Horizon Pulse November 2022

  • Do you have questions about our plan and need to contact someone from Horizon NJ Health? Review the list of our Network Relations Assignments.

  • Your patients enrolled in Horizon NJ TotalCare (HMO D-SNP) are assigned a Care Manager who can assist you with any coordination of care.

    To speak with your patient's Care Manager, call 1-888-621-5894 (TTY 711) and select option 2.

    Representatives are available weekdays, from 8 a.m. to 5 p.m., Eastern Time (ET).

    You can find the direct phone number of Horizon NJ TotalCare (HMO D-SNP) Care Managers on your provider panel roster reports.

  • Please be aware of these policies when treating your patients: New guidelines for the New Jersey State-Based Exchange (SBE) allow certain members to enroll in Children-Only policies. These members are under a single contract or parent and child contract with Horizon NJ Health. Under the Children-Only policy, only the children will be enrolled with valid coverage, while their parent/adult will be treated as a responsible adult without coverage.

  • If your Horizon NJ Health patients present a digital ID card for proof of coverage, you must accept it. Digital member ID cards are an easy way for members to show you their benefit information. With more members relying on their phones to access important information, we want to make getting care more convenient.

    You must provide services to a member who presents a digital ID card based on our policy.

  • Studies have shown that early primary care engagement following an Emergency Room (ER) visit or an inpatient hospitalization can reduce costs, improve coordinated care, improve health outcomes and reduce hospital readmissions. Patients with multiple complex chronic conditions, who account for a large percentage of readmissions among Medicaid and Medicare beneficiaries, may benefit more from timely follow up with a Primary Care Provider (PCP).

    It is recommended that patients follow-up with their PCP within seven days of a hospital admission and following an ER visit. Telemedicine may be appropriate for these visits, depending on the patient's medical condition and access. Remind your patients that telemedicine could be an option for them.

    Find more information about your Horizon NJ Health patients on HealthSphere, which shows a 360-degree view of their patient records. Access HealthSphere on NaviNet or contact support at HealthSphere_Training@HorizonBlue.com.


    • American Journal of Managed Care (AJMC). Postdischarge Engagement Decreased Hospital Readmissions in Medicaid Populations. Retrieved November 2, 2022 from ajmc.com.
    • JAMA Network. Association of a Dedicated Post-Hospital Discharge Follow-Up Visit and 30-Day Readmission Risk in a Medicare Advantage Population. Retrieved November 2, 2022 from jamanetwork.com.
    • JAMA Network. Outcomes of a Citywide Campaign to Reduce Medicaid Hospital Readmissions With Connection to Primary Care Within 7 Days of Hospital Discharge. Retrieved November 2, 2022 from jamanetwork.com.
  • According to the National Committee for Quality Assurance (NCQA), 40.3 million Americans age 12 and older were classified as having a Substance Use Disorder (SUD) in 2020. Also, individuals with SUD have a higher utilization of high-intensity care treatment (e.g., inpatient hospitalizations). Timely follow up after treatment of SUD is critical to reduce negative health outcomes, decrease relapse and prevent disengagement from the health care system.

    Healthcare Effectiveness Data and Information Set (HEDIS) measures are curated by the NCQA. Follow-Up After Emergency Department Visit for Substance Use (FUA) and Follow-Up After High-Intensity Care for Substance Use Disorder (FUI), are two HEDIS measures focusing on improving clinical outcomes for members age 13 and older:

    1. FUA - assesses the percentage of Emergency Room visits with a principal diagnosis of SUD, or any diagnosis of drug overdose
    2. FUI - assesses the percentage of acute inpatient hospitalizations, residential treatment or detoxification visits for a diagnosis of SUD

    To meet compliance, documentation must indicate a follow up visit occurred within seven days, or 30 days of discharge for emergency visit including medication-assisted treatment (MAT) dispensing events.

    Best Practices:

    • Schedule timely follow-up visits, reschedule cancellations and/or address barriers to keeping appointments (e.g., transportation).
    • Schedule follow-up appointments before a patient leaves.
    • Maintain appointment availability, or consider telemedicine visits when in-person visits are not available.
    • Coordinate care with the patient, patient's guardian and/or other treating providers.
    • Refer patients for culturally appropriate treatment and consider co-occurring issues.
    • Refer members requiring additional support to Horizon Behavioral Health case management services.
    • Instruct patients and caregivers on safety planning and crisis intervention options, including specific contact information and facilities.

    Horizon's Behavioral Health HEDIS Team is available to assist providers with meeting performance goals. Email them at BH_HEDISTeam@HorizonBlue.com.


