Horizon Pulse Provider Newsletter
Horizon Pulse March 2023
The information we maintain about you must be accurate, current and complete. You need to keep your information up-to-date with us.
Use our New Horizon Data Submission Template to Update Your Data
Effective March 1, 2023, you can begin using our new Horizon Data Submission Template. The template allows you to send us your updates and meet the requirement to validate your data in our systems quarterly. As of April 1, 2023, we will no longer accept updates sent to the Enterprise PDM mailbox. This new process is a faster way to update your information updated.
Practitioners and Group Practices
Submit all your changes using this new process, including network terminations, TIN changes and practice name changes.
You can continue to use them Provider Data Maintenance Tool on NaviNet for all changes except network terminations, TIN changes and practice name changes.
Use this new process to make updates to your phone or fax number, email address(es) and billing information. All other changes can be made by contacting your Horizon NJ Health Ancillary Contract Specialist.
How to use the Horizon Data Submission Template
You will need a blank template to make changes to your data.
- Email a request for a blank template to autosubmission_@HorizonBlue.com
- The subject line should state Requesting Practitioner Template or Requesting Ancillary Template
You will receive an instruction guide on how to fill out and send us your completed template.
Review important details on Demographic Updates.
Call Provider Services at 1-800-682-9091, weekdays, 8 a.m. to 5 p.m., Eastern Time (ET). Behavioral health providers can also email BHNetworkRelations@HorizonBlue.com. Please include your name, NPI and county.
View our Provider Directory Management administrative policy to learn more about how we ensure our provider files are accurate.
Thank you for your help in providing our members with accurate information about our networks.
You can return any improper or excess claim reimbursement amounts from patient billing or claims processing with our Credit Balance Adjustment Request Form. Use the form to report all credit balances outstanding for 30 days or more.
Submit completed forms and relevant documentation (i.e., previous adjustment requests, payment vouchers, correspondence, etc.) to Schaheda Fischer:
- Schaheda Fischer
Mail Station PP-12P
3 Penn Plaza East
Newark, NJ 07105-0420
- Schaheda Fischer
Per New Jersey state and federal guidelines, and as outlined in our Horizon NJ Health Provider Administrative Manual in sections 9.1, 12.1, 12.7 and Appendix C-4, Horizon is the sole recourse for payment to participating and nonparticipating providers for services provided to patients enrolled in a Horizon NJ Health NJ FamilyCare plan, a Horizon NJ TotalCare (HMO D-SNP) plan or the Managed Long Term Services & Supports (MLTSS) program.
All members enrolled in a Horizon NJ Health plans have the right to be free from inappropriate balance billing.
Providers may not:
- Seek payment from an enrollee, an enrollee's family member, any legal representative of the enrollee, or anyone else acting on the enrollee's behalf.
- Institute or cause the initiation of collection proceedings or litigation against an enrollee, an enrollee's family member, any legal representative of the enrollee, or anyone else acting on the enrollee's behalf.
Providers who believe that the adjudication of a claim is incorrect or that additional amounts are owed should call Horizon NJ Health Provider Services at 1-800-682-9091.
All participating Horizon and Horizon NJ Health hospital-based physicians and other health care professionals — except Radiologists, Anesthesiologists, Pathologists, and Emergency Room Physicians — must be recredentialed every three years.
Please review our Credentialing and Recredentialing Policy for Participating Physicians and Health Care Professionals administrative policy. If you fail to meet any of the standards, you will be subject to loss or restriction of network participation and termination of your Agreement.
How to get recredentialed with Horizon:
We encourage you to use CAQH ProView, a valuable credentialing and recredentialing resource.
- If you're already registered with CAQH, please review and/or update your information and then re-attest that your information is true, accurate and complete.
- If you're not registered with CAQH, please register. After registration, complete an online application and then attest that the information provided is true, accurate and complete.
- New Jersey Universal Recredentialing Application Form
If you are unable to use CAQH ProView, complete a copy of the NJ Physician Recredentialing Application Form available at New Jersey Department of Banking and Insurance.
Thank you for your cooperation with Andros, the business partner who works with us to help manage our recredentialing responsibilities, when they reach out to you.
Andros is independent from and not affiliated with Horizon Blue Cross Blue Shield of New Jersey.
