COVID-19

Stay informed. Get the latest information on COVID-19.

Utilization Management

Horizon BCBSNJ’s Utilization Management Program is a coordinated and comprehensive program designed to achieve medically appropriate and cost-effective delivery of health care services to members within the parameters of the benefits available under each member’s benefit contract.

While there is recognition that there is a wide variation of appropriate medical practice, Utilization Management activities are intended to identify optimal modes of practice and, when possible, to help ensure physicians manage care in a medically appropriate and cost-effective manner. We know that underutilization of appropriate services can be as dangerous to our member’s health status and our medical costs as overutilization.

Horizon BCBSNJ adheres to the following principles in the conduct of our Utilization Management Program:

Bases Utilization Management decisions on necessity and appropriateness of care and service within the parameters of the member’s benefit package.
Does not compensate those responsible for making Utilization Management decisions in a manner that encourages them to deny coverage for medically necessary and appropriate covered services.
Does not offer our employees or delegates performing Utilization Management reviews incentives to encourage denials of coverage or service and does not provide financial incentives to physicians and other health care professionals to withhold covered health care services that are medically necessary and appropriate.
Emphasizes the provision of medically necessary and cost-effective delivery of health care services to members and encourages the reporting, investigation and elimination of underutilization.

Horizon BCBSNJ’s Utilization Management Program functions under the HCAPPA definition in much the same way as it has previously (when applicable). Our medical policies and criteria used to help us reach decisions about medical necessity for coverage purposes have been revised for compliance with HCAPPA’s definition standard.

As required by HCAPPA, policies and criteria, information about the processing and reimbursement of claims, and MCG clinical guidelines are available at HorizonBlue.com.

MCG Health’s Care Guidelines (MCG) is used to make behavioral health care coverage determinations for members enrolled inall Horizon BCBSNJ plans.

Horizon BCBSNJ uses American Society of Addiction Medicine (ASAM) criteria when making coverage determinations for services related Substance Use Disorders.

Horizon BCBSNJ will provide the clinical rationale for the determination(s) in the adverse determination letter. In addition, the MCG Care Guidelines used in making the specific determination are available free of charge upon request.

REQUESTING AUTHORIZATION

You must contact Horizon BCBSNJ before rendering services to our members who require prior authorization.

Horizon BCBSNJ accepts requests for authorization for coverage of services from members and/or from providers acting on behalf of the member.

This includes but is not limited to the attending/ordering physician or provider that is requesting the authorization as the member/claimant's authorized representative.

Benefits will always dictate coverage; some services are subject to individual benefit limitations. The individual protocols and criteria that Horizon BCBSNJ uses to render Utilization Management decisions are available upon request.

Authorizations older than six months, in accordance with industry standards, will not be honored by Horizon BCBSNJ and will require a new review of the current clinical circumstances.

Services Requiring Prior Authorization

Providers must contact Horizon BCBSNJ before rendering services or providing supplies to our members who require prior authorization.

Please use our Prior Authorization Procedure Search Tool to determine if services require prior authorization for your Horizon BCBSNJ patients.

Our Prior Authorization Procedure Search tool allows you to enter a CPT® or HCPCS code and select a place of service (e.g., inpatient, outpatient, office, home) to determine if the particular service provided in the selected service setting requires a prior authorization.

This tool can also be accessed on NaviNet by selecting Horizon BCBSNJ on My Health Plans menu, or by visiting HorizonBlue.com/providers and

Clicking Policies & Procedures
Clicking Utilization Management
Clicking Services Requiring Prior Authorization

Note: Our Prior Authorization Procedure Search Tool presently will only display results for insured Horizon BCBSNJ plans. Prior authorization information for members enrolled in self-insured, Administrative Services Only (ASO) plans, Medicare or Medicaid products cannot be accessed through this tool.

The information provided by this tool is not intended to replace or modify the terms, conditions limitations and exclusions contained within health benefit plans issued or administered by Horizon BCBSNJ. In the event a conflict between the information contained on the tool and member plan documents, member plan documents shall prevail.

This application is intended for informational purposes only. The results provided by this tool are not a guarantee of payment. Claim processing is subject to member eligibility and all member and group benefit limitations, conditions and exclusions.

OBTAINING AUTHORIZATION

Physicians and other health care professionals can obtain online authorizations easily and securely for most services using the online Utilization Management Request tool. Log in to NaviNet.net and select Horizon BCBSNHJ from the My Health Plans menu. Mouse over Referrals and Authorization then select Utilization Management Requests.

Using online Utilization Management Request Tool, providers can submit authorization, predetermination and specialty pharmacy requests securely over the Internet using a data entry form that captures pertinent client-defined data. It also allows for early identification of case and disease management candidates, focusing on better health outcomes and lower costs.

