing medical condition.
The ACA does not require health insurers to remove the pre-existing condition exclusion from Medicare, Medigap and Medicaid plans. Horizon currently only applies a pre-existing condition waiting period on Medigap coverage.
The effective date of the removal of the pre- existing condition exclusion will vary.
The State Health Benefits Program and Federal Employee Program® do not have pre-existing condition restrictions.
HORIZON MANAGED CARE NETWORK
If you are a participating Horizon Managed Care Network health care professional, members enrolled in the following plans use their in-network benefits when they receive care from you.
- Horizon HMO
- Horizon HMO Access
- Horizon HMO Access Value
- Horizon HMO Coinsurance
- Horizon HMO Coinsurance Plus
- Horizon HMO (SHBP and SEHBP)
- Horizon HMO1525 (SEHBP)
- Horizon HMO2030 (SEHBP)
- Garden State Health Plan
- Horizon Direct Access
- Horizon Advantage Direct Access
- Horizon Direct Access Value
- NJ DIRECT10 (SHBP and SEHBP)
- NJ DIRECT15 (SHBP and SEHBP)
- NJ DIRECT1525 (SHBP and SEHBP)
- NJ DIRECT2030 (SHBP and SEHBP)
- NJ DIRECT2035 (SHBP and SEHBP)
- NJ Educators Health Plan (SEHBP)
- CWA Unity Direct (SHBP)
- CWA Unity DIRECT 2019 (SHBP)
- NJ DIRECT (SHBP)
- NJ DIRECT 2019 (SHBP)
- OMNIA Health Plans
- Horizon Advantage EPO
- Horizon Patient-Centered Advantage EPO
¹ Members enrolled in these plans do not have out-of-network benefits, except in the event of an emergency
Consumer-Directed Healthcare (CDH)
- Horizon HMO Access HSA
- Horizon HSA/HRA (Direct Access)
- OMNIA HSA/HRA
- NJ DIRECT HD1500 (SHBP)
- NJ DIRECT HD4000 (SHBP)
- Horizon POS
HORIZON MANAGED CARE NETWORK NJPA
Certain Individual and Small Group Market plans (HMO, POS and Advantage EPO plans without BlueCard® benefits) are part of the Horizon Managed Care Network NJPA. Member ID cards for this plan say “NJPA” along with the plan name.
Horizon HMO members select a PCP who will either provide the necessary care or refer them to the appropriate specialist or facility. Members receive full benefit coverage, including coverage for preventive care, when services are provided or referred by their PCP.
Horizon HMO offers various office visit copayments and some must pay a coinsurance payment. Carefully check the member’s ID card for the copayment amount due for an office visit.
HORIZON HMO ACCESS AND HORIZON HMO ACCESS VALUE
Under Horizon HMO Access plans, members may receive care from Horizon Managed Care Network specialists without a referral.
Members enjoy both the benefits of working with a selected PCP and the freedom to coordinate their needs without a referral. Members may not self-refer to PCP-type providers; they must use their preselected PCP.
Horizon HMO Access plans include split copayments for physician services. A lower office visit copayment applies to visits to preselected PCPs. A higher office visit copayment applies to office visits to non-preselected PCPs, all other participating PCP-type physicians and other health care professionals, and to participating specialist office visits.
Horizon HMO Access includes various inpatient and outpatient facility copayments and other professional health care services.
Some Horizon HMO Access members are required to pay a coinsurance payment for most services not performed in an office setting, including Durable Medical Equipment.
Horizon HMO Access members may visit participating specialists without a referral. Preapproval is required for some services.
Horizon HMO Access members have no out-of-network benefits.
The Horizon HMO Access and the Horizon HMO Access Value plans are identical except that Horizon HMO Access Value includes:
- A higher specialist copayment amount
- A lower maximum out-of-pocket amount
- A higher hospital inpatient copayment amount
HORIZON HMO COINSURANCE AND HORIZON HMO COINSURANCE PLUS
The Horizon HMO Coinsurance and Horizon HMO Coinsurance Plus plans are managed care products. They require PCP selection, use of the Horizon Managed Care Network and referrals/ precertification to receive benefits. Out-of-network services are not covered under these plans.
These plans offer 100 percent coverage after office visit copayment for all services received in a network practitioner’s office. For all other network services, coverage is subject to deductible and coinsurance.
