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Inquiries, Complaints and Appeals

Horizon's goal is to provide prompt responses to your inquiries and timely resolution of complaints. To help you with such issues, you are encouraged to use our IVR system or to speak with a Provider Services Representative by calling 1-800-624-1110, weekdays, between 8 a.m. and 5 p.m., ET.

PROVIDER INQUIRIES

An inquiry is a verbal or written request for administrative action or information, or an expression of opinion or comment regarding any aspect of Horizon's (or its subsidiaries' or affiliates') health care plans, or those of its Administrative Service Only (ASO) accounts1.

Examples of inquiries include, but are not limited to, questions regarding eligibility of members, benefits or a particular claim's status.

To speed our ability to assign, investigate and resolve your inquiries, please complete and submit our Inquiry Request and Adjustment Form (579).

Certain ASO accounts handle inquiries and complaints related to their self-insured plans. In such cases, Horizon will refer you to the proper person or office for you to pursue your inquiry or complaint.

PROVIDER COMPLAINTS

A complaint is a verbal or written expression of dissatisfaction made by a physician or other health care professional, on his/her own behalf, regarding any aspect of Horizon's (or its subsidiaries' or affiliates') health care plans, or the plans of its ASO accounts, including Horizon's administration of those plans generally or with respect to a specific action or decision made or taken by Horizon BCBSNJ in connection with any of those health care plans.

Examples of complaints include, but are not limited to:

Administrative difficulties
Claims issues
Credentialing

Complaints relating to claims may typically involve:

Contract benefit issues
CPT-4 code inconsistencies
Incorrect coding
Reimbursement disagreements
Rebundling of charges

Complaints do not include issues related to specific utilization management determinations. The process for challenging utilization management determinations is described later in this section.

No physician or other health care professional who exercises the right to file a complaint shall be subject to any sanction, disaffiliation and termination or otherwise penalized solely due to such action.

You may submit complaints in writing, to:

Horizon BCBSNJ Provider Services
PO Box 199
Newark, NJ 07101-0199

TIME LIMITS FOR INQUIRY OR COMPLAINT FILING

You may submit a written or verbal complaint within 18 months from the date of Horizon's decision or action with which you are dissatisfied. There is an 18-month time limit for all claim adjustments from the date of Horizon's decision.

There is no time limit for you to make an inquiry, with the exception that an inquiry related to a specific claim cannot be made beyond the longer of the timely claims filing time period requirement within your contract or the relevant member or covered person's underlying benefits contract.

There is also no limit applicable for the filing of a complaint relating to matters in general with which you are dissatisfied that do not involve a specific decision or action taken by Horizon BCBSNJ.

RESOLVING YOUR INQUIRIES AND COMPLAINTS

Horizon will attempt to address your inquiries and complaints immediately, whenever possible. Inquiries and complaints will typically be responded to no later than 30 days from Horizon's receipt.

If an inquiry or complaint involves urgent or emergent care issues, responses are expedited consistent with the circumstances and patient need involved. Our final response will describe what further rights you may have concerning the matter in question.

Those who remain dissatisfied with the outcome of their inquiries and complaints at the conclusion of the internal inquiry and complaint process have the right to contact the following state agency:

Department of Banking and Insurance Consumer Protection Services
PO Box 329
Trenton, NJ 08625-0329
1-888-393-1062

WHAT IS AN HCAPPA CLAIM APPEAL?

A claim appeal is a written request made by a physician or other health care professional asking for a formal review by Horizon of a dispute relating to the reimbursement of claims. This includes, but is not limited to, a request for a formal review of a Horizon Claim Payment Determination described as follows.

PROVIDER CLAIM REIMBURSEMENT APPEAL PROCESS

The Health Claims Authorization, Processing and Payment Act (HCAPPA) affects only insured products offered by Horizon BCBSNJ and its subsidiaries. The law does not apply to Administrative Services Only (ASO) plans, the New Jersey State Health Benefits Program (SHBP) and School Employees' Health Benefits Program (SEHBP) and federal programs, including Federal Employee Program® (FEP®) and Medicare.