The Substance Abuse and Mental Health Services Administration (SAMHSA) under the U.S. Department of Health and Human Services recently updated their OBAT requirements. You no longer need to be DATA 2000 waivered. See the full update from SAMHSA.
We invite Doula services practitioners who are enrolled with New Jersey Medicaid to submit an application to participate in our network to treat members enrolled in Horizon NJ Health Medicaid plans, including Division of Developmental Disabilities (DDD), Horizon NJ FamilyCare and Managed Long Term Services & Supports (MLTSS).
Visit our Doula Services Practitioners webpage for more information and instructions.
To encourage eligible members to take advantage of certain preventive measures necessary to maintain their best health, beginning on March 13, 2023 Horizon will collaborate with Walgreens to provide convenient, local support for a select group of 4,000 qualified Horizon NJ TotalCare (HMO D-SNP) members who are experiencing gaps in care.
Your patients who are part of the targeted pilot population will have access to certain health services at a local Walgreens Health Corner. These services will be completed by a Health Advisor who is a Registered Nurse or Clinical Pharmacist.
Services available to these members include:
- At-home colorectal cancer and diabetes screening kits
- HbA1c control
- Annual flu vaccine
- Blood pressure measured
- Functional assessment survey: Monitoring physical activity
- Fall risk assessment survey: Reducing risk of falling
- Older adult care: medication review
- Older adult care: pain assessment
The Walgreens Health Advisor will advise your patients to call you to schedule their annual visits, screenings and follow ups and may contact your office to help set up those appointments. In addition, Walgreens Health will provide you with an after-visit summary and test results for participating members seen in one of their Health Corners.
Member of Walgreens Boots Alliance ©2021 Walgreen Co. All rights reserved.
Walgreens is independent from and not affiliated with Horizon Blue Cross Blue Shield of New Jersey.
The CAHPS Survey is coming, and here are some fast facts on how it impacts members, patients, physicians and care staff.
Fast Facts on the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey:
CAHPS is a mandated survey administered by Centers for Medicare and Medicaid Services (CMS) and is an integral part of CMS' efforts to improve health care in the U.S.
The surveys contain 68 questions and measures a member's perception of the care they received from primary care providers and specialists.
CMS sends the CAHPS surveys to a random sample of the health plan members annually from March to June.
The survey will be sent to members who are enrolled in Braven℠ Medicare Choice (PPO), Braven Medicare Freedom (PPO) or Horizon NJ TotalCare (HMO D-SNP) plans.
Medicare uses this information to give an overall performance Star Rating to Medicare health and prescription drug plans. CAHPS accounts for nine measures within the overall Stars ratings and over half of the survey questions ask about the member's interactions with providers.
Star Ratings are released annually and reflect the experiences and health outcomes of people enrolled in Medicare Advantage and Part D prescription drug plans.
Fast Facts on Measuring Patient Experience:
Patient experience includes the range of interactions that patients have with the health care system. This includes care from doctors, nurses, support staff, their health plan and other health care facilities.
Patient experience includes several aspects of health care delivery that patients value highly when they seek and receive care, such as getting timely appointments, easy access to information, and good communication with health care providers.
The more patient-centric a practice becomes, the better the quality of the patient experience will be realized. In addition, this will help primary care providers attract/retain and create loyal patients.
Research shows that better patient experiences with their healthcare translates into better adherence to medical advice and treatment plans. Moreover, it can help reveal problems and gaps in communication that can have broad impact on clinical quality, safety and efficiency.
For key tips and best practices on how to improve the patient experience for Medicare members in Braven or Horizon NJ TotalCare (HMO D-SNP) plans, register for our Playbook for Patient Engagement.
For more information about the CAHPS survey, read our Tip Sheet and Discussion Checklist.
Mental illness and/or substance use may emerge at any time of life with symptoms including behavior disruptions, interpersonal struggles, suicidal-ideation, self-harm, overdose and severe depression. The National Committee for Quality Assurance (NCQA) emphasizes providing follow-up care to patients after Emergency Room (ER) visits or inpatient/high-intensity admissions for mental health or substance use. Doing so improves patient outcomes, decreases the likelihood of re-hospitalization, decreases relapse risk and reduces overall costs of care.
- Follow-up after hospitalization for mental illness (FUH): percentage of inpatient discharges with a diagnosis of mental illness or intentional self-harm among patients six years old and older that resulted in follow-up care with a mental health provider within seven days or within 30 days.