The deductible applies to all services rendered outside of the physician’s office except for:
- Diagnostic lab work and X-ray
- Emergency Room care
- Prescription drugs
HORIZON HMO (SHBP AND SEHBP) HORIZON HMO1525 (SEHBP)
HORIZON HMO2030 (SHBP AND SEHBP)
Horizon BCBSNJ offers members of the State Health Benefits Program (SHBP) and School Employees’ Health Benefits Program (SEHBP) access to the following HMO options:
- Horizon HMO10
- Horizon HMO15
- Horizon HMO1525
- Horizon HMO2030
These plans provide safe and effective care through physicians, health care professionals and facilities that participate in the Horizon Managed Care Network.
HORIZON DIRECT ACCESS
Our Horizon Direct Access products allow members to visit participating specialists without a referral from a PCP. It has in- and out-of-network benefits.
PCP selection and referrals are not required. PCPs are encouraged to refer members to participating physicians and other health care professionals.
Members are responsible for sharing the cost of their health care. Patients who receive care out of network may have higher out-of-pocket costs.
Horizon Direct Access and BlueCard®
These ID cards display the PPO-in-the-suitcase logo indicating that these members have access to PPO physicians and health care professionals when receiving services outside of New Jersey.
HORIZON ADVANTAGE DIRECT ACCESS
Horizon Advantage Direct Access plan are similar to Horizon Direct Access plans but include:
Split copayments: Lower office visit copayments for PCP visits and higher office visit copayments for all other physicians. Members are not required to select a PCP; however, the lower copayment for PCP services is only available for a PCP-type doctor (a participating physician specializing in family practice, general practice, internal medicine or pediatrics).
Separate (and higher) out-of-network deductible amounts and maximum out-of- pocket (MOOP) levels to help discourage out-of-network utilization. The deductible and MOOP do not cross accumulate between the in-network and out-of-network benefits.
These plans also include a $2,000 benefit maximum for out-of-network ambulatory surgery centers.
Horizon administers direct access plans on behalf of the New Jersey State Health Benefits Program (SHBP) and School Employees’ Health Benefits Program (SEHBP).
All NJ DIRECT plans:
- Do not require PCP selection or referrals.
- Allow members to receive care in or out of network.
- Require prior authorization for certain services (refer to the online prior authorization list).
- Use the Horizon Managed Care Network in New Jersey and the national BlueCard® PPO network outside of New Jersey.
- Cover eligible preventive care services, as outlined in the federal health care reform law, the Patient Protection and Affordable Care Act (PPACA), with no member cost share when rendered in network.
NJ DIRECT copayment plans
SHBP/SEHBP members may select a copayment plan:
- NJ DIRECT10
- NJ DIRECT15
- NJ DIRECT1525
- NJ DIRECT2030
- NJ DIRECT2035
- NJ Educators Health Plan
- CWA Unity DIRECT
- CWA Unity DIRECT 2019
- NJ DIRECT
- NJ DIRECT 2019
High-Deductible (HD) Health Plans
SHBP members may select one of two high-deductible plans.
- NJ DIRECT HD1500
- NJ DIRECT HD4000
In the High-Deductible Health Plans, all eligible services (except for eligible preventive services) are subject to deductible, coinsurance and out-of- pocket maximums before services will be considered for benefit. No copayments apply.
SHBP/SEHBP: Multiple coverages prohibited
A New Jersey state law enacted in 2010 prohibits multiple coverage under the State Health Benefits Program (SHBP) and/or the School Employees’ Health Benefits Program (SEHBP).
- An employee or retiree cannot be enrolled for coverage as both a subscriber and a dependent under the SHBP and/or SEHBP.
- An employee cannot be enrolled for coverage as an employee and as a retiree under the SHBP/SEHBP.
- Children cannot be enrolled as dependents for coverage under both SHBP/SEHBP covered parents.
- NJ DIRECT members who have coverage under a non-SHBP/SEHBP plan can maintain enrollment in NJ DIRECT and the non- SHBP/SEHBP plan.
Read more about all SHBP/SEHBP plans.
OMNIA℠ HEALTH PLANS
Our OMNIA Health Plans give enrolled members the flexibility to visit any New Jersey health care professional in our broad Managed Care Network.
OMNIA Health Plan members incur lower out-of-pocket costs when they use OMNIA Tier 1 doctors, hospitals and other health care professionals.