    • National Committee for Quality Assurance (NCQA). Follow-Up After High-Intensity Care for Substance Use Disorder (FUI). Retrieved November 2, 2022 from ncqa.org.
  • Long-term opioid use often begins with the treatment of acute pain.¹ The probability of chronic opioid use rapidly increases after the third day of therapy. Approximately one in seven people who received a refill or a second opioid prescription still continued opioid use one year later.²

    You should have active discussions with your patients about the risks of long-term opioid use early on. When prescribing opioids for acute pain, it is recommended to prescribe the lowest effective dose of immediate-release opioids and the minimum quantity needed.¹ In most cases, three days or less of opioid therapy is sufficient for the management of acute pain.¹ New Jersey state law prohibits providers from prescribing more than a five-day supply of opioids for acute pain for the initial prescription.³

    If long-term opioid use is the prescribed treatment because the benefits outweigh the risks, you should reassess whether opioid treatment is still effective before increasing total opioid dosage to ≥50 morphine milligram equivalent (MME) per day.¹ High opioid dosages have been associated with increased risk of motor vehicle injury, opioid use disorder and overdose.¹ Dosage increases to ≥90 MME per day should be avoided or carefully justified based on diagnosis and individualized patient assessments.¹ If patients' pain and function does not improve with doses of ≥90 MME per day, providers should consider tapering to a lower dosage, discontinuing use or consulting a pain specialist.¹

    You should consider treating pain without opioids. Non-pharmacologic therapy and non-opioid therapies are preferred and can be combined with opioids, if used.¹ Non-opioid therapies may be effective in treating pain while also decreasing risks and unfavorable side effects.⁴ Horizon NJ Health covers non-opioid analgesic therapy, such as acetaminophen, generic non-steroidal anti-inflammatory agents (NSAIDs), topical lidocaine (Aspercreme® products), duloxetine and capsaicin. Horizon NJ Health may also cover non-pharmacologic therapies, such as physical therapy, as part of the member's benefits.


    • Centers for Disease Control and Prevention (CDC). CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. Retrieved on August 8, 2022 from cdc.gov.
    • Centers for Disease Control and Prevention (CDC). Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use —United States, 2006-2015. Retrieved on November 4, 2022 from cdc.gov.
    • Centers for Disease Control and Prevention (CDC). Nonopioid Therapies. Retrieved on November 4, 2022 at cdc.gov.
    • New Jersey Division of Consumer Affairs. New Jersey Administrative Code Title 13 Law and Public Safety Chapter 35 Board of Medical Examiners. Retrieved on August 2, 2022 from njconsumeraffairs.gov.
  • 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 Emgality (galcanezumab-gnlm)
    Formulary Vonjo (pacritinib)
    Non-Formulary EC-Naprosyn 500 (naproxen DR) generic Motrin (ibuprofen), generic Advil (ibuprofen), generic Naprosyn (naproxen), generic Relafen (nabumetone), generic Orudis (ketoprofen), generic Cataflam (diclofenac), generic Voltaren (diclofenac), generic Dolobid (diflunisal), generic Indocin (indomethacin), generic Indocin SR (indomethacin ER), generic Clinoril (sulindac), generic Ansaid (flurbiprofen), generic Mobic (Meloxicam)
    Non-Formulary Terazol (terconazole) vaginal cream Over-the-counter (OTC) miconazole vaginal suppository/cream, OTC clotrimazole vaginal cream

    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
    isosorbide dinitrate/hydralazine Bidil
    bortezomib Velcade
    lenalidomide Revlimid
    pirfenidone Esbriet
    fluticasone HFA Flovent HFA
    sorafenib Nexavar
    dabigatran Pradaxa

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

  • We now cover doula services for Horizon NJ Health and 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.

  • It is important that your information displayed within our Online Doctor & Hospital Finder is accurate so our members can easily locate your practice and access the care and services they need from you.

    Help Us with Timely Updates

    Participating providers must notify us of any changes to their practice information especially to comply with the Consolidated Appropriations Act (CAA) that went into effect January 1, 2022.

    To make this process as easy and timely as possible, in December 2022, we will be introducing the Horizon Submission File Template — a more efficient way for you to send us updates that require supporting documentation. We will no longer accept updates sent to the EnterprisePDM mailbox.

    You can continue to use our online Provider Data Maintenance tool for all other data updates.

    How to Update Your Data

    You can send us changes to your information through our:

    • Provider Data Maintenance Tool: The fastest and most convenient way to review, add to or update your data is online using our Provider Data Maintenance tool, on NaviNet. Your information is updated within two days when you submit changes using this tool.
    • Horizon Submission File Template: This new online template will allow you to submit updates for all demographic changes including updates that require supporting documentation. More information on accessing and using the template will be provided prior to the effective date on the Horizon NJ Health Demographic Update page.

    Not Registered for NaviNet?

    As a participating provider, you are required to register for NaviNet within 30 days of your effective date of participation.

    You can sign up for free with your Federal Tax ID.

    Physicians and healthcare professionals can validate their information every 90 days in CAQH ProView™ or participate in our phone outreach efforts.

    If you have any questions, please call Horizon NJ Health 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.

    Thank you for your help in providing our members with accurate information about our networks.

  • 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.

  • Please remind your patients 6 months of age 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 November 2, 2022 from cdc.gov.

  • The Centers for Disease Control and Prevention (CDC) recommends pneumococcal vaccination for all children 2 years old and younger, and all adults 65 years old and older.

    CDC recommends PCV13 for:

    • All children younger than 2 years old
    • People age 2 years or older with certain medical conditions
    • Adults age 65 years or older also should discuss and decide, with their doctor, whether to get PCV13.

    CDC recommends PPSV23 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.