Horizon Pulse Provider Newsletter

Horizon Pulse June 2023

  • We encourage the delivery of integrated health care and helping your patients find the resources they need to address their behavioral health. To help you identify available behavioral health outpatient providers, visit our directory.

    How to find a behavioral health provider using our directory:

    • Search for the type of care/provider the patient is looking for (either behavioral health practitioner or behavioral health facility).
    • Select the patient's Horizon plan type, enter their city or ZIP code, and then click “Find.”
    • To locate facility-based outpatient clinics, select the behavioral health facility option.
    • Then, in the “other healthcare services name” field, select either “Outpatient Psych Facility” or “Substance Use Disorder Outpatient.”

    Our Horizon Behavioral Health team is here to help your patients get the treatment and care they need. Our team can assist patients in accessing urgent/virtual care, and in finding an in-network behavioral health professional or treatment facility. If your patient needs help, our dedicated care team is available 24/7 by calling 1-800-626-2212.

    Below is a list of external behavioral health resources for your patients who may need assistance.

    Wellness and Recovery-oriented Support Services

    Collaborative Support Programs of New Jersey
    Housing, financial and employment support
    Phone: 1-732-780-1175 (TTY 711)
    Fax: 1-732-780-8977

    National Alliance on Mental Illness (NAMI)
    Support, education and advocacy
    Phone: 1-732-940-0991 (TTY 711)
    Email: info@naminj.org

    New Jersey Children's System of Care (Perform Care®)
    Assistance for families with behavioral health challenges

    Phone: 1-877-652-7624 (TTY 711)

    The Quell Foundation
    Counseling and social work
    Email: liftthemask@thequellfoundation.org

    New Jersey's youth helpline; helps youth ages 10 to 24 find solutions to the problems they face at home or school
    Phone: 1-888-222-2228 (TTY 711)

    Depression and Suicide

    National Suicide Prevention Lifeline 24/7
    English 1-800-273-8255
    Spanish 1-888-628-9454
    TTY 711, then 1-800-273-8255
    (Additional access to online chat)

    National Crisis Text Line 24/7
    Text HOME to 741741
    (Available links to text, connect with Facebook or WhatsApp)

    New Jersey Suicide Prevention Hopeline
    24/7 Support
    Phone: 1-855-NJ-HOPELINE (1-855-654-6735) (TTY 711)
    (Available links to chat, text and phone)

    Eating Disorders

    National Eating Disorders Association
    Call or text: 1-800-931-2237 (TTY 711)

    Eating Disorder Referral and Information Center
    (Directory service and information on eating disorders)

    Rape, Abuse, Incest, Domestic Violence

    RAINN: National Sexual Assault Hotline
    Confidential 24/7 support
    Phone: 1-800-656-4673 (TTY 711)
    Chat online: online.rainn.org

    National Domestic Violence Hotline
    Phone: 1-800-799-7233 (TTY 711)


    Garden State Equality
    Anti-bullying hotline
    Phone: 1-973-509-5428 (TTY 711)

  • Care Coordination is a process of organizing and coordinating health care services and resources across multiple providers, settings and timeframes to ensure that patients receive comprehensive and patient-centered care.

    Consider that current health care systems are often disjointed, and processes vary between primary care and specialty sites. Patents are often unclear about why they are being referred from a primary care provider (PCP) to a specialty care provider (SCP), how to make appointments, and what to do after seeing a specialist.

    The SCPs do not consistently receive clear reasons for the referral or adequate information on tests that have already been done. Likewise, PCPs often do not receive information about what happened in a referral visit.

    Care coordination between the SCP and the PCP is a critical component of safe, efficient and patient-centered care, and research consistently shows that when services are coordinated, patients are more likely to receive timely, appropriate and effective care, leading to better health outcomes.

    Here are some industry standard best practices:

    • Engage patients in their care and educate them about their health conditions and treatment options.
    • Implement pre-visit planning to ensure all screening and test results are received before the patient's appointment.
    • Encourage the patient to provide updates at each visit regarding any new medications or care they received from any health care provider or facility since the last visit.
    • Discuss any specialist referral with the patient, including the reason, the type of referral and the selection of the specialist. Provide this in writing and assist the patient in scheduling specialist visits if needed.
    • Consider a “Care Service Agreement” which can outline a process for patient referral expectations between PCP and SCP. Key issues include:
      • How to access the specialist in a timely manner.
      • What information each party should provide.
      • Who is responsible for which parts of a patient's care.
    • Use technology to help manage care, such as your electronic health record (EHR), telemedicine and patient portals.
  • As health care providers, you know that collaboration and communication are essential to providing the best possible care to your patients. This is especially true for patients receiving both physical and behavioral health treatment, where coordination between providers is critical for optimal care outcomes.