- Follow-up after ER visit for mental illness (FUM): percentage of ER discharges with a diagnosis of mental illness or intentional self-harm among patients six years old and older that resulted in follow-up care with a mental health provider within seven days or within 30 days.
- Follow-up after hospitalization for Substance Use Disorder (FUA): percentage of inpatient discharges with a diagnosis of Substance Use Disorder among patients 13 years old and older that resulted in follow-up care with a provider within seven days or within 30 days.
- Follow-up after high-intensity treatment for Substance Use (FUI): percentage of high intensity discharges with a diagnosis of substance use among patients 13 years old and older that resulted in follow-up care with a provider within seven days or within 30 days.
Best Practice Suggestions:
- Provide education on importance of follow-up within seven or 30 days from discharge, medication compliance and side-effects.
- Coordinate care with patient's treatment team.
- Maintain appointment availability and outreach to patients who miss appointments.
- Discuss safety planning and crisis/relapse intervention with the patient.
Horizon's Behavioral Health HEDIS Team is available to assist providers by emailing BH_HEDISteam@HorizonBlue.com.
Risk adjustment uses member demographics and health status to help control premium rates and protect patients. Successful risk adjustment programs can result in better health management for your patients and a decreased administrative burden for you.
We support risk adjustment programs for Commercial, Braven Medicare Advantage and Medicaid members. These risk adjustment programs rely on accurately coded claims and medical records. That's why it's important to properly document your patients' medical records and use codes to the highest level of specificity using ICD-10-CM.
Important Coding Information
Accurate and complete coding allows us to correctly identify patients who could benefit from our Chronic Care and Complex Case Management programs. These programs, offered free of charge, focus on education and improving the health of our members. You should code for any condition that is Monitored, Evaluated, Assessed and/or Treated (MEAT) during a patient's visit.
The steps below, performed at least annually, can help to reduce our chart retrieval requests and your administrative efforts.
Thoroughly document all medical conditions (acute/chronic, status and history). Please note that status and history codes will not close risk gaps.
Accurately code to the highest level of specificity.
Report all coded conditions on the claim.
A patient's medical record can provide more insight into existing conditions, which may not be found in claims. By reviewing charts every year, we can look for ways to improve clinical documentation and follow the Centers for Medicare & Medicaid Services (CMS) and ICD-10 guidelines.
Using unspecified codes may not identify the severity of the disease(s) correctly and as a result, patients may not be directed to certain services like our Chronic Care and Case Management Programs. Also, if unspecified codes are used, we may need you to submit medical records to appropriately identify a patient's health status and recognize any risk. This causes more work for you and can delay claims payments.
- To achieve consistency and ensure the highest level of care, physicians must “MEAT” patients with chronic conditions at least once per year.
If you have questions about risk adjustment, please email RiskAdjustment@HorizonBlue.com.
Providing the right care at the right time is important to your patients. Please review the standards below.
Primary Care Provider (PCPs) are responsible for supervising, coordinating and managing patient care by providing or authorizing the services needed for each member on his or her panel. This includes arranging for practice coverage 24 hours a day, seven days a week. PCPs and specialists should arrange to have an answering service during off-hours. If an answering machine is used, a forwarding phone number to connect with a physician must be given. Providers are considered non-compliant if a forwarding phone number is not provided.
Please review the following appointment scheduling standards to ensure timely access to quality care. Compliance with these standards will be audited by periodic onsite review of physician offices and phone calls. Please note, the appointment availability guidelines are the same for telemedicine and in-person.
Emergency services: immediately
- Urgent care: within 24 hours
- Symptomatic acute care: within 72 hours
- Routine care: within 28 days
- Specialist referrals: within four weeks or sooner, as medically indicated
- Urgent specialty care: within 24 hours of referral
- Baseline physicals for new adult enrollees: within 180 calendar days of initial enrollment
- Baseline physicals for new child enrollees and adult clients of Division of Developmental Disabilities (DDD): within 90 days of initial enrollment or in accordance with Early and Periodic Screening, Diagnostic and Treatment (EPSDT) guidelines
- Prenatal care: within three weeks of a positive pregnancy test (home or laboratory), within three days of identification of a high-risk pregnancy, within seven days during the first and second trimesters, and within three days in the third trimester
- Routine physicals: within four weeks for routine physicals for school, camp, work or similar
- Lab and radiology services: within three weeks for routine care and 48 hours for urgent care
- Wait time in office: less than 45 minutes
- Initial pediatric appointments: within three months of enrollment
- Emergency dental treatment: no later than 48 hours, as condition warrants
- Urgent care appointments: within three days of referral
- Routine non-symptomatic appointments: within 30 days of referral
Mental Health/Substance Use Disorder Appointments (DDD, MLTSS and HMO-D-SNP only)
- Emergency services: immediate; urgent care within 24 hours
- Routine care: within 10 days of request
- Wait time in office: less than 45 minutes
For more information, review Section 12.18 of the Provider Administrative Manual.
