Clinical Guidelines
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COVID-19 InformationCOVID-19 Information
- COVID-19 Information
- Reminder: Use correct codes when evaluating for COVID-19Reminder: Use correct codes when evaluating for COVID-19
- Policy Update: Antibody Testing ClaimsPolicy Update: Antibody Testing Claims
- Update: Members’ cost sharing waived for treatment of COVID-19 through June 2021Update: Members’ cost sharing waived for treatment of COVID-19 through June 2021
- Submitting claims for COVID-19 vaccines delivered in non-traditional medical settingsSubmitting claims for COVID-19 vaccines delivered in non-traditional medical settings
- For Essential Workers, COVID-19 Treatment Covered Under Workers' Compensation BenefitsFor Essential Workers, COVID-19 Treatment Covered Under Workers' Compensation Benefits
- Submitting Pharmacy Claims for COVID-19 VaccinationsSubmitting Pharmacy Claims for COVID-19 Vaccinations
- Update: Prior Authorization Requirements for Inpatient Admissions and Post-Acute Facility Admissions to be ReinstatedUpdate: Prior Authorization Requirements for Inpatient Admissions and Post-Acute Facility Admissions to be Reinstated
- Teledentistry Reminder for ProvidersTeledentistry Reminder for Providers
- COVID-19 Vaccine COVID-19 Vaccine
- COVID-19 vaccines available in Essex County – Information for your staff and patientsCOVID-19 vaccines available in Essex County – Information for your staff and patients
- Reimbursement Policy effective January 1, 2021: Add-on Payment for COVID-19 Diagnostic Testing Run on High Throughput Technology (U0005)Reimbursement Policy effective January 1, 2021: Add-on Payment for COVID-19 Diagnostic Testing Run on High Throughput Technology (U0005)
- COVID-19 vaccines will be covered at 100%COVID-19 vaccines will be covered at 100%
- Coverage for antibody infusion therapyCoverage for antibody infusion therapy
- Waiving Prior Authorization Requirements for Emergent In-Network Inpatient Admissions and Post-Acute Facility AdmissionsWaiving Prior Authorization Requirements for Emergent In-Network Inpatient Admissions and Post-Acute Facility Admissions
- Update Regarding Automatic Extension of Private Duty Nursing AuthorizationsUpdate Regarding Automatic Extension of Private Duty Nursing Authorizations
- New Update for Automatic Extension of Private Duty Nursing AuthorizationsNew Update for Automatic Extension of Private Duty Nursing Authorizations
- Update: Antibody Testing ClaimsUpdate: Antibody Testing Claims
- Update: Cost-share waiver for telemedicine and COVID-19 testing extendedUpdate: Cost-share waiver for telemedicine and COVID-19 testing extended
- Reminder: Horizon NJ Health members are not responsible for PPE chargesReminder: Horizon NJ Health members are not responsible for PPE charges
- Teledentistry reminderTeledentistry reminder
- Dates for Certain Prior Authorization Waivers Further ExtendedDates for Certain Prior Authorization Waivers Further Extended
- Guidance for Dentists and Staff on Reopening Dental Offices During the COVID-19 Pandemic (May 22, 2020)Guidance for Dentists and Staff on Reopening Dental Offices During the COVID-19 Pandemic (May 22, 2020)
- Providing teledentistry for Horizon NJ Health members during COVID-19Providing teledentistry for Horizon NJ Health members during COVID-19
- Dates for Prior Authorization Waivers ExtendedDates for Prior Authorization Waivers Extended
- New Laboratory COVID-19 Antibody Testing Codes: 86328 and 86769New Laboratory COVID-19 Antibody Testing Codes: 86328 and 86769
- COVID-19 Update: Medical Policy Revisions & ImplementationsCOVID-19 Update: Medical Policy Revisions & Implementations
- 72 Doctors, Nurses, Pharmacists and Health Clinicians from Horizon BCBSNJ Answer Governor Murphy’s “HealthCare Professionals Call to Serve”72 Doctors, Nurses, Pharmacists and Health Clinicians from Horizon BCBSNJ Answer Governor Murphy’s “HealthCare Professionals Call to Serve”