    In our annual Behavioral Health Office Manager Satisfaction Study, we surveyed providers to gain insight into the frequency, sufficiency and timeliness of communication between behavioral health providers and the patients' Primary Care Providers (PCPs) or other medical specialists. The results of the survey offer valuable information that can help us improve the quality of care we provide to our patients.

    Looking at the results

    First, we found that 88 percent of surveyed behavioral health providers obtain member consent to share information with other providers. This is a crucial step in ensuring that patient information is shared appropriately and that all providers have the necessary information to make informed treatment decisions.

    However, we also found that only 51 percent of surveyed providers request information related to member treatment from other providers. This suggests that there may be missed opportunities for collaboration and that providers are not accessing all the information they need to provide comprehensive care.

    When providers receive information from other providers, the overwhelming majority (92 percent) reported that the information provided is sufficient for treatment and provision of care. This is encouraging and suggests that when providers collaborate and communicate effectively, patients receive high-quality care.

    The survey also looked at the frequency of communication between providers. We asked providers how often they exchange information with other providers in various situations, such as a significant change in treatment plan or when initiating new medications. The results showed that there is room for improvement in this area, with only 20 percent of providers reporting that they always exchange information in the case of a significant change in treatment plan.

    Improving the Communications

    In summary, our survey results indicate that there is room for improvement in the frequency and sufficiency of communication between behavioral health providers and other medical specialists. By prioritizing communication and collaboration and using available resources and technology to facilitate information exchange, you can provide your patients with the highest quality of care.

    To improve the frequency and sufficiency of communication between you and other health care providers, we encourage you to consider the following strategies:

    • Discuss the importance of communication and collaboration with your patient's PCP and other health care providers involved in your patient's care;
    • Obtain a signed authorization from your patient, allowing exchange of information between you and other health care providers involved in the member's care;
    • Utilize available resources and technology to facilitate information exchange, such as electronic health records and secure messaging; and
    • Communicate with your patient's PCP and other providers on a regular basis, particularly in the following points in treatment:
      • Initial evaluation
      • Critical changes in diagnosis or treatment
      • Medication adjustments
      • Discharge treatment plan

    By prioritizing communication and collaboration, we can ensure that all providers involved in the patient's care have the necessary information to make informed treatment decisions and that your patients receive high quality comprehensive care. Thank you for your ongoing commitment to improving patient outcomes and ensuring that your patients receive the best possible care.

  • While treating adults and children with antipsychotic medications, it is important to remember that these patients experience higher rates of metabolic health issues.

    The National Institutes of Health estimates that people with schizophrenia are between two to five times more likely to develop type 2 diabetes than the general population. Patients with mental illness often have higher incidence of poor cardiovascular risk factors, including smoking and sedentary lifestyles.

    The National Committee for Quality Assurance (NCQA) recognizes the importance of screening and monitoring for metabolic health complications in patients with mental health and medical issues. Data is collected for multiple Healthcare Effectiveness Data Information Set (HEDIS) measures:

    Diabetes screening for people with schizophrenia or bipolar disorder using antipsychotics (SSD): Assesses members age 18 to 64 with schizophrenia, schizoaffective disorder or bipolar disorder who were dispensed an antipsychotic medication and had a diabetes screening test (glucose or HbA1c) during the measurement year.

    Diabetes monitoring for people with diabetes and schizophrenia (SMD): Examines the percentage of members age 18 to 64 with schizophrenia or schizoaffective disorder and diabetes who had both an LDL-C test and an HbA1c test during the measurement year.

    Cardiovascular monitoring for people with cardiovascular disease and schizophrenia (SMC): Assesses adults age 18 to 64 with schizophrenia and cardiovascular disease who had an LDL-C test during the measurement year.

    Metabolic monitoring for children and adolescents on antipsychotics (APM): Examines children and adolescents age 1 to 17 who had two or more antipsychotic prescriptions and complete metabolic testing for Glucose or HbA1c lab test, LDL-C or cholesterol lab test, and members who receive both tests.