If your complaint involves a specific Claim Payment Determination that relates to your treatment of an insured member, written appeals must be initiated on the New Jersey Department of Banking and Insurance's (DOBI) required form on or before 90 calendar days following receipt of the health insurer's claim determination.

Use the DOBI form, the Application for Independent Health Care Appeals Program. This form may also be found on state.nj.us/dobi.

You should include all pertinent information and documents necessary to explain your position on why you dispute the health insurer's determination of the claim.

Claim appeals for medical services* should be mailed to:

Horizon BCBSNJ Appeals Department
PO Box 10129
Newark, NJ 07101-3129

The HCAPPA appeal process is not the correct process for medical necessity determinations. Medical necessity determination disputes should be appealed through the Independent Health Care Appeals Program (IHCAP).

A health insurer is required by law to make a determination (either favorable or unfavorable) and notify the physician or other health care professional of its decision on or before 30 calendar days following its receipt of the appeal form.

If a favorable determination is made for the physician or other health care professional, the health insurer must make payment within 30 calendar days of notification of the appeal determination together with any applicable prompt pay interest, which shall accrue from the date the appeal was received.
If an unfavorable determination is made for the physician or other health care professional, the health insurer must provide the physician or other health care professional instructions for referral to external arbitration.

If you are not notified of the determination timely, or disagree with the final decision, youmay refer the dispute to external arbitration.

WHAT IS AN HCAPPA CLAIM PAYMENT DETERMINATION?

A claim payment determination is Horizon's decision on a submitted claim or a claims-related inquiry or complaint. Claim payment determinations may involve recurring payments, such as a base monthly capitation payment made to a participating physician or other health care professional pursuant to the terms of the contract.

A claim dispute that concerns a utilization management determination, where the services in question are reviewed against specific guidelines for medical necessity or appropriateness to determine coverage under the benefits plan, may not be appealed under this process. These decisions are considered adverse utilization management determinations and follow a different process.

HCAPPA EXTERNAL APPEALS ARBITRATION

The New Jersey Department of Banking and Insurance (DOBI) awarded the independent arbitration organization contract to MAXIMUS, Inc.

Parties with claims eligible for arbitration may complete an application and submit it, together with required review and arbitration fees, directly to MAXIMUS, Inc. External appeals are not submitted through Horizon BCBSNJ.

Visit njpicpa.maximus.com for additional information and applications.

Physicians and other health care professionals must initiate a request for an external appeal of their claim within 90 calendar days of their receipt of the health insurer's internal appeal decision.

However, to be eligible for this second level arbitration appeals process, disputes must be in the amount of $1,000 or more. Physicians and other health care professionals may aggregate claims (by carrier and covered person or by carrier and CPT code) to reach the $1,000 minimum.

The independent arbitrator's decision must be issued on or before 30 calendar days following receipt of the required documentation.

The decision of the independent arbitrator is binding.

Payment must be issued within 10 business days of the arbitrator's decision.

PROVIDER CLAIM PAYMENT APPEAL PROCESS: THIRD-PARTY REPRESENTATION

Participating and nonparticipating physicians and other health care professionals may wish to use the services of a third-party organization or service to file a claim appeal on their behalf. If so, Horizon BCBSNJ has specific requirements that must be met to safeguard the patient health information entrusted to us by our members or covered persons.

Call Provider Services at 1-800-624-1110 for more details.

INQUIRIES, COMPLAINTS AND APPEALS ON BEHALF OF MEMBERS

Horizon offers complaint and appeal processes for members/covered persons.

These member-based processes relate to our utilization management decision-making, as well as all other non-utilization management issues. As with our physician-based processes, these processes are designed to handle our members' or covered persons' concerns in a timely manner.

Our members may seek your help in pursuing an inquiry, complaint or appeal on their behalf. You must obtain the patients' consent to appeal on their behalf.

NONUTILIZATION MANAGEMENT MEMBER INQUIRIES AND COMPLAINTS

Member inquiries and complaints are handled through our Member Services Department at 1-800-355-BLUE (2583), Monday through Wednesday and Friday, between 8 a.m. and 6 p.m., and Thursday, between 9 a.m. and 6 p.m. Eastern Time.

Our Member Services Representative can respond to member inquiries or complaints, or those made by a physician or other health care professional on behalf of a member with their consent. Our service staff is often able to immediately resolve questions at the point of contact.