- New Jersey Pandemic Relief Fund Efforts Get $2 Million Boost from HorizonNew Jersey Pandemic Relief Fund Efforts Get $2 Million Boost from Horizon
- A special message from Howard A. Cutler, Vice President, Healthcare DeliveryA special message from Howard A. Cutler, Vice President, Healthcare Delivery
- Behavioral Health Continuity During the COVID-19 Public Health EmergencyBehavioral Health Continuity During the COVID-19 Public Health Emergency
- COVID-19 Frequently Asked QuestionsCOVID-19 Frequently Asked Questions
- Waiving Pre-Certification/Prior Authorization requirements for Physical Health Post-Acute Facility AdmissionsWaiving Pre-Certification/Prior Authorization requirements for Physical Health Post-Acute Facility Admissions
- Horizon BCBSNJ Commits $2.5 Million for Masks, Face Shields, Food and Social Services to Protect Our Communities and Our Health ProfessionalsHorizon BCBSNJ Commits $2.5 Million for Masks, Face Shields, Food and Social Services to Protect Our Communities and Our Health Professionals
- Reminder to use specific codes when evaluating for COVID-19Reminder to use specific codes when evaluating for COVID-19
- Administrative Policy: Credentialing and Recredentialing During the COVID-19 PandemicAdministrative Policy: Credentialing and Recredentialing During the COVID-19 Pandemic
- Waiving Pre-Certification/Prior Authorization requirements for acute inpatient facility admissionsWaiving Pre-Certification/Prior Authorization requirements for acute inpatient facility admissions
- Referrals no longer required for in-network specialistsReferrals no longer required for in-network specialists
- Providing telephonic care with no costs to membersProviding telephonic care with no costs to members
- COVID-19 Response: Eliminating Cost-Sharing for Qualified In-Network Telemedicine ServicesCOVID-19 Response: Eliminating Cost-Sharing for Qualified In-Network Telemedicine Services
- COVID-19 CPT testing codesCOVID-19 CPT testing codes
- State of Emergency and Public Health Emergency – Office ClosuresState of Emergency and Public Health Emergency – Office Closures
- Telemedicine and Telehealth Services Reimbursement PolicyTelemedicine and Telehealth Services Reimbursement Policy
- Eliminating Cost Sharing Related to COVID-19 Testing and EvaluationEliminating Cost Sharing Related to COVID-19 Testing and Evaluation
- Staying Informed: COVID-19 (Coronavirus)Staying Informed: COVID-19 (Coronavirus)
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ResourcesResources
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- 21st Century Cures Act21st Century Cures Act
- Adolescent Risk Behaviors and Depression PIP HandbookAdolescent Risk Behaviors and Depression PIP Handbook
- Advance DirectivesAdvance Directives
- ASAM Criteria for Patients and FamiliesASAM Criteria for Patients and Families
- Clinical and Preventive GuidelinesClinical and Preventive Guidelines
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Credentialing and Recredentialing ResponsibilitiesCredentialing and Recredentialing Responsibilities
- Credentialing and Recredentialing Responsibilities
- Credentialing and Recredentialing Policy for Participating Physicians and Healthcare ProfessionalsCredentialing and Recredentialing Policy for Participating Physicians and Healthcare Professionals
- Credentialing and Recredentialing Policy for Ancillary and Managed Long Term Support Service (MLTSS) ProvidersCredentialing and Recredentialing Policy for Ancillary and Managed Long Term Support Service (MLTSS) Providers
- Cultural CompetencyCultural Competency
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Educational Material for ProvidersEducational Material for Providers
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- ClaimsXTen FAQsClaimsXTen FAQs
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- SimpleClaim Training ResourcesSimpleClaim Training Resources