    For assistance from Horizon's Behavioral Health HEDIS Team, email BH_HEDISteam@HorizonBlue.com.

  • The Health Outcome Survey (HOS) is an annual survey administered by the Centers for Medicare and Medicaid Services (CMS) to assess the health status and quality of life of Medicare beneficiaries.

    The HOS measures several key areas of health and well-being, including physical and emotional health as well as general health perceptions. Medicare Advantage patients are asked questions about things like their risk of falling, urinary incontinence, monitoring of their physical activity, and other topics related to their physical and mental health.

    The survey information will help identify a patient's overall health status and quality of life and help providers track changes in a patient's health status over time to evaluate the effectiveness of treatments or interventions.

    Here are some best practice recommendations:

    • Provide a welcoming, safe and non-judgmental environment so your patients feel comfortable talking about their health concerns with you.
    • Normalize discussing health concerns; let patients know discussing health concerns is a normal part of the doctor-patient relationship.
    • Encourage questions and provide clear and concise answers so patients feel more informed and empowered to take control of their health.

    We encourage you to learn more information about the HOS Survey and how you can drive results.

  • Patient portals (PPs) can engage and empower patients in their health care, especially when they have chronic health conditions. Moreover, using this technology can improve care by enhancing patient engagement, improving communication, increasing adherence to treatment plans, and improving the efficiency of health care delivery.

    Even though older adults are the primary consumers of health care services, their use of a patient portal has been overlooked as they are assumed to be non-technology users. While it's true that their use is lower than the general population, their access to necessary technologies is rapidly increasing and it's currently estimated that about 50 percent of seniors have access to broadband.

    Here are just a few ways in which a provider can support an older patient's portal use:

    • Promote your portal and discuss its many benefits, including how they can communicate with you directly and where they can get their test results quicker.
    • Be prepared to assist your patients with a portal orientation, e.g., have a dedicated practice member offer a tutorial on how to sign in and perform simple or more complex tasks depending on the patient's skill set and interests. You can also create a reference document with instructions they can follow at home.
    • Some older patients still prefer the phone, so offer the portal as a complement to this option and not as a substitute.

    In summary, many older adults actively use patient portals and value their helpful functions, and many more may be willing to use this technology with some targeted support and guidance.

  • As part of our program for continuous quality improvement, we monitor the medical record-keeping and office standards from a random selection of our Primary Care Provider (PCP) network. This annual medical record review (MRR) is conducted for adult and pediatric members. Additionally, Early and Periodic Screening, Diagnostic and Treatment(EPSDT) standards are audited for pediatric members over the age of 21.

    For measurement year 2021 (2022 audit), several areas scored below the 90 percent threshold and the following areas present opportunities for improvement:

    MRR standards below 90 percent:

    • Evidence that Advance Directives were discussed or on file for members over the age of 18
    • Documentation that the member was evaluated for smoking, alcohol and substance use and referred for treatment when appropriate
    • Documentation of any cultural, language, visual, auditory or religious barriers to care
    • Documentation of follow-up timeframe (weeks, months or as needed)
    • Documentation of communication between specialists and PCP concerning consults or referrals
    • Documentation of colorectal, prostate and breast cancer screenings when age appropriate

    EPSDT standards below 90 percent:

    • Documentation of a BMI percentile for children age 2 to 20 years
    • Documentation of dental assessment, dental visits/hygiene or dental referral
    • Documentation of full immunization history for members under age 21 years
    • Documentation of a verbal lead risk assessment at each visit from age 6 months to 6 years
    • Documentation of a blood lead level, once between age 9 and 18 months and again between age 18 and 26 months

    For the 2022 audit, the majority of categories exceeded compliance targets, which showcases your professionalism and hard work. Our aim is for continued quality improvement, and focusing on the areas mentioned above will result in more comprehensive evaluation and treatment for our members.

    A member's medical record/chart contains pertinent information about their past and current medical history and treatment status. Documentation should be complete, consistent, clear and updated regularly to ensure efficient continuity and quality of care.

    For more information, visit horizonNJhealth.com/providermanual. Information is available on Medical Record-Keeping Standards (section 12.19), Advance Directives (section 12.21) and EPSDT Program and Guidelines (section 13.11).

