Frequently Asked Questions

Updated on March 30, 2020

Horizon BCBSNJ has completed the transition of 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.

All Horizon BCBSNJ’s plans that include behavioral health benefits through the Horizon Behavioral Health program will now be managed by our internal staff

Below are answers to questions you may have about the changes to the management of the Horizon Behavioral Health program and the day-to-day operations.

Q1. Why have we made this change?
A1. Internal management of behavioral health services and benefits allows 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 are impacted?
A2. The following plans/products transitioned 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 D-SNP)

March 30, 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®)

Q3. Are all plans/products impacted?
A3. All plans that include behavioral health benefits through the Horizon Behavioral Health program are impacted by this change in the administrative and clinical management of the Horizon Behavioral Health program.

Q4. How does this change in the administrative management of the Horizon Behavioral Health program help providers to improve behavioral services offered to our members?
A4. Internal management of behavioral health services and benefits will allows 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.

Q5. Where can behavioral health professionals access information regarding the transition?
A5. Information and updates about the Horizon Behavioral Health program transition are posted on HorizonBlue.com/providernews and horizonNJhealth.com/providernews. We encourage you to check these web pages regularly for updates and for other updates.

PROVIDER NETWORK

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

Q7. Does the Horizon BCBSNJ provider networks change?
A7. The transition from Beacon Health Options to Horizon BCBSNJ’s internal operations has 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.

RECREDENTIALING

Q8. Are there changes to the recredentialing process?
A8. Yes. As of July 1, 2019, Horizon BCBSNJ began managing the recredentialing of behavioral health practitioners and facilities for providers who are due to be recredentialed on and after January 1, 2020.

Q9. Who is Medversant and what do they do for Horizon BCBSNJ?
A9. 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 D-SNP) doctors and other health care professionals.

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

Q10. Does Medversant handle recredentialing for all of Horizon BCBSNJ’s networks?
A10. 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 D-SNP) Network.

Q11. Should I contact Medversant about my recredentialing?
A11. 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.

CREDENTIALING

Q12. How can a nonparticipating behavioral health care professional join one of Horizon BCBSNJ’s networks?
A12. All behavioral health professionals and ancillary facilities can 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). For more information, visit Join Our Networks

Q13. How do I begin the credentialing process?
A13. 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.

Q14. How long will it take to process my application?
A14. 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.

DEMOGRAPHIC UPDATES

Q15. How do I update demographic information?
A15. All behavioral health professionals and ancillary facilities will work directly with Horizon BCBSNJ to request provider file changes.

Providers can send Horizon BCBSNJ, Horizon NJ Health and Horizon NJ TotalCare (HMO D-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.

Please always include the submitter’s name, email and telephone number with all email requests.

Q16. How will I know that my emailed demographic update requests have been received?
A16. When you submit a demographic update request to EnterprisePDM@HorizonBlue.com, our system will generate an auto-response email to confirm receipt and to let you know that we are working on your request.

To help ensure that you are getting these responses (and that they are not flagged as spam), please add EnterprisePDM@HorizonBlue.com to your list of safe or approved senders/contacts. This will keep emails from us out of your junk/spam folder.

Q17. How much advance notice should I provide for a demographic update?
A17. Please submit demographic update requests (along with supporting documentation) at least 30 days before the effective date of the change.

Q18. Are there other details I should know about sending emails to EnterprisePDM@HorizonBlue.com?
A18. Our EnterprisePDM@horizonblue.com is not managed by a representative who reads and responds immediately to your emails. Emails received are converted to service requests which are then addressed offline by our network team.

Please only submit demographic updates to this email address. Please DO NOT email initial credentialing submissions, claims, questions, etc.

Q19. How long will it take to process changes to my demographic information?
A19. A provider file maintenance change can take up to 30 days to process if all applicable documentation is submitted.

NETWORK CONTACT INFORMATION

Q20. Who is my Network Specialist?
A20. The Network Specialists who can provide support and education as part of the Horizon Behavioral Health program are organized based on line of business.

Review the current list of Network Specialists supporting the Horizon Behavioral Health program for members enrolled in Horizon Medicare Advantage plans, Horizon BCBSNJ fully insured plans/products, self-insured ASO employer group plans including the SHBP and the SEHBP and the FEP.

Review the current Professional Contracting and Servicing Staff supporting the Horizon Behavioral Health program for members enrolled in Horizon NJ Health and Horizon NJ TotalCare (HMO D-SNP) plans.

MEDICAL NECESSITY CRITERIA

Q21. Which medical necessity criteria is used to make behavioral health care utilization management determinations?
A21. Horizon BCBSNJ, Horizon NJ Health and Horizon NJ TotalCare (HMO D-SNP) will use the behavioral health care guidelines from MCG Health, to make behavioral health care utilization management determinations. Beacon’s medical necessity criteria will no longer be used as of the dates listed below.

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

The effective dates 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 D-SNP)
  • March 30, 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®)

Q22. How will I get information on the MCG criteria Horizon BCBSNJ/Horizon NJ Health/Horizon NJ TotalCare (HMO D-SNP) uses to make the utilization management determination?
A22.When the MCG Care Guidelines are used to support an adverse medical necessity determination, the clinical rationale for the determination(s) will be included in the adverse determination letter from Horizon BCBSNJ/Horizon NJ Health/Horizon NJ TotalCare (HMO D-SNP). Upon request, we will provide the MCG care Guidelines used in making the specific determination.

Q23. Do I need to have a license for MCG?
A23. Horizon BCBSNJ, Horizon NJ Health and Horizon NJ TotalCare (HMO D-SNP) does not require you to have a license to access MCG criteria. Upon request, Horizon BCBSNJ, Horizon NJ Health and Horizon NJ TotalCare (HMO D-SNP) we will provide the MCG care Guidelines used in making the specific determination.

 

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.