Inquiries or complaints may also be submitted in writing to:

Horizon BCBSNJ Member Services
PO Box 820
Newark, NJ 07101-0820

Physicians and other health care professionals are reminded that he/she must have the consent of the member before inquiring on their behalf.

Member inquiries and complaints are typically responded to within 15 days from receipt when they involve any claims for a benefit that requires Horizon's approval in advance prior to receipt of services (a pre-service determination), and 30 days from receipt in all other instances (a post-service claim).

If a member inquiry or complaint involves urgent or emergent care issues, responses are expedited consistent with the circumstances and patient need involved.

Our final response will describe what further rights the member may have concerning the matter in question.

FILING AN APPEAL ON BEHALF OF A MEMBER

Prior to receiving services, a covered person or a person designated by the covered person may sign a consent form authorizing a physician or other health care professional acting on the covered person's behalf to appeal a determination by the carrier to deny, reduce or terminate benefits. The consent is valid for all stages of the carrier's informal and formal appeals process and the Independent Health Care Appeals Program.

The covered person has the right to revoke his/her consent at any time.

When appealing on behalf of the member, HCAPPA requires that the physician or health care professional provide the member with notice of the appeal whenever an appeal is initiated and again at each time the appeal is continued to the next stage, including any appeal to the Independent Utilization Review Organization (IURO).

NONUTILIZATION MANAGEMENT DETERMINATION APPEALS

Member Appeals – Requesting an Appeal1

Following the receipt of the complaint determination, in appropriate instances, the member/covered person, or a physician or other health care professional on behalf of, and with the consent of the member or covered person, may request an appeal either orally, in person or by phone or in writing as instructed by Horizon in its complaint determination.

Horizon's written complaint determinations will detail the member's appeal rights. Members are directed to send their appeal requests, whether by phone or in writing, to the appeals unit at the address and phone number supplied.

An Appeals Coordinator investigates the case and collects the information necessary to forward the case to the Appeals Committee.

Within five calendar days of receiving the appeal request, the Appeals Coordinator sends the member/covered person a letter acknowledging the request for appeal, describing the Appeals Committee process and advising of the actual hearing date.

1 Members/covered persons enrolled in certain plans, such as ASO and self-insured accounts, may not have the appeal rights described here.

Resolving the Member's Appeal

Cases are scheduled within five days of receiving the request for an appeal related to a pre-service determination and within 10 days for an appeal related to a post-service claim. Appeals that involve requests for urgent or emergent care may be expedited.

The member/covered person is given the option of attending the hearing in person or via phone conference. The Appeals Coordinator makes the appropriate arrangements.

Members/covered persons, or physicians and other health care professionals on behalf of, and with the consent of, members or covered persons, who participate in the hearing are notified of the Committee's decision verbally, on the day of the hearing, whenever possible. Written confirmation of the decision is sent to the member/or covered person and/or the physician or health care professional who pursued the appeal on their behalf, within two business days of the decision.

Members/covered persons who choose not to appear are notified of the Committee's decision in writing within two business days of the decision.

Appeals are decided within 15 days of receipt for pre-service determinations and 30 days of receipt for post-service claims.

Letters of decision advise members what other remedies may be available to them if they remain dissatisfied with the resolution reached through the internal complaint system.

Expedited Complaints and Appeals

Member complaints and appeals may be expedited if the complaint or appeal involves a request for urgent or emergent care. Horizon reserves the right to decide if the complaint or appeals process should be expedited in instances where the member/covered person or their representative is not a physician.

Expedited complaint review determinations are made as soon as possible, in accordance with the medical urgency of the case, which in no event shall exceed 72 hours.

In cases where an expedited appeal is required, the chairperson of the Appeals Committee will convene an expedited Appeals Subcommittee, which will review the case and render a determination to the appellant within 72 hours, or sooner, if the medical circumstances dictate.

The member/covered person, or the physician or other health care professional acting on behalf of and with the consent of the member/covered person, will be notified of the outcome of the expedited complaint or appeal within 72 hours of receipt of the complaint or appeal.