These products are offered to individual consumers purchasing coverage on and off the Health Insurance Marketplace (Exchange) as well as to employer groups of all sizes, including SHBP.
HORIZON ADVANTAGE EPO
Horizon Advantage Exclusive Provider Organization (EPO) plans provide in-network only benefits through the Horizon Managed Care Network.
PCP selection and specialist referrals are NOT required.
There are no Out-of-Network Benefits
Certain employer groups may choose to provide their members with access to the BlueCard® PPO program.
If a member’s Horizon Advantage EPO ID card includes the: PPO-in-the-suitcase logo or the empty-suitcase logo, they have access to the BlueCard® PPO program for services provided outside our local service area.
HORIZON PATIENT-CENTERED ADVANTAGE EPO
The Horizon Patient-Centered Advantage EPO plan is offered to employer groups and provides in-network only benefits through the Horizon Managed Care Network.
Our Horizon Patient-Centered Advantage EPO plan is similar to our other Horizon Advantage EPO plans, except this plan uses different member cost-sharing levels to encourage enrolled members to select and use a Primary Care Physician (PCP) affiliated with one of our established value-based practices. Horizon Patient-Centered Advantage EPO members incur a lower out-of-pocket expense when they select and use a PCP who participates in one of our patient-centered programs.
No PCP selection or specialist referrals are required.
Members must use LabCorp or Quest Diagnostics for laboratory services.
Please confirm specific benefits for members enrolled in the Horizon Patient-Centered Advantage EPO plan.
CONSUMER-DIRECTED HEALTHCARE (CDH) PLANS
Consumer- Directed Healthcare (CDH) incorporate a Health Reimbursement Arrangement (HRA) or a Health Savings Account (HSA) with a high-deductible medical plan.
Key Features of CDH Plans
Copayments – Collect copayments during visits (if applicable).Copayment information will appear on the member’s ID card.
No referrals required for specialists
Horizon MyWay – Direct Access Plan Design
The Horizon MyWay Direct Access product combines a high-deductible Horizon Direct Access plan with a spending/savings account. This health plan offers in- and out-of-network benefits and covers preventive care at 100 percent in network. Members maximize benefits by using participating managed care physicians, other health care professionals and participating facilities.
You can identify Horizon MyWay HRA/HSA Direct Access members by the following ID card prefixes:
Horizon MyWay – PPO Plan Design
The Horizon MyWay PPO product combines a high-deductible PPO plan with a medical account. This health plan offers in- and out-of-network benefits and covers preventive care at 100 percent in network. Members can maximize benefits by using participating PPO physicians, health care professionals and participating facilities.
You can identify Horizon MyWay HRA/HSA PPO members by the following ID card prefixes:
Horizon MyWay – HMO Access Plan Design
The Horizon MyWay HMO Access product combines a high-deductible Horizon HMO Access plan with a spending/savings account. This health plan offers in network benefits only and covers preventive care at 100 percent. Members must use participating managed care physicians, other health care professionals and contracting facilities.
You can identify Horizon MyWay HSA HMO Access members by the following ID card prefix:
SHBP/SEHBP High-Deductible Plans
The New Jersey State Health Benefits Program (SHBP) and the School Employees’ Health Benefits Program (SEHBP) committees offer enrolled members access to two high-deductible plans designs: NJ DIRECT HD1500 and NJ DIRECT HD4000. These plans offer in- and out-of-network benefits and include $0 copayments for preventive care services. Members maximize benefits by using participating managed care physicians, other health care professionals and participating facilities.
You can identify NJ DIRECT HD1500 and NJ DIRECT HD4000 members by the following ID card prefix:
Horizon Advantage EPO HSA/HRA
The Horizon Advantage EPO HSA/HRA plans combine our Exclusive Provider Organization plan with either a Health Savings Account (HSA) or Health Reimbursement Arrangement (HRA). These plans provide in-network only benefits through the Horizon Managed Care Network. Members enrolled in Horizon Advantage EPO plans are NOT required to select a Primary Care Physician and referrals are not required for members to see specialists who participate in the Horizon Managed Care Network.
You can identify Horizon Advantage EPO HSA/HRA members by the following ID card prefixes:
Horizon POS is a point-of-service program providing the advantages of a HMO, but incorporating patient cost sharing and an option for members to access care from any physician without a referral from their PCP, at a lower level of benefits.