  • In the United States, more than 25 million Americans, or one in 12 citizens, manage asthma daily. Asthma is common, offers no cure, and is costly; therefore, it remains a pressing health care concern in United States. The 2022 Global Initiative for Asthma Management and Prevention guidelines include the following recommendations:

    • All adults and adolescents with asthma should receive inhaled corticosteroid-containing controller treatment to reduce their risk of serious exacerbations and to control symptoms.
    • Inhaled corticosteroids are also recommended for children age 6 to 11 years with asthma.
    • For all patients with asthma, encourage adherence with controller medication.


    Centers for Disease Control and Prevention. “Asthma in the US”. Retrieved March 27, 2023, from cdc.gov/vitalsigns/asthma/index.html.

    Global Initiative for Asthma. “Global Strategy for Asthma Management and Prevention, 2022”. Retrieved May 17, 2023 from https://ginasthma.org/gina-reports/.

  • Being available 24/7 is a critical component of a patient's access to care. After-hour availability enhances quality and continuity of care, fosters appropriate use of services and increases member satisfaction.

    PCPs are expected to be available for our members 24/7. PCPs must return after-hours calls from members within 45 minutes to comply with our access standards. After-hours coverage can be completed by using an answering service or machine. If an answering machine is used, a forwarding number to connect with a physician should be provided.

    Our goal is for all of our participating PCPs to comply with these standards.

    We have identified opportunities to improve the overall compliance rate, which was 59 percent in 2022.

    In 2022, sites that use an answering service for after-hours calls had a higher compliance rate (74.5%) than sites that use an answering machine (2.3%).

    Answering methods used include:

    • Answering machine: 25.4%
    • Answering service: 55.5%
    • Direct answer: 18.5%
    • Not complete: .6 %

    Reasons for non-compliance include:

    • Unable to complete survey: 72.5% (Examples include: perpetual ringing, on hold for five or more minutes, voicemail inbox full, no alternative number provided on voice message)
    • No return phone call: 20.79%
    • Call returned outside of 45-minute timeframe: 3.1%
    • Call directed to Emergency Room: 3.6%

    Appointment Availability

    Appointment availability measures our members' ability to get timely care with their PCP, network specialty physician or a behavioral health practitioner. This measure is used to assess the number of days it takes from the date of a request to the first available appointment date. The audit is site-specific. An office location is only counted once, regardless of the number of physicians in an office. However, offices that have PCPs and specialists are counted once for each specialty type.

    Below are the performances based on service type:

    Service Type Appointment for Routine Service Care (0-28 days) Appointment for Urgent Care: Within 24 hours (0-1 day) Appointment for Emergency Care (Immediately)
    PCP 93% 80% 28%
    OB/GYN 69% 58% 68%
    SPECIALIST 77% 52% 74%

    Further details on these standards are available in our Administrative Policies, and may also be reviewed within our Provider Administration Manual.

    “Providers who are non-compliant with the Access Standards may be asked to submit a Corrective Action Plan to ensure future compliance. In addition, you may receive an administrative sanction for non-compliance.”

  • Childhood lead poisoning is one of the most common and preventable pediatric environmental health problems in the United States today. There is no safe level of lead.Even small amounts of lead exposure can affect a child's brain and nervous system resulting in developmental delays, hyperactivity and attention deficits, to name a few.

    Learn more about an educational opportunity offered by the New Jersey Chapter of the American Academy of Pediatrics (NJAAP), “Childhood Lead Prevention Education Project ECHO®”. You do not have to be a member of the NJAAP to participate—any practitioner providing care to children can register and there is no cost to participate. CME credits and MOC Part 4 points are available to participants.

    The next session will begin in the fall of 2023.

    Information on the next session and application:

    NJAAP: https://njaap.org/lead/

    Project ECHO®: https://njaap.org/pedproviders/projectecho/

    For questions, contact Sharleen van Vlijmen, Program Manager, NJAAP:

  • Please remind your patients age 6 months and older to get a flu vaccine every year.

    The flu and COVID-19 share many of the same symptoms, but they are different from one another.