The turnaround time for nonurgent prior authorization requests is up to 15 calendar days of receipt. The turnaround time for urgent prior authorization requests is within 72 hours of receipt.

For questions, call the Utilization Management Department at 1-800-664-BLUE (2583).

Note: As a participating physician or other health care professional, it is your responsibility to make sure all authorization procedures are followed. If authorization is needed for services you are referring for or rendering and no authorization is obtained, claim reimbursement may be limited or denied, and if denied, the member may not be billed for the service.

ONLINE AUTHORIZATIONS FOR PT AND OT SERVICES

In most cases, Horizon BCBSNJ authorizes the initial 25 visits of outpatient physical therapy or occupational therapy (PT/OT) services upon receipt of an initial claim from a participating physical therapist or occupational therapist.. Eligibility and benefits must be confirmed prior to providing the service.

A prior authorization must be obtained in the following situations:

Other PT or OT services have already been authorized in the current calendar year.
Diagnosis-related temporomandibuar joint (TMJ) disorders.
Treatment for work-related injuries.
Patients under 19 years of age.
More than 25 visits are required.
All services from nonparticipating providers. Prior authorizations can be requested using our
Physical and Occupational Therapy Authorization tool available on NaviNet.net.

Remember that you still must check member eligibility and benefits by logging on to NaviNet.net prior to treating the patient.

Claims processing and reimbursement for services provided are subject to member eligibility and all member and group benefits, limitations and exclusions.

Note: The PT/OT tool is for the use of rendering physical therapy and occupational therapy providers only. This tool cannot be used to create referrals for physical therapy or occupational therapy services.

Include the CPT-4 procedure codes and the ICD-10 diagnosis codes when you fax the information.

Upon prior review of all routine, nonurgent requests are determined and not to exceed 15 days from our receipt of all required clinical information for commercial plans (14 days for Medicare).

Urgent requests are determined as soon as possible, not to exceed 72 hours from receipt, based on the medical urgency of the case.

If you receive a denial notification for a patient, you may discuss the determination with the physician who rendered the decision. The physician’s name and phone number will be on the denial notification.

Prior Authorization Procedure Search Tool

The tool, as well as certain prior authorization lists for ASO member groups, is accessible on HorizonBlue.com/priorauthtool.

To determine if a patient is fully insured or part of an ASO member group, refer to the back of the member’s ID card.

Fully-insured members’ cards will state: “Insured by Horizon Blue Cross Blue Shield of New Jersey.” ASO members’ cards will state: “Horizon Blue Cross Blue Shield of New Jersey provides administrative services only and does not assume financial risk for claims.”

TIME FRAMES FOR AUTHORIZATION/ ADDITIONAL INFORMATION REQUESTS

Horizon BCBSNJ follows HCAPPA-mandated time frames, where applicable, when responding to requests for authorization or when requesting additional information from a physician, facility or other health care professional.¹

HCAPPA mandates that health insurers respond to requests for authorizations as soon as possible but not greater than 72 hours. Hours for current urgent care situations including inpatient admissions and within 15 calendar days for elective inpatient or outpatient services. However, Horizon BCBSNJ does not require prior authorization for emergency services and, therefore, our practices relating to emergency services have not changed as a result of HCAPPA.

Generally, all nonemergent inpatient admissions and some outpatient services require an authorization. For urgent admissions, HCAPPA requires that the hospital, physician or other health care professional respond to our request for additional information within 72 hours.

The law provides that if a hospital, physician or other health care professional does not respond within this time frame, the original authorization request within the HCAPPA time frame will be deemed withdrawn.

Conversely, if Horizon BCBSNJ fails to respond timely to an authorization request, it is deemed an approval of the request.

¹Members/covered persons enrolled in certain plans are not affected by HCAPPA and their authorization/additional information time frames may vary from what is described here. For example, authorization/additional information time frames for members/covered persons of certain plans such as ASO andself-insured accounts may vary from what is described here.

HONORING OTHER CARRIERS’ AUTHORIZATION

Under HCAPPA (where it applies), in the event a member is no longer eligible for coverage from Horizon BCBSNJ and Horizon BCBSNJ issued an authorization, the member’s subsequent health insurer must honor the authorization.²

However, HCAPPA also provides that the subsequent health insurer does not need to honor the authorization if the service is not covered under the member’s benefits contract with the subsequent health insurer.

In instances where Horizon BCBSNJ is the subsequent carrier, Horizon BCBSNJ will request adequate proof of the prior carrier’s authorization, and that it was obtained based on an accurate disclosure of te relevant medical facts and circumstances involved in the case.

