Frequently Asked Questions

Updated on September 23, 2019

Additional information has been added to address questions you may have regarding upcoming process changes to:

  • The credentialing of new behavioral health professionals and ancillary facilities that wish to join one of our networks.
  • How updates to existing provider demographic information need to be initiated/requested.
  • The medical necessity criteria to be used to make utilization management determinations for behavioral health services.

Horizon Blue Cross Blue Shield of New Jersey will transition the administrative and clinical management of the Horizon Behavioral Health℠ program – behavioral health services and benefits – from Beacon Health Options (formerly ValueOptions) to Horizon BCBSNJ’s internal operations.

The transition to Horizon BCBSNJ’s internal management will occur in a phased approach based on line of business. The effective dates are targeted for on or about:

  • January 1, 2020: Horizon Medicare Advantage, Horizon NJ Health and Horizon NJ TotalCare (HMO SNP) plans
  • April 1, 2020: Horizon BCBSNJ fully insured plans/products, self-insured (Administrative Services Only [ASO]) employer group plans including the State Health Benefits Program (SHBP) and the School Employees’ Health Benefits Program (SEHBP) and the Federal Employee Program® (FEP®)

We will continue to provide updates as Horizon BCBSNJ works with Beacon Health Options to prepare for the full transition of the Horizon Behavioral Health program.

Below are answers to questions you may have about the change in the management of the Horizon Behavioral Health program from Beacon Health Options to Horizon BCBSNJ’s internal operations.

Q1. Why are we making this change?
A1. Internal management of behavioral health services and benefits will allow us to be in a stronger position to work directly with providers and health systems to improve the integration of physical health and behavioral health care for our members and to assist health care professionals in treating the whole member and their unique needs.

Q2. Which plans/products will be impacted on or about January 1, 2020?
A2. The following plans/products will transition to Horizon BCBSNJ internal operations on or about January 1, 2020:

  • Horizon Medicare Advantage plans
  • Horizon NJ Health plans including:
    • Division of Developmental Disabilities (DDD),
    • NJ FamilyCare
    • Managed Long Term Services & Supports (MLTSS) plans
  • Horizon NJ TotalCare (HMO SNP)

Q3. Which plan/products will be impacted on or about April 1, 2020?
A3. The following plans/products that include behavioral health benefits through the Horizon Behavioral Health program will transition to Horizon BCBSNJ internal operations on or about April 1, 2020:

  • Horizon BCBSNJ fully insured plans/products and self-insured (Administrative Services Only [ASO]) employer group plans, including:
    • Advantage EPO
    • Direct Access
    • EPO
    • HMO
    • Indemnity
    • OMNIA℠ Health Plans
    • PPO
    • POS
    • State Health Benefits Program (SHBP) and School Employees’ Health Benefits Program (SEHBP)
  • Federal Employee Program® (FEP®)

Q4. Are all plans/products impacted?
A4. All plans that include behavioral health benefits through the Horizon Behavioral Health program will be impacted by this change in the administrative and clinical management of the Horizon Behavioral Health program.

Q5. How will this change in the administrative management of the Horizon Behavioral Health program help providers to improve behavioral services offered to our members?
A5. Internal management of behavioral health services and benefits will allow us to be in a stronger position to work directly with providers and health systems to improve the integration of physical health and behavioral health care for our members and to assist health care professionals in treating the whole member and their unique needs.

Q6. Will current Horizon Behavioral Health Provider Agreements be impacted by the change in the management of behavioral health benefits?
A6. Existing Horizon Behavioral Health practitioner and facility agreements will NOT be impacted by the change in the management of behavioral health benefits.

Q7. Will the Horizon BCBSNJ provider networks change?
A7. The transition from Beacon Health Options to Horizon BCBSNJ’s internal operations will have no impact on the participation status of any doctors, other health care professionals, ancillary providers or facilities that treat patients as part of the Horizon Behavioral Health program.

Q8. Why is Horizon BCBSNJ announcing this change now?
A8. Horizon BCBSNJ is announcing this change to ensure our providers are aware of the transition and to let them know we will communicate any details regarding this change during the transition.