    • Fever or feeling feverish/chills
    • Cough
    • Shortness of breath or difficulty breathing
    • Fatigue (tiredness)
    • Sore throat
    • Runny or stuffy nose
    • Muscle pain or body aches
    • Headache
    • Some people may have vomiting and diarrhea, though this is more common in children than adults


    • Flu viruses can cause mild to severe illness, including common symptoms listed above
    • COVID-19 causes more serious illness in some people: possible change in or loss of taste or smell, diarrhea and chest pain.

    Please discuss the benefits of getting a yearly flu vaccine with your patients.

    CDC. “Similarities and Differences between Flu and COVID-19”. Retrieved on May 19, 2023 from cdc.gov.

  • The Centers for Disease Control and Prevention (CDC) recommends pneumococcal vaccination for all children age 2 years old and younger, and all adults age 65 years and older who have never received any pneumococcal conjugate vaccine or whose previous vaccination history is unknown.

    CDC recommends PCV13 or PCV15 for:

    • All children younger than 2 years old
    • People age 2 years or older with certain medical conditions

    CDC recommends PCV15 (followed by a dose of PPSV23 one year later) or PCV20 for:

    • All adults age 65 years or older
    • Those people age 2 to 64 years with certain medical conditions
    • Adults age 19 to 64 years who smoke cigarettes


  • Breast cancer - The U.S. Preventive Services Task Force recommends that women ages 50 to 74 years who are at average risk for breast cancer get a mammogram every two years. We encourage you to reach out to your patients in this age category if they have not already completed or scheduled a mammogram. Also, we encourage you to talk to women ages 40 to 49 years about when to start and how often to get a mammogram.

    Prostate cancer - According to the CDC, men ages 55 to 69 years should make individual decisions about being screened for prostate cancer with a prostate specific antigen (PSA) test. We encourage you to reach out to your patients in this age category if they have not already completed or scheduled a prostate exam.


  • Claim Appeals

    A claim appeal is dissatisfaction with a claim payment, including prompt payment or no payment made by Horizon NJ Health. All claim appeals must be initiated on the appropriate appeal application form created by the Department of Banking and Insurance.

    An appeal application form must be submitted within 90 calendar days following the claim determination or the date on the Explanation of Benefits.

    Claim appeals may be faxed to 1-973-522-4678 or mailed to:

    Horizon NJ Health
    PO Box 63000
    Newark, NJ 07101-8064

    Please do not submit utilization management appeals, FIDE SNP appeals or Health Insurance Portability and Accountability Act (HIPAA) requests to this address.

    The status of your appeal(s) can be accessed via NaviNet. NaviNet opens a dialog window in the administrative reports menu. For assistance with accessing claim appeal status, contact NaviNet Support at 1-888-482-8057.

    Fair Hearings

    Our NJ FamilyCare A and ABP members have the option to request a Medicaid State Fair Hearing after the internal appeal is finished. Medicaid State Fair Hearings are administered by staff from the New Jersey Office of Administrative Law. The member has up to 120 calendar days from the date on the internal appeal outcome letter to request a Medicaid State Fair Hearing. The member can request a Medicaid State Fair Hearing by writing to the following address:

    Fair Hearing Section Division of Medical Assistance and Health Services
    PO Box 712
    Trenton, NJ 08625-0712

    If the member makes an expedited Medicaid State Fair Hearing request, and they meet all of the requirements for an expedited appeal, a decision will be made within 72 hours of the day the state agency receives the Medicaid State Fair Hearing request. For more information, review Section 10.4 of the Provider Administrative Manual.


    We have a grievance procedure for resolving disagreements available to all members and physicians. Grievances will be resolved as soon as possible and will not exceed 48 hours from initiation of the grievance for urgent cases and 30 days for all other issues. For more information, review Section 10 of the Provider Administrative Manual.

  • Members have rights, responsibilities and choices in the care they receive. To find member rights and responsibilities, please direct members to their Member Handbook or select one of the options below, depending on the line of business.

    • There are millions of people in the United States living with cognitive impairment. One of the greatest risks for cognitive impairment is age. The Baby Boomer generation has already started to pass the age of 65 and the number of people with cognitive impairment is expected to increase substantially.
    • Please educate your patients on the normal versus abnormal signs of aging.

    Normal Aging Abnormal Aging
    Making a bad decision once in a while Often makes poor judgments and decisions
    Missing a monthly payment Continually forgetting to pay bills
    Forgetting what day it is and remembering later Losing track of the date or time of year
    Forgetting what word should be used Trouble having conversations
    Losing things Misplacing things often and being unable to find them

    For more information, visit the Centers for Disease Control and Prevention or the National Institute on Aging.