- How to Correctly Submit Claims with J or Q CodesHow to Correctly Submit Claims with J or Q Codes
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- FAQ for MUE NotificationFAQ for MUE Notification
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Federally Qualified Health Center (FQHC)Federally Qualified Health Center (FQHC)
- Federally Qualified Health Center (FQHC)
- Federally Qualified Health Center (FQHC) Resource GuideFederally Qualified Health Center (FQHC) Resource Guide
- Federally Qualified Health Center (FQHC) - Dental Billing GuideFederally Qualified Health Center (FQHC) - Dental Billing Guide
- DAVIS VISION Federally Qualified Health Center (FQHC) – Vision Billing GuideDAVIS VISION Federally Qualified Health Center (FQHC) – Vision Billing Guide
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FormsForms
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- Age - Appropriate EPSDT FormsAge - Appropriate EPSDT Forms
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- COVID Vaccine FormCOVID Vaccine Form
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- Physical Therapist, Occupational Therapist, Speech TherapistPhysical Therapist, Occupational Therapist, Speech Therapist
- Electronic Funds Transfer (EFT) FormsElectronic Funds Transfer (EFT) Forms
- Clinical Authorization FormsClinical Authorization Forms
- Lead Risk AssessmentLead Risk Assessment
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- Health LiteracyHealth Literacy
- HealthSphereHealthSphere
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Laboratory Corporation of America (LabCorp)Laboratory Corporation of America (LabCorp)
- Laboratory Corporation of America (LabCorp)
- LabCorp Alert and Panic Results PolicyLabCorp Alert and Panic Results Policy
- LabCorp Connectivity SolutionsLabCorp Connectivity Solutions
- LabCorp introduces RoadNet<sup>®</sup>LabCorp introduces RoadNet<sup>®</sup>
- LabCorp Beacon<sup>TM</sup>: PatientLabCorp Beacon<sup>TM</sup>: Patient
- NuSwab: Candida and STD testingNuSwab: Candida and STD testing
- Medicaid Reimbursement and BillingMedicaid Reimbursement and Billing
- MLTSS Bed Type Revenue CodesMLTSS Bed Type Revenue Codes
- MLTSS Non-Medical Professional Provider ManualMLTSS Non-Medical Professional Provider Manual
- MLTSS OrientationMLTSS Orientation
- MUE Rule Notification Letter MedicaidMUE Rule Notification Letter Medicaid
- NJ Addiction Services HotlineNJ Addiction Services Hotline
- Pharmacy Utilization Management ProgramsPharmacy Utilization Management Programs
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PoliciesPolicies
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Reimbursement Policies & GuidelinesReimbursement Policies & Guidelines
- Reimbursement Policies & Guidelines
- Add-on Payment for COVID-19 Diagnostic Testing Run on High Throughput Technology (U0005)Add-on Payment for COVID-19 Diagnostic Testing Run on High Throughput Technology (U0005)
- Advance Care PlanningAdvance Care Planning
- Allergy ServicesAllergy Services
- Ambulance ServicesAmbulance Services
- Billing Requirements for Clinical TrialsBilling Requirements for Clinical Trials
- Brachytherapy Billing RequirementsBrachytherapy Billing Requirements
- Breastfeeding ReimbursementBreastfeeding Reimbursement
- COVID 19 Antibody TestingCOVID 19 Antibody Testing
- Centering Pregnancy Prenatal CareCentering Pregnancy Prenatal Care
- Chiropractic Manipulation Diagnosis PolicyChiropractic Manipulation Diagnosis Policy
- Chronic Care ManagementChronic Care Management
- Claim Editing PolicyClaim Editing Policy
- DIR ServicesDIR Services
- Daily Maximum Units for Surgical Pathology and Microscopic ExaminationDaily Maximum Units for Surgical Pathology and Microscopic Examination
- Diabetic Screening ServicesDiabetic Screening Services
- Doula ServicesDoula Services
- Early Elective DeliveriesEarly Elective Deliveries
