Do you have questions about our insurance and need to contact someone from Horizon NJ Health? If yes, review the list of our Network Relations Assignments.

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 change to our formulary.

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:

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

It is important to be sensitive to ways in which sexual orientation, culture and faith may impact your patients’ health care. Cultural beliefs can influence how an illness is perceived by a patient, or the way an individual and his or her family makes decisions about their health care.

Cultural competency is critical to ensuring quality care and a positive patient experience. Review more resources on our Cultural Competency webpage.

It is important that your patients have access to care. Please see the standards below.

24-Hour Coverage

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.

Appointment Availability

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.

Medical Appointments

• 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

Dental Appointments

• 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 FIDE-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.

The Horizon Neighbors in Health program was developed to help at-risk members in their own community. See how Neighbors in Health recently helped some of our members in Camden.

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.

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.

• Medicaid Member Rights & Responsibilities
• FIDE-SNP Member Rights & Responsibilities

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 understanding their 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
• 1-888-621-5894 (TTY 711), select option 2 for Case Management and then select option 2 for Horizon NJ TotalCare (HMO D-SNP) members, weekdays, 8 a.m. to 5 p.m., Eastern Time

We provide clinical and preventive guidelines for the care you give to your patients. These guidelines are determined by evidence-based medicine and rigorous review of published medical literature. For more details, review our list of Clinical Practice Guidelines.

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.

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

For continuous quality improvement, we monitor the medical record keeping and office standards from a random selection of our PCP network. This annual medical record review (MRR) is conducted for adult and pediatric members. EPSDT standards are audited for pediatric members 21 years of age and younger.

These audits are conducted remotely at this time. It is possible that certain information was documented, but not included in the submitted medical records due to the remote audit.

For measurement year 2020 (2021 audit), several areas scored below the 90 percent threshold and the following categories present opportunities for improvement.

MRR Standards Below 90 Percent:

• Evidence that Advanced Directives were discussed or on file for members over 18 years old
• Documentation of questions related to smoking, alcohol and drug use
• Documentation of questions related to potential cultural, language, visual, auditory and religious barriers to care
• Documentation of follow-up timeframe (weeks, months or pro re nata (PRN))
• Documentation of colorectal, prostate and breast cancer screenings

EPSDT Standards Below 90 Percent:

• Documentation of past medical history, family medical history, and developmental or behavioral assessment
• Documentation of BMI percentile in our members ages 2 to 21
• Documentation of dental assessment
• Documentation of vision and hearing assessment
• Documentation of immunization history
• Documentation of verbal lead risk assessment and blood lead level testing

The member’s medical record/chart should be complete, consistent, clear and updated regularly to ensure continuity of care and to promote efficient, effective quality of care. For the 2021 audit, the majority of categories exceeded compliance targets, which showcases your professionalism and hard work. However, we always aim for continued quality improvement, and focusing on the areas mentioned above will result in more comprehensive evaluation and treatment for our members.

For more information, review Section 12.19: Medical Record-Keeping Standards, Section 12.21: Advance Directives and Section 13.11: EPSDT Program and Guidelines of the Provider Administrative Manual.

HEDIS ratings are important in helping health plans understand the quality of care that is being provided to their members. We understand that, as a provider in our network, your role is crucial in improving patient outcomes. To better support you in achieving this goal, the Behavioral Health Quality Team recently expanded to include Clinical Quality Improvement Liaisons (CQILs) specific to Behavioral Health.

The Behavioral Health CQIL team will collaborate with your practice and support you in improving HEDIS quality performance and care provided to our members. They will monitor 11 HEDIS measures that include: continuity of care, psychotropic medication management and compliance, initiation and engagement of mental health and SUD treatment, and metabolic monitoring for certain prescribed medications. Your assigned Behavioral Health CQIL can provide you with a comprehensive variety of tools, including resources, education, data and practice transformation with the objective of enhancing treatment delivery.

Behavioral Health CQILs can:

• Act as your single point of contact to assist you with navigating HEDIS measures
• Collaborate inter-departmentally with Behavioral Health Network Relations representatives
• Provide you with a variety of resources, tools and HEDIS education
• Offer interactive webinars to support and reinforce your HEDIS knowledge
• Address barriers to care within your practice
• Assist you in analyzing quality performance reports
• Meet with you and your staff regularly to promote best practices and close gaps in care

To reach one of the Behavioral Health CQIL’s or for more information, email BH_HEDISTeam@HorizonBlue.com.

Integrated care is a best practice model. Our members benefit from collaboration because it improves the safety and efficacy of services to support better outcomes. Mental health, SUDs and general health problems are frequently intertwined. Coordination of health care between PCPs and behavioral health providers will produce the best outcomes for members.

• Behavioral Health Providers: We require you to obtain consent from the member to share information with their PCP.
• PCPs: You must obtain consent from the member to collaborate with Behavioral Health providers at the time of referral. You should communicate any changes in the member’s health status to the Behavioral Health provider.

Interested in increasing your lead screening rates? Review our Leading the Way on Lead page for helpful tips.

We’d like to remind you that you should not directly bill Horizon NJ Health members for any balance due on medical claims for medically necessary, covered services. Providers enrolled in the NJ FamilyCare Fee-for-Service program or in Managed Care are required to accept the reimbursement rate established by these programs as payment in full.

Reimbursement rates are determined by your contract with us. However, if you wish to dispute the amount you received from us, please mail an HCAPPA claim appeal to:

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

If your patients that have Horizon NJ Health also carry other health insurance, these other plans should be billed first. Services our members receive should first be reviewed against benefits under their other carriers, such as Medicare, employee health plans or other third-party medical insurance. Please ask your patients for all of their health plan member ID cards and about all of their insurance coverage before providing services.

Please follow the primary insurer’s administrative requirements and forms for claims submission. Providers should not file a claim with us until they receive an Explanation of Benefits (EOB) from the other insurance carrier(s).