Upon validation, Horizon BCBSNJ will honor the prior carrier’s authorization. However, in accordance with industry standards, authorizations more than six months old will not be honored by Horizon BCBSNJ and will require a new review of the current clinical circumstances.

²Members/covered persons enrolled in certain plans, such as ASO and self-insured accounts, are not affected by HCAPPA and their authorization information may not be honored by the subsequent carrier.

HORIZON CARE@HOME PROGRAM SERVICES

Horizon BCBSNJ is committed to providing our members with access to high-quality home health care services. As part of that commitment, Horizon BCBSNJ collaborates with CareCentrix¹, a home health benefits management company, to administer certain services for the Horizon Care@Home program.

CareCentrix credentials, manages and maintains the Horizon Care@Home network of ancillary services providers, arranges for delivery and conducts the utilization management for these Horizon Care@Home services:

Durable medical equipment (including medical foods [enteral], and diabetic and other medical supplies)
Orthotics and prosthetics
Home infusion therapy services, including hemophilia

Traditional home health (including in-home nursing services, physical therapy, occupational therapy and speech therapy) is managed by Horizon BCBSNJ.

¹Horizon BCBSNJ contracts with CareCentrix, Inc., a Delaware corporation and its subsidiary, CareCentrix of New Jersey, Inc., a New Jersey Corporation licensed by the NJ Department of Banking and Insurance as an Organized Delivery System toadminister certain services for the Horizon Care@Home program.

Prior Authorization/Pre-Service Registration

CareCentrix is responsible for ensuring certain Horizon Care@Home services are medically necessary and appropriate through its utilization management activities, including:

Durable medical equipment (including medical foods [enteral], and diabetic and other medical supplies)
Orthotics and prosthetics
Home infusion therapy
Diabetic and other medical supplies. For home health services (including in-home nursing services, physical therapy, occupational therapy and speech therapy), you must obtain prior authorization using Horizon BCBSNJ’s online utilization management request tool via NaviNet.

Rendering Providers

Participating Horizon Care@Home ancillary services providers of home care services are required to complete a pre-service registration for certain services, including:

Durable medical equipment (including medical foods [enteral], and diabetic and other medical supplies)
Orthotics and prosthetics
Home infusion therapy, including hemophilia

Registrations can easily be submitted by calling CareCentrix at 1-855-243-3324 between 8 a.m. and 6 p.m., Eastern Time. When you refer a patient to a participating Horizon Care@Home ancillary services provider, that rendering provider will work with CareCentrix to ensure that the appropriate prior authorization/pre-service registration is performed.

Referring/Ordering Providers

Physicians, other health care professionals, hospital discharge planners and case managers may initiate a prior authorization/pre-service registration by calling CareCentrix at 1-855-243-3321 between

8 a.m. and 6 p.m. (ET) for:

Durable medical equipment (including medical foods [enteral], and diabetic and other medical supplies)
Orthotics and prosthetics
Home infusion therapy
Diabetic and other medical supplies

You may also call CareCentrix at 1-855-243-3321 to find a Horizon Care@Home participating ancillary services provider.

For home health services (including in-home nursing services, physical therapy, occupational therapy and speech therapy), you must obtain prior authorization using Horizon BCBSNJ's online utilization management request tool via NaviNet.

As part of the review of a request for home care services to be provided, Horizon BCBSNJ or CareCentrix may contact your office for information required to conduct/complete their review.

Members with BlueCard Coverage

As a reminder, you have the ability through NaviNet to access the online prior authorization tools of other Blue Plans to review/initiate prior authorizations online for BlueCard members.

Members with BlueCard coverage who are enrolled through another Blue Cross and/or Blue Shield Plan and are receiving care in New Jersey would access in-network home care services through a participating Horizon Care@Home provider; however, prior authorization requirements may vary based on the member’s benefits. Log in to NaviNet.net and:

Mouse over Referrals and Authorization.
Select Pre-Service Review for Out-of-Area Members.
Home infusion therapy
Diabetic and other medical supplies

After entering the member’s alpha prefix, you’ll be routed to the member’s Home Plan. You can then follow the prompts to review a member’s pre-service authorization requirements as well as submit a prior authorization request, if necessary.

Find a Provider

Participating Horizon Care@Home providers may be located by visiting our Online Doctor & Hospital

Finder. Select Other Healthcare Services from the What are you looking for? dropdown menu. Choose one of the services from the Service Type dropdown menu, select a plan and click Search.