Horizon POS has two levels of benefits: in network and out of network. To receive the highest level of benefits, members must access care through their PCP (and obtain referrals as appropriate).
When members’ care is not coordinated through their PCP, the lower, or out-of-network, benefits apply. Members are given the choice to seek services either in network or out of network at each point of service.
Members are responsible for sharing the cost of their health care. For in-network care, this can amount to a basic office visit copayment, a deductible and/or coinsurance. Patients who go out of network or see a specialist without a PCP referral pay a higher share of the costs, including higher deductibles, coinsurance and copayment amounts.
Employers or association groups select the level of cost sharing for their employees. Horizon POS is designed to encourage members to maximize their benefits by using their PCP.
When Horizon POS members who have not selected you as their PCP come to you without a referral, you should bill us first. We will provide you with an Explanation of Payment (EOP) advising you of our reimbursement and the amount you can collect from your patient.
HORIZON PPO NETWORK
If you are a participating Horizon PPO Network health care professional, members enrolled in the following plans use their in-network benefits when they receive care from you.
- BCBS Service Benefit Plan (FEP PPO)
- BlueCard® PPO
- Horizon Advantage PPO
- Horizon High Deductible PPO Plan D
- Horizon PPO
- Basic Blue℠ Plan A
- Comprehensive Health Plan
- Comprehensive Major Medical
- Horizon Basic Health Plan A
- Horizon Basic Plan A/50
- Horizon Comprehensive Health Plan A
- Horizon High Deductible Plan C
- Horizon High Deductible Plan D
- Horizon MSA Plan C
- Horizon MSA Plan D
- Horizon Traditional Plan B, C, D
- Major Medical
- Network Comprehensive Major Medical
- Medical/Surgical Fixed Fee 14/20 Series
- Medical/Surgical Fixed Fee 500 Series
- Medical/Surgical Fixed Fee 750 Series
- Student Program
Consumer-Directed Healthcare (CDH)
- Horizon MyWay HRA
- Horizon MyWay HSA
Members with Horizon PPO plans do not have to select a Primary Care Physician (PCP).
Members incur lower out-of-pocket costs and higher plan benefits, and do not need to file claims, when they receive care from Horizon PPO Network providers.
Members may also choose to use their out-of- network benefits, which provide access to care from any physician or hospital outside the network in exchange for higher out-of-pocket costs.
Nationwide and worldwide access to medical care is available through the BlueCard® PPO program.
FEDERAL EMPLOYEE PROGRAM
The Federal Employee Program® (FEP®) is a fee-for-service plan (Standard, Basic and Blue Focus) with a preferred provider organization that is sponsored and administered by the Blue Cross Blue Shield Association and participating Blue Cross and/or Blue Shield Plans.
FEP is a traditional type plan that encourages members to use Preferred or in-network physicians, other health care professionals and facilities to receive the highest level of benefits.
FEP members may be identified by their unique ID card. Member ID numbers include an R prefix and 8 digits.
Plan highlights include:
- PPO reimbursement levels
- Referrals are not required
- Some services may require prior authorization
FEP Inquiry/Claim Submission:
Providers should submit claims electronically through NaviNet or through their vendor using Payer ID 22099. If necessary, mail inquiries/claims to:
Federal Employee Program PO Box 656
Newark, NJ 07101-0656
To enroll a member in our Chronic Care Program, call 1-866-967-9696, weekdays, between 8 a.m. and 5 p.m., Eastern Time, or visit HorizonBlue.com/chronic-care.
For more information about FEP plans, call 1-800-624-5078 or visit fepblue.org.
HORIZON INDEMNITY PLANS
These products combine hospital, medical/surgical and major medical-type benefits into one product. After a deductible, we will pay a percentage of our applicable allowance for eligible services. There are no office visit copayments; however, the patient is responsible to pay the deductible, coinsurance and any amount charged for ineligible services.
The following pages include brief benefit descriptions of:
- Horizon Comprehensive Health Plans A, B, C, D, E
- Horizon Traditional Plans B, C, D
- Basic Blue℠ Plan A
- Comprehensive Health Plan (CHP)
- Comprehensive Major Medical (CMM)
- Horizon Basic Health Plan A/50
- Network Comprehensive Major Medical
HORIZON COMPREHENSIVE HEALTH PLAN A
These plans are available to employee groups of two to 50 employees under the Small Employer Insurance Reform Act.
