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 and visit Progress Toward Horizon NJ Health’s Goals. For more information about our QI Program goals, processes and outcomes for care and service, please call Provider Services at 1-800-682-9091.

The Division of Medical Assistance and Health Services, in collaboration with the Division of Mental Health and Addiction Services, launched a program to cover and support Medication Assisted Treatment (MAT) and Office Based Addiction Treatment (OBAT). This program coordinates care for services provided by Primary Care Providers (PCPs), eligible prescribers and behavioral health specialists to members with a substance use diagnosis. These services are covered for members in the following plans: Division of Developmental Disabilities (DDD), NJ FamilyCare, Managed Long Term Services & Supports (MLTSS), and Horizon NJ TotalCare (HMO D-SNP). Find more information on the OBAT program and how to become an OBAT provider.

Early identification and treatment of alcohol or other drug (AOD) abuse or dependence is essential to avoid future substance-related illness and death, and can significantly improve your patients’ quality of life.

In fact, among the Healthcare Effectiveness Data and Information Set (HEDIS) performance measures developed by the National Committee for Quality Assurance (NCQA) is Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment (IET). IET measures the percentage of adolescent and adult members with a new episode of AOD abuse or dependence who received the following:

• Initiation of AOD Treatment: The percentage of members who initiate treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization, telehealth or medication treatment within 14 days of the diagnosis.
• Engagement of AOD Treatment: The percentage of members who initiated treatment and were engaged in ongoing AOD treatment within 34 days of the initiation visit.

Strategies to improve member engagement:

• Screen members regularly for alcohol and drug abuse (e.g., DAST, CAGE, AUDIT)
• Discuss the importance of timely follow-up visits, schedule follow-up appointments before the member leaves the office and/or contact members who cancel appointments to reschedule
• Use the same diagnosis for substance use at each follow-up visit
• Coordinate care with all treating providers
• Refer members to culturally appropriate treatment, which focuses on co-occurring issues such as mental health, trauma, eating disorders, etc.
• Consider referring members to our Behavioral Health Case Management Program
• Discuss barriers to follow-up care with members
• Use Motivational Interviewing to help members address resistance to treatment
• Consider evidence-based treatment. For example, the Substance Abuse and Mental Health Service Administration (SAMHSA) has implemented the Screening, Brief Intervention and Referral to Treatment (SBIRT). SBIRT is a reimbursable, evidence-based prevention and early intervention initiative.

Our Behavioral Health HEDIS team is available to assist you with meeting performance goals. Our Clinical Quality Improvement Liaisons (CQILs) are here to help you. You can email BH_HEDISteam@HorizonBlue.com.

Do you have questions about our health plans and need to contact someone from Horizon NJ Health? If yes, review the list of our Professional Contracting and Servicing staff on our Contact Us page.

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. You can request paper copies of the formulary by calling Pharmacy Services at 1-800-682-9094.

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.

Please review the recent change to our formulary.

Did you know? If your patient has Horizon NJ TotalCare (HMO D-SNP), you can access their Care Manager’s name and direct extension by checking your monthly Panel Roster Report via NaviNet, or asking your Provider Representative for a copy. The Care Manager can assist with care coordination, durable medical equipment (DME) and other aspects of your patient’s care.

All providers who participate in a Medicaid Managed Care Organization (MCO) are required to register with the state of New Jersey under the 21st Century Cures Act. Compliance is mandatory. Learn how to register and become compliant.

According to the Centers for Disease Control and Prevention (CDC), men ages 55 to 69 years should make individual decisions about being screened for prostate cancer with a prostate-specific antigen (PSA) test.

The health and wellness of our members and the communities we serve is important to us. That’s why we partnered with the National Cancer Institute’s (NCI’s) Center for Cancer Research (CCR), part of the National Institutes of Health (NIH), to make it easier for you and your patients to find clinical trial opportunities that offer access to advanced cancer therapies.