Online listings of Horizon Care@Home providers who provide home health services, including in-home nursing services, physical therapy, occupational therapy and speech therapy, will include the provider’s physical address and phone number. If you provide these services and are interested in participating in the Horizon Care@Home program, call 1-800-624-1110.

Online listings of Horizon Care@Home providers who provide services for Durable Medical Equipment (DME), including medical foods (enteral), and diabetic and other medical supplies); orthotics and prosthetics (O&P) and home infusion therapy (HIT) services, including hemophilia, include the provider’s actual physical address, but display CareCentrix’s phone number, 1-855-243- 3321.

If you provide these services and are interested in participating in the Horizon Care@Home program, call CareCentrix at 1-855-243-3324 for information between 8 a.m. to 6 p.m., ET.

About Nonparticipating Home Health Care Service Providers

We remind participating physicians and other health care professionals that you are required to adhere to our Out-of-Network Referral Policy. This policy requires that you, whenever possible, refer Horizon BCBSNJ members to participating providers (including participating ancillary services providers) unless the member has, and wishes to use, his or her out-of-network benefits, understands that a much greater member financial liability may be involved and signs a completed copy of our Out-of-Network Consent Form.

Participating physicians and other health care professionals who do not comply with our

Out-of-Network Referral Policy will be at risk of an audit regarding their compliance with Horizon BCBSNJ policies and procedures.

To access our Out-of-Network Referral Policy, registered NaviNet users affiliated with participating practices should log on to NaviNet.net, select Horizon BCBSNJ within the My Health Plans menu and:

Select Provider Reference Materials.
Mouse over Policies & Procedures.
Select Policies, then Administrative Policies.
Select Out-of-Network Referral Policy.

Please note that prior authorization requirements still apply (for home health care services that require prior authorization) to services provided by a home health care provider that is not participating in the Horizon Care@Home program.

Home Infusion Therapy

Magellan Rx Management and CareCentrix will have shared responsibilities for certain medical injectable drugs subject to the Horizon BCBSNJ Medical Injectables Program depending upon where they will be administered, as follows:

For medical injectable drugs that are to be administered in the patient’s home by a participating Horizon Care@Home ancillary service provider, please initiate a pre-service registration with CareCentrix.
For medical injectable drugs that are to be administered at a freestanding or hospital- based dialysis center, in an outpatient facility or in a doctor’s office, please continue to contact Magellan Rx Management to initiate a medical necessity and appropriateness review.

For more information, visit HorizonBlue.com/hcah.

PROGRAMS ADMINISTERED BY EVICORE HEALTHCARE

Horizon BCBSNJ contracts with eviCore healthcare, to manage nonemergency radiology services, Advanced Imaging Services (MRI, CT, PET Scans, Nuclear Medicine including Nuclear Cardiology), cardiac imaging services, radiation therapy and pain management services provided to members enrolled in many of the plans we offer.

eviCore healthcare helps ensure that medically necessary and appropriate services are provided to our members. eviCore healthcare also provides clinical consultation and support to participating physicians and other health care professionals. They help in scheduling radiology/imaging services for our members.

For more information, including impacted services, medical criteria and FAQs, click here.

MEDICAL INJECTABLES PROGRAM (MIP)

Horizon BCBSNJ is committed to providing our members with access to high-quality health care that is consistent with nationally recognized clinical criteria and guidelines. As part of that commitment, we collaborate with a specialty pharmaceutical management company, Magellan Rx Management, to administer our Medical Injectables Program (MIP). Magellan Rx Management (MRxM) conducts medical necessity and appropriateness reviews (MNARs) for specific injectable medications.

MRxM conducts reviews of injectable medications administered:

At a freestanding or hospital-based dialysis center
In an outpatient facility.
In a patient’s home*
In a physician’s office
MRxM will not perform MNARs on injectable medications administered
During an inpatient stay,
In an observation room, or
In an Emergency Room

For more information, including an in-depth FAQ, click here.

Magellan Rx Management Contact Information

Visit IH.MagellanRx.com or call MRxM at 1-800-424-4508.

Medical Injectables

We require the review of certain injectable medications to ensure that these medications are administered within our Medical Policy criteria and guidelines as well as to improve quality of care and patient safety.

The list of injectable medications that require review is available on HorizonBlue.com/mip.

UM Determinations

UM Decisions

Prior authorization decisions will be made as soon as possible and in accordance with applicable law, rules, regulations and accreditation standards. The turnaround time for non-urgent prior authorization requests (measured from the receipt of the request to decision [approval/denial] notification) is up to 14 calendar days of receipt. The turnaround time for urgent prior authorization requests is within 72 hours of receipt.

If additional information is needed to make a decision, the request may be pended or denied for lack of clinical information to support the request consistent with applicable law and accreditation standards.