Q9. Will there be changes to the recredentialing process?
A9. Yes. Effective July 1, 2019, Horizon BCBSNJ will begin to manage the recredentialing of behavioral health practitioners and facilities for providers who are due to be recredentialed on and after January 1, 2020. Beacon Health Options will continue to manage the recredentialing process for practitioners and facilities that are due to be recredentialed through December 31, 2019

Practitioners and facilities due for recredentialing on or after January 1, 2020 will receive information directly from Horizon BCBSNJ regarding recredentialing next steps.

Q10. Who is Medversant and what do they do for Horizon BCBSNJ?
A10. Medversant is a credentialing verification organization that works with Horizon BCBSNJ to collect recredentialing documentation for participating Horizon BCBSNJ, Horizon NJ Health and Horizon NJ TotalCare (HMO SNP) doctors and other health care professionals.

Horizon BCBSNJ will handle all credentialing and recredentialing for ancillary and acute care facilities.

Q11. Does Medversant handle recredentialing for all of Horizon BCBSNJ’s networks?
A11. Yes, Medversant provides assistance in regard to the recredentialing of participating doctors and other health care professionals for all of our networks – including the Horizon Managed Care Network, Horizon PPO Network, Horizon NJ Health Network and the Horizon NJ TotalCare (HMO SNP) Network.

Q12. Should I contact Medversant about my recredentialing?
A12. There is no need for you to contact Medversant or send them any documentation at this time. Horizon BCBSNJ will provide additional information about the recredentialing process for behavioral health practitioners and facilities as the effective date for this change approaches.

Q13. Where can behavioral health professionals access new information regarding the transition?
A13. Information and updates about the Horizon Behavioral Health program transition will be posted on HorizonBlue.com/providernews and horizonNJhealth.com/providernews. We encourage you to check these web pages regularly for updates.

Q14. Who will my Network Specialist be following this transition?
A14. Horizon BCBSNJ will provide full details and instructions about Horizon Behavioral Health program contacts as we get closer to the transition dates. Please continue to work with your current Beacon Health Options contacts.

Credentialing and Provider Demographic Updates

Q15. What changes are being made to the current process for credentialing?
A15. Beginning October 1, 2019, all behavioral health professionals and ancillary facilities will work with Horizon BCBSNJ to complete the initial credentialing of nonparticipating behavioral health professionals and ancillary facilities that are seeking to join one of our network(s).

Beacon Health Options will no longer perform these processes. Beacon Health Options will continue to manage all changes and applications received prior to October 1, 2019.

Q16. How do I update demographic information after October 1, 2019?
A16. Beginning October 1, 2019, all behavioral health professionals and ancillary facilities will work directly with Horizon BCBSNJ to request provider file changes. Beacon Health Options will no longer perform updates to the demographic/provider file information of currently participating behavioral health professionals and ancillary facilities.

Providers can send Horizon BCBSNJ, Horizon NJ Health and Horizon NJ TotalCare (HMO SNP) provider file updates via email or mail to:

  • Email: EnterprisePDM@HorizonBlue.com (Please include the provider’s name in the subject line.)
  • Mail:
    Horizon BCBSNJ
    3 Penn Plaza East
    Mail Station PP14C
    Newark, NJ 07105

When sending file changes, please include the provider’s name, attach supporting documentation and indicate the applicable network(s). For more information, visit HorizonBlue.com/demographics.

Q17. Do the changes to the credentialing process and provider file updates impact all Horizon BCBSNJ networks?
A17. Yes, all of our networks are impacted by these changes – including the Horizon Managed Care Network, Horizon PPO Network, Horizon NJ Health Network and Horizon NJ TotalCare (HMO SNP) Network.

Behavioral health professionals and ancillary facilities that are seeking to join one or more of our networks and/or update current demographic information will need to work with Horizon BCBSNJ.

Q18. How do I begin the credentialing process?
A18. Information on the credentialing process is located online. Simply visit HorizonBlue.com/why-join and select Join Our Networks or access the Provider Recruitment tab at HorizonNJHealth.com/for-providers.

The web pages provide information about joining our networks, access to the forms and documentation we require to consider a professional provider for credentialing and details on how an ancillary facility can request information to initiate the credentialing process.

