Help us help you and our members, your patients, by making sure we have the most current information on your practice and practitioners working with you.

During a routine check on a member, we discovered that their Primary Care Provider (PCP) with 288 other Horizon NJ Health members had left the practice seven months prior. The member had seen five different PCPs during that time. We helped them establish a relationship with another PCP to help manage their health-related issues and avoid another hospitalization.

Please visit our website to update your practice information whenever a change occurs, such as relocation, opening a new office, adding or removing a provider, opening or closing your panel, etc.

Mental illness may emerge in childhood or adolescence with symptoms including behavior disruptions, hallucinations, illogical thinking and severe depression, which can be especially distressing at this time of life. The National Committee for Quality Assurance (NCQA) states that while antipsychotic medications serve as effective treatment for a closely defined set of psychiatric disorders in children and adolescents, they are commonly prescribed for nonpsychotic conditions where psychosocial interventions are considered first-line treatment. As a result, psychosocial interventions may be underutilized, and children and adolescents may needlessly experience the risks associated with antipsychotic medications.

To improve the quality of care for members, we use the Healthcare Effectiveness Data and Information Set (HEDIS) measures developed by the NCQA. First-Line Psychosocial Interventions for Children and Adolescents on Antipsychotics (APP) measures the percentage of children and adolescents, ages 1 to 17 years old with a new antipsychotic medication prescription who had documentation of psychosocial care as first-line treatment. To meet this measure, documentation of psychosocial care needs to occur within 90 days before and 30 days after the earliest prescription dispensing date.

Best Practices:

• Educate patients and caregivers on the importance of medication compliance and side-effects
• Coordinate care with the child’s treatment team when appropriate
• Maintain appointment availability in your practice and schedule follow-up appointments before patient and/or their caregiver leave your office
• Contact patients and/or their caregivers who do not keep follow-up appointments and develop a tracking method for patients due or past due for follow-up visits
• Instruct patients and/or their caregivers on safety planning and crisis intervention options, including specific contact information and facilities

Our Behavioral Health HEDIS Team is available to assist you with meeting performance goals. For help, email BH_HEDISteam@HorizonBlue.com.

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

Primary Care Providers (PCPs) are expected to be available to 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 52.2 percent in 2021.

In 2021, sites that use an answering service for after-hours calls had a higher compliance rate than sites that use an answering machine. Compliance was 69.5 percent for practices using an answering service versus 1.8 percent for those using an answering machine.

Answering methods used include:

• Answering service: 49.9%
• Answering machine: 26.2%
• Direct answer: 17.2%
• Not complete: 6.7%

Reasons for non-compliance include:

• Unable to complete survey: 77.5% (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: 16.9%
• Call returned outside of 45-minute timeframe: 4.3%
• Call directed to Emergency Room: 1.3%

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.

Further details on these standards are available on our Administrative Policies page, and may also be reviewed within our Provider Administration Manual. Access Standards information is also made available to our members.

Good health — and health care — shouldn’t depend on what you look like or where you live. Unfortunately, for people of color, that’s not always the case.

Through Our Pledge, we continue to address health care disparities related to race and other social barriers our members face in accessing care. As part of this commitment, we’re helping our participating providers understand how implicit bias, or how having attitudes toward people or associating stereotypes with them without our conscious knowledge, can adversely impact patient outcomes.

We encourage you to take advantage of free virtual training that’s available to you and your staff. The U.S. Department of Health and Human Services’ Office of Minority Health has free, continuing education e-learning programs to help health care professionals provide culturally competent care.

Please educate your patients on creating and submitting to you their advance directive. This will ensure their preferences for various medical treatments are followed if they cannot make their own health care decisions.

For more information, direct your patients to the state’s website.

We encourage you to help your patients find the resources they need to address their behavioral health, not just their physical health. For more information, please review our Behavioral Health Patient Resources.

Do you have questions about our plans 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.

Utilization Management (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 an 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) UM appeals and denials are processed through us. Please make sure you send us the appeal, not eviCore healthcare. 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

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

For more information on aspiration pneumonia, visit Medline Plus.

Sources: Medline Plus, National Library of Medicine

In the United States, about one in four adults age 65 and older report falling each year. Each year, 3 million older people 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 ages 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

Source: Centers for Disease Control and Prevention (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

Source: MedlinePlus

About one out of 10 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.

Sources: CDC

Your staff may be used to asking for a physical member ID card to copy or scan. But if your patient with Horizon NJ Health benefits presents a digital member ID card, please accept it.

More members are using digital member ID cards, which they can conveniently access from smartphones using the Horizon NJ Health app. You can be confident that it contains all the information of a physical member ID card.

You Still Need to Verify Member’s Eligibility

The Horizon NJ Health member ID card cannot be accepted as the sole verification of a member’s eligibility to receive benefits. Member ID cards do not list an expiration date and are not always returned to Horizon NJ Health when a member’s coverage terminates.

At the time of the visit, confirm eligibility by calling 1-800-682-9091. Or, visit NaviNet and:

• Select Horizon NJ Health within the Health Plans menu.
• Select Eligibility & Benefits Inquiry from Workflows from this Plan.
• Enter your patient’s Horizon NJ Health member ID number and date of birth and click Search.
  OR
• Enter your patient’s first name, last name and date of birth and click Search.
• Select a category from the Benefits menu (on the left) to view the benefit detail within the same window.
  OR
• Click View/Print (to the right, below the logo), check ALL the benefits you need and click Print to view the selected benefits in a separate window with the ability to print.

For more information, review Section 2.4: Member Identification Cards and 2.5: Determining Eligibility of the Provider Administrative Manual.

How Members Can Access the Horizon NJ Health App

The app is free – members can simply download it from the App Store® or Google Play™, or text NJHLTH to 422-272.

There is no charge to download the Horizon NJ Health app, but rates from the wireless provider may apply.

App Store® is a service mark of Apple Inc., registered in the U.S. and other countries. Google Play™ is a trademark of Google LLC.

Did you know that adding modifier 8P to Quality review services disqualifies you from receiving credit for Quality measures? To receive credit for Quality services reviewed but not performed, you can report the code without modifier 8P. For example:

Urgent Care centers are a great alternative to the Emergency Room for members. Please remind members they can access our network of Urgent Care centers in our Doctor & Hospital Finder.

We’re pleased to announce that you can now use our Prior Authorization Procedure Search Tool to determine if services require prior authorization (PA) for your patients enrolled in Horizon NJ Health and Horizon NJ TotalCare (HMO D-SNP) plans.

Simply enter a CPT® or HCPCS code to see if that service requires PA in a variety of settings.

You can access our Prior Authorization Procedure Search Tool directly, through links on the NaviNet® Horizon NJ Health plan central page or the Horizon BCBSNJ plan central page, or by visiting horizonNJhealth.com/priorauthtool.

CPT® is a registered trademark of the American Medical Association.

NaviNet® is a registered trademark of NaviNet, Inc.