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 Brand (Generic) Alternatives (if applicable) Formulary Optivar (azelastine) Formulary Pyrukynd (mitapivat) Formulary Releuko (filgrastim-ayow) Formulary Vijoice (alpelisib) Formulary Voxzogo (vosoritide) Formulary (as of 4/10/23) Latuda (lurasidone) Formulary (as of 4/10/23) Aubagio (teriflunomide) Formulary (as of 4/10/23) Vigamox (moxifloxacin) Formulary (as of 4/10/23) Alymsys (bevacizumab-maly) Formulary (as of 4/10/23) Hyftor (sirolimus) Formulary (as of 4/10/23) Byooviz (ranibizumab-nuna) Formulary (as of 4/10/23) Cimerli (ranibizumab-eqrn) Non-Formulary Ceclor (Cefaclor) Suspension Cefuroxime Suspension, Cefprozil Suspension Non-Formulary (as of 4/10/23) Fioricet/codeine (butalbital-acetaminophen-caffeine with codeine) 50-300-40-30mg capsule Fioricet/codeine (butalbital-acetaminophen-caffeine with codeine) 50-325-40-30mg capsule Non-Formulary (as of 4/10/23) Lucentis (ranibizumab) Cimerli, Byooviz Non-Formulary (as of 4/10/23) Eylea (aflibercept) Cimerli, Byooviz
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.
New Generic Drugs
We encourage using generic drugs before using brand name drugs when appropriate. Generic drugs are the same as brand name drugs in quality, strength, purity and stability, as required by the U.S. Food and Drug Administration.
The following generic drugs are currently on the market or are expected to be on the market within the next three months:
Generic Name Brand Name lurasidone Latuda fingolimod Gilenya
You can request paper copies of the formulary by calling Pharmacy Services at 1-800-682-9094.
If a patient presents without an insurance card, prior to making the patient a self-pay patient, providers must check for and verify eligibility and coverage through NaviNet or by calling 1-800-682-9091 if they believe the patient could be a Horizon NJ Health Member.
Horizon NJ TotalCare (HMO D-SNP) members are automatically assigned a Care Manager (CM) at the time of their enrollment. This benefit offers members assistance with plan benefits, finding providers and navigating their health care. CMs help coordinate care to home or a facility upon discharge from an inpatient hospital stay, Emergency Room event or Urgent Care visit. They also assist in medication management, scheduling appointments and more, with the ultimate goal of preventing and reducing hospital readmissions.
If you have a Horizon NJ TotalCare (HMO D-SNP) member that needs assistance, please call:
- Member Services: 1-800-543-5656
- Case Management: 1-888-621-5894 (TTY 711), option 2 and then select option 2 for Horizon NJ TotalCare (HMO D-SNP) members, weekdays, 8 a.m. to 5 p.m., Eastern Time.
Register Today: Horizon and Rutgers Biomedical and Health Sciences present: Understanding and Addressing Implicit Bias
Join an interactive discussion about recognizing implicit bias and how it may impact patient care and safety. This free webinar will use real-life examples to show where there is bias and empowers you to improve patient relationships and outcomes. You'll hear how most people don't realize bias occurs and how you can have certain attitudes toward people or stereotypes without realizing it.
Date: Wednesday, April 5, 2023
Time: Noon to 2 p.m.
Via Zoom: Registration is required. Please register by April 3, 2023.
We are committed to working with you to end health care disparities and make sure patients get the care they need. Through Our Pledge, we continue to address health care disparities related to race and other social barriers our members face in accessing care.
Rutgers Biomedical and Health Sciences is independent from and not affiliated with Horizon Blue Cross Blue Shield of New Jersey.