Following approval, an authorization/approval is generated and faxed (or made viewable via the CareCentrix Portal) to the servicing/requesting Horizon Care@Home program participating provider.

For Medicare Advantage members, copies of the approval are also mailed to the patient and referring physician.

Adverse Determinations

An adverse determination of a prior authorization request is a decision that the requested services will not be covered based on a determination that the services are not deemed to be medically necessary, are not a covered service or are not covered based on other factors as described by CareCentrix in their adverse determination letter or otherwise communicated. Any adverse determination of a prior authorization request based on medical judgment will be made by a board certified/board eligible licensed physician, operating with an active, unrestricted license.

An adverse determination will be communicated to the requesting physician verbally or in writing, and to the member in writing, and include at least:

the clinical rationale and reason(s) for the determination;
instructions for arranging peer-to-peer discussion with the licensed physician who made the determination (provided such discussion has not already occurred, in which case the communication of denial shall indicate that such a peer to peer discussion has already taken place);
instructions for requesting a written statement of the clinical rationale for the denial, including the clinical review criteria used in making the determination, if such is not included in the adverse determination notice;
instructions for appealing the denial to Horizon BCBSNJ or CareCentrix, as appropriate and peer matched reviewer/advisor information if one was used to review the case; and
all other required content under all applicable laws, rules and regulations.

Claim Processing & Billing through the Horizon Care@Home program

CareCentrix will submit claims to Horizon BCBSNJ on behalf of their Horizon Care@Home program participating providers.

Following our adjudication and payment of a claim, CareCentrix:

Will collect any member cost-sharing responsibility owed.
Provides reimbursement to the individual Horizon Care@Home program participating provider (at their contracted rate with CareCentrix) for services rendered or supplies provided.

Members with BlueCard Benefits

Based on Blue Cross and Blue Shield Association (BCBSA) DME claim submission guidelines, DME claims must be submitted to the Blue Cross Blue Shield plan in the state where the item is delivered. If a DME item is not delivered, the claim must be submitted to the Blue Cross Blue Shield plan in the state where the item is purchased.

Use of nonparticipating home health care service providers

The member has, and wishes to use, his or her out-of-network benefits;
Understands that a much greater member financial liability may be involved; and
Signs a completed copy of our Out-of- Network Consent Form.

To access our Out-of-Network Referral Policy, registered NaviNet users affiliated with participating practices should log on to NaviNet.net, access the Horizon BCBSNJ from the My Health Plans menu, and:

Select Provider Reference Materials.
Mouse over Policies & Procedures.
Select Policies, then Administrative Policies.
Select Out-of-Network Referral Policy.

Participating physicians and other health care professionals who do not comply with our

Out of Network Referral Policy will be at risk of an audit regarding their compliance with Horizon BCBSNJ policies and procedures.

AIM SPECIALTY HEALTH

Certain self-insured employer group health plans administered by Horizon BCBSNJ offer an integrated advanced imaging and sleep management program for their members.

Horizon BCBSNJ has contracted with AIM Specialty Health® to provide evidence-based clinical guidelines for elective, outpatient CT, MRI, nuclear cardiology, PET, echocardiography exams and sleep management exams for educational and quality purposes. This is not a formal utilization management program.

Imaging studies performed in conjunction with emergency room services, inpatient hospitalization, outpatient surgery (hospitals and free-standing surgery centers), urgent care centers or 24-hour observations are not included in this program.

The goal of this program is to provide you and certain Horizon BCBSNJ members with information to make informed choices. The program could mean significant savings for impacted members who have coinsurance plans and pay a percentage of costs out of pocket.

This Horizon BCBSNJ program through AIM Specialty Health is applicable only to beneficiaries enrolled in certain National Account self-insured groups. It does not replace our existing programs with eviCore healthcare, which serve the majority of our insured membership, including the New Jersey State Health Benefits Program (SHBP).

For more information, including that about the AIM Specialty Health Musculoskeletal Program, access our AIM webpage.

SURGICAL AND IMPLANTABLE DEVICE MANAGEMENT PROGRAM

Horizon BCBSNJ collaborates with TurningPoint Healthcare Solutions, LLC (TurningPoint) to administer ourSurgical and Implantable Device Management Program.

As part of this program, TurningPoint conducts Prior Authorization & Medical Necessity Determination (PA/MND) reviews of certain Orthopedic services, Cardiac Services and Spinal/Pain Services (many of which include implantable devices), and other related services, requested by participating and nonparticipating physicians.

View more information about this program, including a full listing of the procedures/impacted services and CPT codes that are subject to PA/MND review under this program on HorizonBlue.com/turningpoint.