- Evaluation and Management Services billed with Global Radiology, Stress Test, Stress Echo or Myocardial Profusion ImagingEvaluation and Management Services billed with Global Radiology, Stress Test, Stress Echo or Myocardial Profusion Imaging
- Foot Orthotic Shoes and InsertsFoot Orthotic Shoes and Inserts
- Frequency of Ocular PhotographyFrequency of Ocular Photography
- Home Health Certification and Re-CertificationHome Health Certification and Re-Certification
- Laboratory Services Billed by PhysiciansLaboratory Services Billed by Physicians
- Maternity ReimbursementMaternity Reimbursement
- Maximum Units Policy on Hearing Aid BatteriesMaximum Units Policy on Hearing Aid Batteries
- Modifier JW – Drug WasteModifier JW – Drug Waste
- Modifier 22 – Increased Procedural ServicesModifier 22 – Increased Procedural Services
- Modifier 50 – Bilateral and LT/RTModifier 50 – Bilateral and LT/RT
- Modifier 52 – Reduced ServicesModifier 52 – Reduced Services
- Modifier 53 – Discontinued ProceduresModifier 53 – Discontinued Procedures
- Modifier 54 – Surgical Care OnlyModifier 54 – Surgical Care Only
- Modifier 55 – Postoperative Management OnlyModifier 55 – Postoperative Management Only
- Modifier 56 – Preoperative Management OnlyModifier 56 – Preoperative Management Only
- Modifier 57 – Decision for SurgeryModifier 57 – Decision for Surgery
- Modifier 62 – Two SurgeonsModifier 62 – Two Surgeons
- Modifier 66- Surgical TeamModifier 66- Surgical Team
- Modifier 73 - Discontinued Outpatient Procedure Prior to the Administration of AnesthesiaModifier 73 - Discontinued Outpatient Procedure Prior to the Administration of Anesthesia
- Modifier 76- Repeat Procedure or Service by Same PhysicianModifier 76- Repeat Procedure or Service by Same Physician
- Modifier 77- Repeat Procedure or Service by Another PhysicianModifier 77- Repeat Procedure or Service by Another Physician
- Modifier 78 – Unplanned Return to the ORModifier 78 – Unplanned Return to the OR
- Modifiers 80, 81, 82 and AS – Assistant SurgeonModifiers 80, 81, 82 and AS – Assistant Surgeon
- Multiple Procedure ReductionMultiple Procedure Reduction
- Mutually and Non-Mutually Exclusive NCCI EditsMutually and Non-Mutually Exclusive NCCI Edits
- Outpatient Services Prior to AdmissionOutpatient Services Prior to Admission
- Preventative Medicine Services with Auditory ScreeningPreventative Medicine Services with Auditory Screening
- Preventive Medicine ServicesPreventive Medicine Services
- PT/OT/ST ServicesPT/OT/ST Services
- Pulmonary Diagnostic Procedures when billed with Evaluation and Management CodesPulmonary Diagnostic Procedures when billed with Evaluation and Management Codes
- Readmission PolicyReadmission Policy
- Self-Help/Peer Support Billing GuidelinesSelf-Help/Peer Support Billing Guidelines
- Distinct Procedural Service Modifiers (59, XE, XP, XS, XU)Distinct Procedural Service Modifiers (59, XE, XP, XS, XU)
- Telemedicine and TelehealthTelemedicine and Telehealth
- Transitional Care PlanningTransitional Care Planning
- Ulcer Debridement and Ulcer StagesUlcer Debridement and Ulcer Stages
- Unlisted CodesUnlisted Codes
- Urine Drug TestingUrine Drug Testing
- Health Services Policies – Clinical Affairs, Dental, Pharmacy, Quality, Utilization ManagementHealth Services Policies – Clinical Affairs, Dental, Pharmacy, Quality, Utilization Management
- Provider ManualProvider Manual
- Provider NewsletterProvider Newsletter
- State of New Jersey Contractual RequirementsState of New Jersey Contractual Requirements
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Timely Filing RequirementsTimely Filing Requirements
- Timely Filing Requirements
- Billing GuideBilling Guide
- Electronic Data Interchange (EDI)/Electronic Funds Transfer (EFT)Electronic Data Interchange (EDI)/Electronic Funds Transfer (EFT)
- Emdeon Electronic Funds Transfer (EFT) FormsEmdeon Electronic Funds Transfer (EFT) Forms