Q19. What if I am currently working with Beacon Health Options on a credentialing application?
A19. Beacon Health Options will continue to manage applications received prior to October 1, 2019.

Q20. How long will it take to process my application?
A20. As long as all applicable documentation is submitted correctly, an application can take between 45 to 90 days from date of receipt at Horizon BCBSNJ.

Q21. What if I am currently working with Beacon on demographic updates?
A21. Beacon Health Options will continue to manage all changes received prior to October 1, 2019.

Q22. How long will it take to process changes to my demographic information?
A22. A provider file maintenance change can take up to 30 days to process if all applicable documentation is submitted.

Q23. Who can I contact if I have questions about joining one of Horizon BCBSNJ networks or to check the status of my credentialing applications?
A23. Please contact your current Beacon Health Options contact. Beacon Health Options will continue to assist you until the full transition is completed. (See QA2 and QA3 for transition dates.)

Medical Necessity Criteria Changes

Q24. What changes are being made to the medical necessity criteria used to make behavioral health care utilization management determinations?
A24. Beginning in 2020, Horizon BCBSNJ, Horizon NJ Health and Horizon NJ TotalCare (HMO SNP) will begin using the behavioral health care guidelines from MCG Health, to make behavioral health care utilization management determinations. We will no longer apply Beacon’s medical necessity criteria.

Horizon BCBSNJ, Horizon NJ Health and Horizon NJ TotalCare (HMO SNP) will continue to use American Society of Addiction Medicine (ASAM) criteria when making coverage determinations for services related to Substance Use Disorders.

Q25. When will Horizon BCBSNJ/Horizon NJ Health/Horizon NJ TotalCare (HMO SNP) begin using MCGs to make behavioral health care utilization management determinations?
A25. The 2020 effective dates will coincide with our overall transition plan.

  • January 1, 2020:
    Horizon Medicare Advantage plans
    Horizon NJ Health – including Division of Developmental Disabilities (DDD), NJ FamilyCare and Managed Long Term Services & Supports (MLTSS)¹
    Horizon NJ TotalCare (HMO SNP)
    1 Behavioral health outpatient services for Horizon NJ Health members, who are not DDD or MLTSS, are covered through Medicaid Fee for Service and not impacted by this change.

  • April 1, 2020:
    All other Horizon BCBSNJ plans – including fully insured plans/products, self-insured (Administrative Services Only [ASO]) employer group plans including the State Health Benefits Program (SHBP) and the School Employees’ Health Benefits Program (SEHBP) and the Federal Employee Program® (FEP®)

Q26. How will I get information on the MCG criteria Horizon BCBSNJ/Horizon NJ Health/ Horizon NJ TotalCare (HMO SNP) uses to make the utilization management determination?
A26. In all instances in which MCG care guidelines are used to support an adverse medical necessity determination, the rationale for the determination(s) will be included in the determination letter from Horizon BCBSNJ/Horizon NJ Health/ Horizon NJ TotalCare (HMO SNP). In addition, the MCG criteria used in making the determination will be made available free of charge upon request.

Q27. Do I need to have a license for MCG?
A27. Horizon BCBSNJ, Horizon NJ Health and Horizon NJ TotalCare (HMO SNP) does not require you to have a license to access MCG criteria. The MCG criteria used in making the determination will be made available free of charge upon request from Horizon BCBSNJ, Horizon NJ Health or Horizon NJ TotalCare (HMO SNP).

Q28. Where do I find more information on MCG care guidelines?
A28. For more information, please visit mcg.com, mouse over Care Guidelines and select Behavioral Health Care.

 

Medversant supports Horizon Blue Cross Blue Shield of New Jersey in the administration of credentialing and recredentialing services. Medversant is independent from and not affiliated with Horizon Blue Cross Blue Shield of New Jersey or the Blue Cross and Blue Shield Association.

The Horizon Behavioral Health ℠ program is administered by ValueOptions of New Jersey, Inc. ValueOptions of New Jersey, Inc., a subsidiary of Beacon Health Options, Inc., is a New Jersey Corporation licensed by the NJ Department of Banking & Insurance as an Organized Delivery System.