HORIZON TRADITIONAL PLANS B, C, D
These plans are available to individuals under the Individual Health Insurance Reform Act.
Requires subscribers and/or physicians and other health care professionals to notify us within 12 weeks of medical confirmation of pregnancy. If we are not notified, payment of maternity claims will be reduced by 50 percent.
BASIC BLUE PLAN A
Basic Blue Plan A is no longer sold by Horizon; however, we continue to serve those customers currently enrolled.
This limited hospitalization plan covers 30 days of inpatient care and some professional services. The plan does not provide benefits for behavioral health and substance use disorder care services.
BlueCare is no longer sold by Horizon; however, we continue to serve those customers currently enrolled.
COMPREHENSIVE HEALTH PLAN (CHP)
This plan is no longer sold by Horizon; however, we continue to serve those customers currently enrolled.
COMPREHENSIVE MAJOR MEDICAL (CMM)
- Lab and X-ray Covered after deductible
HORIZON BASIC PLAN A/50
This plan is available to individual, nongroup customers.
NETWORK COMPREHENSIVE MAJOR MEDICAL (NETWORK CMM)
FIXED FEE CONTRACTS
Series 14/20 Studsent Program
These programs cover medical and surgical services performed at a hospital and in a physician’s office. Major medical types of service are not covered unless the patient has separate major medical coverage. The term Fixed Fee Contracts accurately describes these products because payment for an eligible service is fixed.
Service Benefits are paid-in-full benefits extended to certain individuals covered under a Fixed Fee Contract. Payments are not considered payment in full unless the subscriber meets specified income limits, which vary depending on whether the contract is for Single or Family coverage and the subscriber’s marital status.
Service Benefits Requirements
The patient must advise you within 120 days of the last day of rendering an eligible service that they qualify for Service Benefits. You may request proof of income by asking for a copy of the Federal Tax Form 1040 for the calendar year preceding the date of service. The subscriber must furnish proof within 45 days of your request.
Service Benefits Income Limits
If you are not notified of Service Benefits eligibility within 120 days of the last date of service, or proof of income is not furnished within 45 days of your request, the customer is disqualified from receiving Service Benefits. The Service Benefits feature described on this page is not related to, or part of, the BCBS Service Benefit Plan (a.k.a., the Federal Employee Program [FEP). Income is defined as the gross annual income from all sources for the calendar year prior to the year services were rendered. The income limits are listed below.
Income limits for 14/20 Series
|Parent and child:||$20,000|
|Husband and wife:||$20,000|
Service Benefit Payments
If your covered patient is enrolled under a fee schedule contract, you must accept our payment for eligible services as payment in full if the subscriber’s income makes him or her eligible for paid-in-full Service Benefits.
If the patient is not eligible for Service Benefits, the combined payment from us, from the patient or from any other source, shall equal your usual or reasonable fee for the procedure performed. You will not submit a fee to us that is higher than the fee usually accepted by you as payment in full for services performed.
Deductibles, copayments and/or coinsurance amounts are part of these contracts. Some groups incorporate cost containment and utilization review programs. For patient-specific information, we recommend reading the patient’s ID card for special benefit messages and phone numbers of dedicated service teams.
Major accounts have unique benefits. For patient-specific information, call Provider Services at 1-800-624-1110, Monday through Friday, between 8 a.m. and 5 p.m., ET.
These plans provide safe and effective care through physicians, health care professionals and facilities that participate in the Horizon Managed Care Network (for Medicare Advantage plans) or that participate with Medicare (Medicare Supplemental plans).
HORIZON MEDICARE ADVANTAGE PRODUCTS
We are an approved Medicare Advantage (MA) Organization and offer several Medicare Advantage products to beneficiaries through our affiliate Braven Health in place of Medicare Parts A and B:
- Braven Health Plans
Braven Health Plans
- Braven Medicare Plus (HMO)
- Braven Medicare Choice (PPO)
- Braven Medicare Freedom (PPO)
- Braven Medicare Group (PPO)
- Braven Medicare Group w/Rx (PPO)
- Braven Medicare Access Group (HMO-POS)
- Braven Medicare Access Group w/Rx (HMO-POS)
Horizon has partnered with Hackensack Meridian Health and RWJBH to form Healthier New Jersey Insurance Company d/b/a Braven Health.