- Claims AddressesClaims Addresses
- ClaimsXTen FAQsClaimsXTen FAQs
- Tips for Claims/Encounters FilingTips for Claims/Encounters Filing
- NIA Claims MatrixNIA Claims Matrix
- False Claims PolicyFalse Claims Policy
- Utilization ManagementUtilization Management
- Well-Being Screening ToolWell-Being Screening Tool
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Horizon Behavioral Health℠Horizon Behavioral Health℠
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- About the Horizon Behavioral Health ProgramAbout the Horizon Behavioral Health Program
- Behavioral Health Training WebinarsBehavioral Health Training Webinars
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- Medical Necessity CriteriaMedical Necessity Criteria
- Prior AuthorizationPrior Authorization
- External ResourcesExternal Resources
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Horizon NJ TotalCare (HMO D-SNP)Horizon NJ TotalCare (HMO D-SNP)
- Horizon NJ TotalCare (HMO D-SNP)
- Educational WebinarsEducational Webinars
- Cognitive ImpairmentCognitive Impairment
- Balance BillingBalance Billing
- FIDE-SNP Quick Reference GuideFIDE-SNP Quick Reference Guide
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- Medicaid EligibilityMedicaid Eligibility
- Model of CareModel of Care
- Critical IncidentsCritical Incidents
- HEDISHEDIS
- Results & Recognition ProgramResults & Recognition Program
- VRIVRI
- Managed Long Term Services and SupportsManaged Long Term Services and Supports
- Mom's GEMS Prenatal ProgramMom's GEMS Prenatal Program
- Office Based Addiction Treatment (OBAT) ProgramOffice Based Addiction Treatment (OBAT) Program
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Quality Improvement ProgramQuality Improvement Program
- Quality Improvement Program
- Results & Recognition ProgramResults & Recognition Program
- Smoking CessationSmoking Cessation
- HEDIS®HEDIS®
- CAHPS (Consumer Assessment of Healthcare Providers and Systems)CAHPS (Consumer Assessment of Healthcare Providers and Systems)
- Progress Toward HNJH’s GoalsProgress Toward HNJH’s Goals
- Hospital Acquired Conditions and Serious Adverse EventsHospital Acquired Conditions and Serious Adverse Events
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Clinical Guidelines - Horizon NJ Health
COVID-19
Stay informed.Get the latest information on COVID-19.
- 21st Century Cures Act
- Adolescent Risk Behaviors and Depression PIP Handbook
- Advance Directives
- ASAM Criteria for Patients and Families
- Clinical and Preventive GuidelinesClinical and Preventive Guidelines
- Credentialing and Recredentialing ResponsibilitiesCredentialing and Recredentialing Responsibilities
- Credentialing and Recredentialing Policy for Participating Physicians and Healthcare Professionals
- Credentialing and Recredentialing Policy for Ancillary and Managed Long Term Support Service (MLTSS) Providers
- Cultural Competency
- Demographic updates
- Educational Material for ProvidersEducational Material for Providers
- ClaimsXTen FAQs
- ClaimsXTen Edit Codes and Messages
- CareAffiliate Training
- SimpleClaim Training Resources
- How to Correctly Submit Claims with J or Q Codes
- eviCore healthcareeviCore healthcare
- FAQ for MUE Notification
- Federally Qualified Health Center (FQHC)Federally Qualified Health Center (FQHC)
- Federally Qualified Health Center (FQHC) Resource Guide
- Federally Qualified Health Center (FQHC) - Dental Billing Guide
- DAVIS VISION Federally Qualified Health Center (FQHC) – Vision Billing Guide
- FormsForms
- Age - Appropriate EPSDT Forms
- Forms
- Behavioral Health
- COVID Vaccine Form
- Nurse Practitioner
- Physician Assistant
- Physician
- Ancillary Provider
- Physical Therapist, Occupational Therapist, Speech Therapist
- Electronic Funds Transfer (EFT) Forms
- Clinical Authorization Forms
- Lead Risk Assessment
- Guides
- Health LiteracyHealth Literacy
- HealthSphere