UTILIZATION MANAGEMENT OR MEDICAL APPEALS

Medical Appeals

Members and physicians and other health care professionals, on behalf of the member and with the member's written consent, generally have the right to pursue an appeal of any adverse benefit determination involving a medical necessity decision made by Horizon BCBSNJ.

An adverse benefit determination involving a medical necessity decision is a decision to deny or limit an admission, service, procedure or extension of stay based on Horizon BCBSNJ's medical necessity criteria. Adverse benefit determinations may usually be appealed up to three times.

Individual consumer plans and some ASO/self-insured plans only allow one level of appeal.1

Members/covered persons enrolled in some plans do not have the appeal rights described here. For example, our Medicare Advantage members follow a different appeal policy, and members/covered persons of certain plans, such as individual consumer, ASO accounts and self-insured accounts, may not have the appeal rights described here.

First Level Medical Appeals

You will be advised how to initiate a first level medical appeal at the time the adverse benefit determination is made.

First level medical appeals are reviewed by our Medical Director or Medical Director's designee. First level urgent and emergent medical appeals are reviewed within 24 hours. Non-emergent medical appeals are reviewed within 10 calendar days.

If the denial is upheld, members, physicians or other health care professionals, on behalf of the member and with the member's written consent, may submit a second level medical appeal.

Second Level Medical Appeals

If a second level medical appeal is received, it is submitted to the Appeals Committee, which is made up of Horizon BCBSNJ Medical Directors and staff, physicians from the community and consumer advocates. The member/covered person is given the option of attending the hearing in person, or via phone conference, and the Appeals Coordinator makes the appropriate arrangements. Appeals that involve requests for urgent or emergent care may be expedited.

Members/covered persons, or physicians and other health care professionals on behalf of and with the written consent of members/covered persons, who participate in the hearing are notified of the Committee's decision verbally by phone on the day of the hearing whenever possible.

Written confirmation of the decision is sent to the member/covered person, and/or the physician or other health care professional who pursued the appeal on their behalf, within five business days of the decision.

Expedited second level medical appeals are decided as soon as possible in accordance with the medical urgency of the case, but will not exceed 72 hours from our receipt of the first level medical appeal request whenever possible.

Standard second level medical appeals involving requests for services, supplies or benefits which require our prior authorization or approval in advance to receive coverage under the Plan are reviewed and decided within 15 calendar days of our receipt.

All other second level medical appeals are decided within 20 business days of our receipt. Second level medical appeals should be mailed to the address provided in the first level medical appeal determination letter or can be verbally requested by calling the phone number listed on the first level

medical appeal determination letter.

Third Level Medical Appeals

If the Appeals Committee upholds the second level medical appeal, the member or the member's physician or other health care professional, acting on behalf of the member and with the member's written consent, may request a third level medical appeal with the Independent Health Care Appeals Program (IHCAP). The Independent Utilization Review Organization (IURO) only considers appeals on denials based on medical necessity. Denials based on contract issues are not reviewed by the IURO. The case will be reviewed by a medical expert under contract with an IURO.

Instructions on how to file with the IURO are included with the denial letter from the second level medical appeal, where applicable. Third level medical appeals must be filed within four months from the receipt of the notice of determination of the second level medical appeal.

The IURO will review the appeal and respond to the member or facility, physician or other health care professional within 45 calendar days.

The IURO decision is binding. Members of certain plans, such as self-funded plans and some Medicare plans, may not appeal to the IURO. Some employers may offer an additional level of appeal.

Appeals Relating to Medicare Members

Medicare Advantage members follow a different appeal policy. For more information visit HorizonBlue.com/medicare.

Speaking with a Medical Director

Our Utilization Management (UM) policy is to always allow the treating or attending physician the opportunity to discuss any utilization management denial determination with the Horizon BCBSNJ reviewing physician who issued the decision.

Each denial determination includes the reviewing physician's name and phone number. Participating physicians can also be connected to that Horizon reviewing physician by calling

1-800-664-BLUE (2583).

UM Protocols and Criteria Available

Horizon makes available to you our individual protocols and criteria that we use to make specific UM decisions on HorizonBlue.com/medicalpolicy.

If you require a printed copy of this information, contact your Network Specialist.