  • We have the resources you need to help you achieve your desired quality rating. Visit our Quality Resource Center to find information on the Consumer Assessment of Healthcare Providers and Systems (CAHPS), Healthcare Effectiveness Data and Information Set (HEDIS®) tips, behavioral health, pharmacy, our Results and Recognition Program and other items that can support your efforts.

    The material in the Quality Resource Center will help you:

    • Achieve the highest level of quality care for your patients
    • Reach HEDIS measures
    • Close gaps in care

    Visit the Quality Resource Center today.

  • Aspiration pneumonia refers to inhalational acute lung injury that occurs after aspiration of sterile gastric contents. An observational study found that the risk of patients hospitalized for community-acquired pneumonia developing aspiration pneumonia is about 13.8 percent. The mortality rate from aspiration pneumonia is largely dependent on the volume and content of aspirate and can be up to 70 percent.

    Please remind your patients that symptoms of aspiration pneumonia can include:

    • Chest pain
    • Chills
    • Fever
    • Shortness of breath
    • Wheezing

    Find more information on aspiration pneumonia.


    Medline Plus. “Aspiration pneumonia”. Retrieved on May 19, 2023 from Aspiration pneumonia: MedlinePlus Medical Encyclopedia.

    NIH. “Aspiration Pneumonia”. Retrieved on May 19, 2023 from Aspiration Pneumonia - StatPearls - NCBI Bookshelf (nih.gov).

  • In the United States, about one in four adults age 65 and older report falling each year. Each year, 3 million adults age 65 and older are treated in Emergency Rooms for fall-related injuries. Many are hospitalized for a head injury or hip fracture.

    Talk with your patients about the dangers of falling. Falls are a threat to the health of older adults and can reduce their ability to remain independent. There are proven ways to reduce and prevent falls, even for adults age 65 years and older. Please encourage your patients to:

    • Do strength and balance exercises
    • Have their eyes checked
    • Make a fall-safe home by getting rid of items they can trip over and installing grab bars and rails


    Centers for Disease Control and Prevention Centers for Disease Control and Prevention opens a dialog window‌(CDC)

  • Bedsores are common among older adults and people with disabilities. Encourage your patients to follow these tips to prevent bedsores:

    • When washing, use a soft sponge or cloth. DO NOT scrub hard.
    • Use moisturizing cream and skin protectants every day.
    • Clean and dry areas underneath breasts and around groin.
    • DO NOT use talc powder or strong soaps.
    • Try not to bathe or shower every day. It can dry out the skin



  • About one out of ten people may have a seizure during their lifetime. Please educate your patients on how they should respond to someone having a seizure.

    These are general steps to help someone who is having any type of seizure:

    • Stay with the person until the seizure ends and they are fully awake.
      • After it ends, help the person sit in a safe place and tell them what happened.
    • Comfort the person and speak calmly.
    • Check to see if the person is wearing a medical bracelet or other emergency information.
    • Keep yourself and other people calm.
    • Offer to call a taxi or another person to make sure the person gets home safely.


    CDC. Seizure First Aid. Retrieved on May 19, 2023 from Seizure First Aid | Epilepsy | CDC.

  • The Quality Improvement (QI) Program is designed to:

    • Oversee efforts to monitor and improve the quality of health care for members
    • Review our initiatives and outcomes related to member and provider satisfaction
    • Effect changes to improve performance on HEDIS and CAHPS scores
    • Oversee the safety and quality of care delivered to members
    • Fulfill quality-related requirements for NCQA, local, state and federal regulatory review organizations

    Please review our Quality Improvement Program Description.

    For more information about our QI Program goals, processes and outcomes for care and service, please call Provider Services at 1-800-682-9091.

  • You no longer need to call Provider Services or rely on the member's ID card for member eligibility and cost share information. With just a single sign in to NaviNet®, you can use the Eligibility and Benefits Cost Share Estimator to check information for your patients enrolled in our Commercial Braven Health℠ plans with a member ID number that includes “3HZN”.