- Laboratory Corporation of America (LabCorp)Laboratory Corporation of America (LabCorp)
- LabCorp Alert and Panic Results Policy
- LabCorp Connectivity Solutions
- LabCorp introduces RoadNet®
- LabCorp BeaconTM: Patient
- NuSwab: Candida and STD testing
- Medicaid Reimbursement and BillingMedicaid Reimbursement and Billing
- Medicaid Provider Enrollment Requirements by State
- Horizon NJ Health Foot Orthotic Shoes and Inserts Reimbursement Policy
- MLTSS Bed Type Revenue Codes
- MLTSS Non-Medical Professional Provider Manual
- MLTSS Orientation
- MUE Rule Notification Letter Medicaid
- NJ Addiction Services Hotline
- Pharmacy Utilization Management ProgramsPharmacy Utilization Management Programs
- PoliciesPolicies
- Medical Policies
- Reimbursement Policies & Guidelines Reimbursement Policies & Guidelines
- Add-on Payment for COVID-19 Diagnostic Testing Run on High Throughput Technology (U0005)
- Advance Care Planning
- Allergy Services
- Ambulance Services
- Billing Requirements for Clinical Trials
- Brachytherapy Billing Requirements
- Breastfeeding Reimbursement
- COVID 19 Antibody Testing
- Centering Pregnancy Prenatal Care
- Chiropractic Manipulation Diagnosis Policy
- Chronic Care Management
- Claim Editing Policy
- DIR Services
- Daily Maximum Units for Surgical Pathology and Microscopic Examination
- Diabetic Screening Services
- Doula Services
- Early Elective Deliveries
- Evaluation and Management Services billed with Global Radiology, Stress Test, Stress Echo or Myocardial Profusion Imaging
- Foot Orthotic Shoes and Inserts
- Frequency of Ocular Photography
- Home Health Certification and Re-Certification
- Laboratory Services Billed by Physicians
- Maternity Reimbursement
- Maximum Units Policy on Hearing Aid Batteries
- Modifier JW – Drug Waste
- Modifier 22 – Increased Procedural Services
- Modifier 50 – Bilateral and LT/RT
- Modifier 52 – Reduced Services
- Modifier 53 – Discontinued Procedures
- Modifier 54 – Surgical Care Only
- Modifier 55 – Postoperative Management Only
- Modifier 56 – Preoperative Management Only
- Modifier 57 – Decision for Surgery
- Modifier 62 – Two Surgeons
- Modifier 66- Surgical Team
- Modifier 73 - Discontinued Outpatient Procedure Prior to the Administration of Anesthesia
- Modifier 76- Repeat Procedure or Service by Same Physician
- Modifier 77- Repeat Procedure or Service by Another Physician
- Modifier 78 – Unplanned Return to the OR
- Modifiers 80, 81, 82 and AS – Assistant Surgeon
- Multiple Procedure Reduction
- Mutually and Non-Mutually Exclusive NCCI Edits
- Outpatient Services Prior to Admission
- Preventative Medicine Services with Auditory Screening
- Preventive Medicine Services
- PT/OT/ST Services
- Pulmonary Diagnostic Procedures when billed with Evaluation and Management Codes
- Readmission Policy
- Self-Help/Peer Support Billing Guidelines
- Distinct Procedural Service Modifiers (59, XE, XP, XS, XU)
- Telemedicine and Telehealth Telemedicine and Telehealth
- Transitional Care Planning
- Ulcer Debridement and Ulcer Stages
- Unlisted Codes
- Urine Drug Testing
- Health Services Policies – Clinical Affairs, Dental, Pharmacy, Quality, Utilization Management
- Provider Manual
- Provider Newsletter
- State of New Jersey Contractual Requirements
- Timely Filing RequirementsTimely Filing Requirements
- Billing Guide
- Electronic Data Interchange (EDI)/Electronic Funds Transfer (EFT)
- Emdeon Electronic Funds Transfer (EFT) Forms
- Claims Addresses
- ClaimsXTen FAQs
- Tips for Claims/Encounters Filing
- NIA Claims Matrix
- False Claims Policy
- Utilization ManagementUtilization Management
- eviCore
- Precertification Reference List Precertification Reference List
- Utilization Management Appeal Process for Administrative Denials
- Well-Being Screening Tool
COVID-19
Stay informed.
Get the latest information on COVID-19.
Get the latest information on COVID-19.
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