Braven Health, an affiliate of Horizon, offers affordable Medicare Advantage health plans with access to the Horizon Hospital Network and the Horizon Managed Care Network. Braven Health individual plan options will be offered to New Jersey’s Medicare-eligible population in all 21 NJ counties for January 1, 2023.
BravenHealth Payer ID 84367.
More information is on the dedicated Braven Health web page.
Members enrolled in MA plans with NO out-of-network benefits
Members enrolled in Braven Medicare Plus (HMO) Plan must use a HearUSA Center for audiology services and hearing aids that are medically necessary, including batteries.
If these members reside in a New Jersey county without a HearUSA Center, they may request that their Primary Care Physician (PCP) refer them to a participating Horizon Managed Care Network audiologist. These same members who reside in a New Jersey county without a HearUSA Center will be reimbursed directly for hearing aids/batteries supplied by any non-HearUSA provider.
Members enrolled in MA plans with out-of-network benefits
If these members choose to use their out-of-network benefits (understanding that they will incur more cost sharing), they may obtain services from a non-HearUSA provider through HearUSA.
Use our Online Doctor & Hospital Finder to find a HearUSA location.
Visit HorizonBlue.com/doctorfinder, select Other Health Services and:
- Select Audiology within the Service Type menu.
- Enter your ZIP Code and indicate a Search Radius, or select your County.
- Click Search.
Emergency and Urgent Care Definitions
For our Medicare Advantage products, a medical emergency is a medical condition manifesting itself by acute symptoms of sufficient severity (including, but not limited to, severe pain) such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:
- Serious jeopardy to the health of the individual or, in the case of a pregnant woman, the health of the woman or her unborn child,
- Serious impairment of bodily functions, or
- Serious dysfunction of any bodily organ or part.
Emergency services include a medical screening examination and inpatient and outpatient services that are needed to stabilize an emergency medical condition.
For our Medicare Advantage products, urgently needed services are those services required to prevent a serious deterioration of a covered person’s health that results from an unforeseen illness, injury or condition that requires care within 24 hours.
MEDICAL RECORD STANDARDS FOR MEDICARE MEMBERS
According to the Centers for Medicare & Medicaid Services (CMS), all information included within a medical record must be legible for review by an approved CMS coder and must include the following information to document a face-to-face encounter.
- The physician or other health care professional must authenticate the services provided or ordered by including either a handwritten or electronic signature along with his/her credentials. The following types of signatures are not acceptable:
- Stamp signatures
- Signature of a physician other than the treating physician
- Signature of a nurse or other office professional on the physician’s behalf
- Statements that indicate: Signed but not read; Dictated but not signed/read; etc.
- The medical record should include sufficient information to ensure that a reviewer can determine the date on which a particular service was performed/ordered.
- The medical record should include sufficient documentation to support the diagnoses billed.
- Each page of a medical record must include the patient’s name.
The official instruction (Change Request 6698) may be accessed at cms.gov/transmittals/downloads/R327PI.pdf.
Medical Record Retention
Physicians and other health care professionals are required to maintain medical records for a minimum of 10 years for all Medicare Advantage members.
Medical Necessity Determinations
The medical necessity review and determination process for Horizon Medicare Advantage products is different than that of other managed care products.
If you or the member disagrees with a coverage determination we have made, the decision may be appealed. We have up to 14 days to determine whether an initial request for a service is medically appropriate and covered. If additional clinical information is required, we may have up to an additional 14 days to make a determination.
In some cases, the standard pre-service review process could endanger the life or health of the member. As a participating physician or other health care professional, you may request an expedited 72-hour pre-service determination for a Medicare Advantage patient if, in your opinion, the health or the ability of your patient to function could be harmed by waiting for a medical necessity determination.
Expedited determinations may be requested by calling 1-800-664-BLUE (2583).
Medicare Part D Prescription Drug Determinations
Requests for a coverage determination will be responded to within 24 hours for an expedited request (or sooner if the member’s health requires us to) or within 72 hours for a non-expedited coverage determination.
Part D drug coverage determinations include:
- Prior authorization determinations for those drugs that require prior authorization.
- Requests that we cover a Part D drug that is not on the plan’s List of Covered Drugs (Formulary).