    The self-service tool will provide you with the following pre-service member information at the diagnosis, CPT® or HCPCS-level:

    • Benefit/eligibility coverage
    • Estimated out-of-pocket costs (i.e., remaining deductible, co-pay, co-insurance)
    • Prior authorization requirements and where to submit the requests


    Simply log on to NaviNet and from the Horizon Plan Central page click on the Cost Share Estimator icon under Quick Links.

    The results will include a “reference number” for your records.

    If the member ID number does not include “3HZN”, please continue to call the Provider Services number on the member's ID card for information.


    Register for one of our upcoming webinars to learn how easy it is to use our online Eligibility and Benefits Cost Share Estimator.

    If you can't make one of our scheduled webinars, contact your Network Specialist or your Hospital Relations Representative to schedule a training session for your staff.

  • You should be using our new Horizon Data Submission Template to modify your demographic information. Use this process to update your provider data and to meet the requirement for quarterly data validation in our systems. Below are some tips to help you through the process.

    1. Requesting a Template

      • Email a request to autosubmission_@HorizonBlue.com.
      • Ensure that your email subject line is one of the following (or our system will not be able to fulfill your request):
        • Requesting Practitioner Template
        • Requesting Ancillary Template

    2. Completing Your Template

      • DO NOT delete ANY rows or columns in the template.
      • DO NOT delete or add content to Line 1 or Line 2.
      • Start making your updates on Line 3.

    3. Saving Your Template

      For our system to appropriately “read” your template, you must format the name as follows:


      • Replace “PROVIDER” with your group or practice name (up to 20 characters).
      • Leave “PRAC_CHANGE_HORIZON” as is in the file name.
      • Replace “MM_DD_YYYY” with the current date (using the same format: e.g., 04_30_2023).

    4. Returning Your Completed Template

      When you are ready to email your completed template to us, you MUST:

      • Reply to the email that we sent you with the blank template. Using this email to reply to us ensures that your interaction with us is secure.

      • Reply within 10 business days of your receipt of the original email from us. The secure connection expires after 10 business days.

      • If you need more time to complete the template:

        • Email us at autosubmission_@HorizonBlue.com to request a new template. Follow step 1 above.
        • We will send you another email to which you can respond with your already completed information. You don't need to fill out a new template if you already completed one.
        • This new email will create a new secure connection and provide an additional 10 business days for you to respond.

    5. Reviewing Processed Template for Success and/or Errors

      If you are having trouble submitting corrections back to Horizon please read the Practitioner User Guide under the section entitled Correct Errors Identified and Resubmit the Template for Processing. You must make your corrections to the original template you submitted, not to the file you received back from Horizon with the error messages.

    Visit our Demographic Updates web page for details and instructions on using this new tool and for other information about maintaining your demographic data.

    You can continue to use the Provider Data Maintenance Tool on NaviNet® for all changes except network terminations, TIN changes and practice name changes.

    Remember, updates are no longer accepted through the Enterprise PDM mailbox (EnterprisePDM@HorizonBlue.com).

  • We want to remind you that we have important tools when doing business with us.

    HealthSphere, an online health care data management tool, is available to all providers. HealthSphere merges and organizes clinical patient information collected from a variety of internal and external health care information sources and systems and makes it available to users.

    We encourage you to learn all that HealthSphere can do.

  • A change was recently made to our drug formulary. This formulary guide includes an explanation and listing of step therapy, quantity/age limits and drugs requiring prior authorization. More information can be found on Pharmacy Medical Necessity Determination and Pharmacy Utilization Management Programs.

    Please review the recent changes to our formulary:

    Formulary Change Description (effective 7/3/23) Brand (Generic) Alternatives (if applicable)
    Formulary Pristiq (desvenlafaxine)
    Formulary Protopic (tacrolimus)
    Formulary Advair Diskus (fluticasone-salmeterol)
    Formulary Symbicort (budesonide-formoterol)
    Formulary Insulin lispro vial
    Formulary Rezvoglar (insulin glargine-aglr)
    Formulary Dupixent (dupilumab)
    Formulary Omnipod (insulin infusion pump)
    Formulary Ontruzant (trastuzumab-dttb)
    Formulary Vegzelma (bevacizumab-adcb)
    Formulary Fylnetra (pegfilgrastim-pbbk)

    Please note that our maximum days' supply limit is 30 days. If, for medical reasons, members cannot be changed to preferred medications, please call our Pharmacy Department to request a prior authorization at 1-800-682-9094.