CCR is currently running 29 prostate cancer clinical trials, including options that use advanced cancer therapies, such as immunotherapy treatments and new alternatives for imaging. View more information on the clinical trials.

During your routine visit, does your patient show signs of cognitive impairment? If so, Medicare covers a separate visit to more thoroughly assess your patient’s cognitive function and develop a care plan. Use CPT® code 99483 to bill for this service.

For more information, review the Cognitive Assessment & Care Plan Services on the Centers for Medicare & Medicaid Services (CMS) website.

CPT Copyright 2017 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.

UM Decisions

When UM decisions are made, members are notified about their approval or denial by mail. This notification includes information about appeal rights. Prior authorizations are valid only for the dates requested. If you disagree with any of our medical necessity decisions or want more information on UM criteria, please see Section 10 of the Provider Administrative Manual regarding appeal rights, or call our UM Medical Appeals Department at 1-800-682-9094, ext. 89606.

UM Ethical Standards

We do not compensate those responsible for making UM decisions in a manner that provides incentive to deny or approve coverage for medically necessary and appropriate covered services. We also do not offer our employees performing UM reviews incentives to encourage denials of coverage or services that are medically necessary, and do not provide financial incentives to hospitals, physicians and other health care professionals to withhold covered health care services that are medically necessary and appropriate.

When your office has routine and non-urgent utilization or medical management determination-related inquiries, you can access our Medical Management staff by:

• Visiting NaviNet
• Calling 1-800-682-9094, weekdays, from 8 a.m. to 5 p.m., Eastern Time (ET)

A registered nurse or physician (medical director) is available during and after business hours by phone, 24 hours a day, seven days a week, to render urgent medical management determinations or to address inquiries.

For FIDE SNP Providers: Horizon NJ TotalCare (HMO D-SNP) eviCore UM appeals and denials are processed through us. Please make sure you send us the appeal, not eviCore. Below are ways you can send your appeals or denials for review:

• Phone: 1-800-682-9094, ext. 89606
• Electronic: NaviNet
• Fax: 1-609-583-3028
• Mail:
  FIDE SNP
  PO Box 10196
  Newark, NJ 07101

Bedsores are common among older adults and people with disabilities. Encourage your patients to contact you right away if they notice:

• Skin redness
• Warm areas
• Spongy or hard skin
• A breakdown of the top layers of skin or a sore

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 on skin 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 more.

Source: MedlinePlus

There are some risk factors that cannot prevent breast cancer, such as family history and older age. However, according to the CDC, there are risk factors you can change. Please encourage your patients to be mindful of the following risk factors.

• Not being physically active. Women who are not physically active have a higher risk of breast cancer.
• Being overweight or obese after menopause. Older women who are overweight or obese have a higher risk of breast cancer than those at a normal weight.
• Taking hormones. Some forms of hormone replacement therapy (those that include both estrogen and progesterone) taken during menopause can raise the risk for breast cancer when taken for more than five years. Certain oral contraceptives (birth control pills) also have been found to raise breast cancer risk.
• Reproductive history. Having a first pregnancy after age 30, not breastfeeding and never having a full-term pregnancy can raise breast cancer risk.
• Drinking alcohol. Studies show that a woman’s risk for breast cancer increases with the more alcohol she drinks.

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 UM 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 in the administrative reports menu. For assistance with accessing claim appeal status, contact NaviNet Support at 1-888-482-8057.

Fair Hearing

Our Plan A/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.

Grievances

We have a grievance procedure available for resolving disagreements to all members and physicians. Timely resolution will be executed 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.

We now cover doula services for Horizon NJ TotalCare (HMO D-SNP) members. A doula is a trained professional who provides continuous physical, emotional and informational support throughout the perinatal period. The services include the following:

• Prenatal visits
• Labor and delivery support
• Postpartum visits

For more information, visit Updates and Announcements or call Provider Services at 1-855-955-5590.