- Requests that we waive a restriction on the plan’s coverage for a drug, including:
- Being required to use the generic version of a drug instead of the brand name drug.
- Being required to try a different drug first before we will agree to cover the drug you are asking for. (This is sometimes called step therapy.)
- Quantity limits. For some drugs, there are restrictions on the amount of the drug patients can have.
- Requests that we pay for a prescription drug the member already purchased (a coverage decision about payment).
- Expedited Medicare Part D drug determinations may be requested by calling 1-800-693-6651.
Non-expedited Medicare Part D drug determinations may be requested in writing to:
Prime Therapeutics LLC
Attn: Medicare Appeals Department 1305 Corporate Center Drive
Eagan, MN 55121
HORIZON MEDICARE ADVANTAGE MEMBER APPEALS
Members have the right to appeal any decision regarding our reimbursement or our denial of coverage based on medical necessity. Appeals may be requested verbally or in writing.
Medical records and your professional opinion should be included to support the appeal.
Based on the medical circumstances of the case, a Horizon BCBSNJ physician reviewer will determine if the request qualifies as an expedited appeal.
However, the member, physician or other authorized representative acting on behalf of the member may request an expedited appeal based on the medical circumstances of the case.
If coverage of services is denied, you must inform your Medicare Advantage patient of their appeal rights. At each patient encounter with a Medicare Advantage enrollee, you must notify the enrollee of their right to receive, upon request, a detailed written notice from the Medicare Advantage organization regarding the enrollee’s benefits. You may issue the appeal rights directly to the member in your office at the time of the denial, or contact Member Services and we will issue the appeal rights to the member.
Details about how to pursue various appeals and appeal levels will be communicated in writing as part of each coverage determination and/or appeal determination notification.
Medical Appeals for Medicare Services
Generally, we have 30 days to process an appeal pertaining to the denial of a requested service (pre-service appeal for service), and 60 days to process an appeal pertaining to post-service denial of claim payment (appeal for payment).
Standard appeals may be filed by calling 1-855-457-1346.
Expedited appeals are processed within 72 hours. To file an expedited appeal, the member may call Member Services at 1-800-365-2223.
Pre-service medical appeals may be faxed to 1-609-583-3021
Post-service appeals may be faxed to 1-732-938-1340 or mailed to:
Horizon Medicare Advantage Appeals Coordinator
Three Penn Plaza East, PP-12L
Newark, NJ 07105-2200
A completed Appointment of Representative (AOR) form or other court-appointed document indicating the member’s consent may be required for a physician to pursue post-service appeals on behalf of the member.
Medicare Part D Prescription Appeals
Generally, we have up to seven days to process an appeal pertaining to a post-service denial of coverage decision or claim for a Medicare Part D prescription drug and up to 72 hours (expedited) or 7 days (standard) to process an appeal pertaining to a coverage decision of a Medicare Part D prescription drug the member has not yet received.
To file an expedited Medicare Part D appeal, the member may call 1-800-693-6651. To request a Medicare Part D prescription drug appeal in writing, members may fax to 1-800-693-6703or write to:
Prime Therapeutics LLC
Attn: Medicare Appeals Department
1305 Corporate Center Drive
Eagan, MN 55121
Subcontractors and Medicare
Participating offices that have entered into business arrangements with a subcontractor must ensure that all contracts with those entities include language that requires them to comply with all applicable Medicare laws and regulations.
Nine-Digit ZIP Codes Required for Claim Submissions
CMS requires the use of nine-digit ZIP codes on all Medicare Advantage claim submissions in certain locations where a five-digit ZIP code spans more than one pricing area.
To avoid delays in claim processing, we recommend that physicians and other health care professionals within these areas bill with the complete nine-digit ZIP code for all patients.
If you’re unsure of your nine-digit ZIP code, visit the United States Postal Service’s ZIP Code Lookup.
For more information and for similar ZIP codes requiring +4 extension that are outside our service area, please visit the CMS Prospective Payment Systems - General Information web page.
MEDICARE SUPPLEMENTAL (MEDIGAP)
We offer a variety of Medicare Supplemental Products to our members who have Original Medicare as their primary insurance coverage.
- Horizon Medicare Blue Supplement Plans C and F, which pay the Medicare Part B deductible, are sold to the following individuals:
- Plan C and Plan F are only available to eligible applicants who turned age 65 prior to January 1, 2020, or to those who turned 65 on or after January 1, 2020, but have a Part A effective date prior to January 1, 2020.
- For the Under Age 65 market, the enrollment opportunities are limited; eligible individuals under age 65 who are enrolled in Medicare due to a disability or end-stage renal disease are guaranteed coverage in Horizon Medicare Blue Supplement Plan C or Plan D.
- Plan C is available to eligible individuals whose Medicare Part B effective date is prior to January 1, 2020 and who apply within six months of receiving a retroactive determination of Medicare eligibility.
- Plan D is available to eligible individuals who apply during one of the following timeframes:
- The Medicare Part B effective date is prior to January 1, 2020 and individual applies 63 days of losing coverage
- The Medicare Part B effective date is on or after January 1, 2020 and the individual applies:
- within 12 months of their enrollment in Medicare Part B;
- within 12 months of receiving a retroactive determination of Medicare eligibility.
- within 63 days of losing creditable coverage.
- within 63 days of losing coverage which entitles the individual to a guaranteed issue right.
Horizon Medicare Blue Supplement Plan D
Horizon Medicare Blue Supplement Plan D is available for the Age 65+, Age 50 to 64 and Under Age 50 markets.
These Medicare Supplementary products supplement or fill the gaps of eligible services paid by Medicare and have also been referred to as complementary coverage in the past.
As required by the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), we offer a new set of standardized Medicare Supplementary plans. The new plans, to distinguish them from the previously offered these plans (which we continue to service, but no longer sell), are identified by a YHW prefix on their ID card and are referred to as Horizon Contemporary Medigap Plans.
We offer the following Horizon Contemporary Medigap Plans:
- Plan A
- Plan C – ages 50 to 64
- Plan C – age 65+
- Plan C – under age 50
- Plan F
- Plan G
- Plan K
- Plan N
For more information about Horizon Contemporary Medigap Plans, visit HorizonBlue.com/medicare.
Horizon Contemporary Medigap Plans are the only Medigap plans we offer for sale. For members enrolled in one of our existing Medigap plans (see below), there will be no change in benefits. However, members may choose to enroll in one of the new Horizon Contemporary Medigap Plans, as long as they meet the requirements for that new plan.
- Horizon Medigap Plans A
- Horizon Medigap Plan C only available to beneficiaries who turned 65 prior to January 1, 2020
- Horizon Medigap Plan F
- Horizon Medigap Basic Plan I
- Horizon Medigap Plan I with Rx
- Horizon Medigap Plan J
- BCBSNJ 65
- BCBSNJ 65 Select
- Super 65
Members enrolled in the above Mediare Supplementary plans are identified by a YHR prefix on their ID card.
Medicare Supplementary plans include a pre-existing condition clause. Under this clause, claims for certain members, may be subject to review.
A pre-existing condition is an illness or injury, whether physical or mental, which manifests itself in the six months before a covered person’s enrollment date, and for which medical advice, diagnosis, care or treatment would have been recommended or received in the six months before his/her enrollment date.
The restriction could remain on the member’s policy as noted below unless a Certificate of Creditable Coverage (COCC) is provided. (A COCC, or a letter from a previous carrier on that carrier’s letterhead indicating the effective and terminating dates of coverage, will nullify or reduce the pre-existing wait period.)
- For beneficiaries age 65 and over, the pre- existing condition limitation waiting period is six months from the date of enrollment.
- For beneficiaries under age 65, the pre-existing condition limitation waiting period is three months from the date of enrollment.
- The pre-existing condition limitation does not apply to individuals who meet the Guarantee Issue Eligibility requirements.
A six-month pre-existing condition limitation applies to an individual’s coverage in the following situations:
- Eligible individuals who apply prior to or during their MSOEP; and
- Eligible individuals who do not qualify for Guaranteed Acceptance but meet underwriting criteria.
The pre-existing condition limitation may be reduced or eliminated by an individual’s prior coverage.
Based on the member’s pre-existing limitation clause under the benefit plan, review of claims in excess of $10,000.00 will be conducted to determine if a pre-existing condition exists. If a pre-existing condition exists, the member will be responsible for payment of services rendered.
Medicare Part D
We also offer Medicare Part D Prescription Drug coverage to our members who have Original Medicare as their primary insurance coverage.