Section 8 - Policies and Procedures

Member Rights and Responsibilities

All members have the following rights:

  1. To have access to a PCP or a backup doctor, 24 hours a day, 365 days a year, for urgent care
  2. To obtain a current directory of doctors within the network
  3. To have a choice of specialists
  4. To have a second opinion
  5. To receive care from an out-of-network provider when a participating Horizon NJ Health provider is not available
  6. If a member has a chronic disability, to be referred to specialists who are experienced in treating his or her disability
  7. To have a doctor make the decision to deny or limit a member's coverage
  8. To have no “gag rules” in Horizon NJ Health. That means doctors are free to discuss all medical treatment options even if the services are not covered
  9. To know how Horizon NJ Health pays its doctors, so a member will know if there are financial incentives or disincentives tied to medical decisions
  10. To be free from inappropriate balance billing
  11. To be treated with respect and with recognition of their dignity and right to privacy at all times
  12. To receive care without regard to race, color, religion, sex, age or national origin
  13. To participate with their doctor in making decisions about their health care
  14. To information and open discussion about the member's own medical condition, and the right to choose from different ways of treating his or her condition, regardless of cost or benefit coverage
  15. To have the member's medical condition explained to a family member or guardian if the member is unable to understand, and have it documented in the member's medical records
  16. To refuse medical treatment with an understanding of the results of refusal
  17. To call 911 in a potential life-threatening situation – without prior approval from Horizon NJ Health
  18. To have Horizon NJ Health pay for a medical screening exam in the ER to determine whether an emergency medical condition exists
  19. To postpartum stays in the hospital no less than 48 hours for a normal vaginal delivery and no less than 96 hours following a cesarean section
  20. To receive up to 120 days of continued coverage, if medically necessary, from a doctor who has been terminated by Horizon NJ Health including:
    • Up to six months after surgery
    • Six weeks after childbirth
    • One year of psychological or oncologic treatment

    No coverage may be continued if the doctor is terminated for cause

  21. To timely notification of changes to the member's benefits or the status of his or her provider
  22. To make an advance directive about medical care; Federal law requires providers to ask about a member's advance directive
  23. To receive information about Horizon NJ Health, its services, doctors and providers and the member's rights and responsibilities
  24. To offer suggestions for changes in policy and procedure, including the member's rights and responsibilities
  25. To have access to a member's own medical records at no charge to the member
  26. To privacy of the member's medical information and records
  27. To refuse the release of personal information (except when required or permitted by law)
  28. To be informed in writing if Horizon NJ Health decides to end a member's membership
  29. To tell Horizon NJ Health when a member no longer wishes to be a member
  30. To appeal a decision to deny or limit coverage, first within Horizon NJ Health and then through an independent organization
  31. To appeal any Horizon NJ Health decision, the care it provides, benefits or membership
  32. To file a grievance about the organization or the care provided in the member's primary language
  33. To know that a member or his or her doctor cannot be penalized for filing a complaint or appeal
  34. To contact the Department of Banking and Insurance or the Department of Human Services whenever the member is not satisfied with Horizon NJ Health's resolution of a grievance or appeal
  35. To give consent and make informed decisions about treatment of a member's minor dependents
  36. Horizon NJ Health will provide care for members younger than 18 years old following all laws and treatment and will be at the request of the minor's parent(s) or other person(s) who have legal responsibility for the minor's medical care. Under certain circumstances, New Jersey law allows minors to make health care decisions for themselves

Horizon NJ Health will allow treatment without parental consent in the following cases:

  • Minors who go to an ER for treatment and that treatment is determined to be medically necessary
  • Minors who want family planning services, maternity care or sexually transmitted diseases (STD) services

All members have the following responsibilities:

  1. To treat health care providers with same respect and kindness in which the member expects to be treated
  2. To talk openly and honestly, and seek care regularly from a doctor
  3. To abide by Horizon NJ Health's rules for medical care
  4. To give information to a doctor and Horizon NJ Health in order for them to provide care
  5. To ask questions of their doctor(s) so that members can understand their health problems and the care they are receiving and participate in developing mutually agreed-upon treatment goals
  6. To follow their doctor's advice that was agreed upon, or to consider the results if they choose not to
  7. To keep appointments and call in advance if an appointment must be cancelled
  8. To read all the Horizon NJ Health materials and follow the rules of membership
  9. To follow the proper steps when making complaints about care
  10. To take advantage of educational opportunities to learn about health issues
  11. To pay any copayments and/or premiums, when applicable
  12. To inform the Health Benefits coordinator and Horizon NJ Health about any doctors the member is currently seeing at the time of enrollment

MLTSS Member Rights and Responsibilities

In addition to the rights a traditional Horizon NJ Health member has, an MLTSS member has the right to:

  1. Ask for and receive information on the choice of services and providers available
  2. Have access to and choice of qualified service providers
  3. Be told about all of their rights before receiving chosen and approved services
  4. Get services no matter what their race, religion, color, creed, gender, national origin, political beliefs, sexual orientation, marital status or disability
  5. Have access to all services that are best for their health and welfare
  6. Make the right decisions after being made to understand the risks and possible effects of the decisions made
  7. Make decisions about their own care needs
  8. Help develop and change their own Plan of Care
  9. Ask for changes in services at any time, including to add, increase, decrease or discontinue them
  10. Ask for and receive from their Care Manager a list of names and duties of any providers assigned to provide services to them under the Plan of Care
  11. Receive support and direction from their Care Manager to resolve concerns about their care needs and/or complaints about services or providers
  12. Be told about a list of resident rights, and receive a copy in writing, upon admission to an institution or community residential setting
  13. Be told of all the covered/required services they are entitled to, required by and/or offered by the institutional or residential setting, and of any charges not covered by Horizon NJ Health while in the facility
  14. Not to be discharged or transferred out of a facility unless it is medically necessary; to protect their welfare and safety as well as the welfare and safety of other residents; or because of failure, after reasonable and appropriate notice, to pay the facility from available income as reported on the statement of available income for Medicaid payment
  15. Have Horizon NJ Health protect and promote all their rights
  16. Have all rights and responsibilities outlined here shared with their authorized representative or court-appointed legal guardian

Along with rights come responsibilities, here are some of the key responsibilities for MLTSS members:

  1. Provide all health- and treatment-related information, including but not limited to, medication, circumstances, living arrangements, and informal and formal supports, to the Care Manager to identify care needs and develop a Plan of Care
  2. Understand their health care needs and work with their Care Manager to develop or change goals and services
  3. Work with their Care Manager to develop and/or revise their Plan of Care to facilitate timely authorization and delivery of services
  4. Ask questions when they need more information
  5. Understand the risks that come with their decisions about care
  6. Understand that Horizon NJ Health does not provide 24/7 care management services and that they will need to work with family and friends to safeguard against potential risks
  7. Develop an emergency back-up plan for care and services with their Care Manager
  8. Report any major changes about their health condition, medication, circumstances, living arrangements, informal and formal supports to the Care Manager
  9. Notify their Care Manager should any problems occur or if they are not pleased with the services being provided
  10. Pay their room and board in a nursing facility or community residential setting and their cost share on time each month (if applicable)
  11. Treat service workers and care providers with dignity and respect
  12. Keep all Horizon NJ Health documents, such as their Plan of Care, emergency back-up plan, etc., for their personal records and future reference
  13. Follow Horizon NJ Health's rules and/or those rules of institutional or community residential settings
  14. Comply with care management activities and allow visits per the contract

Member Non-Compliance

Please call the Member Services Department when a member does not abide by the member responsibilities, continues with disruptive behavior or refuses to comply with the recommended treatment program. MLTSS Member Services will contact the member to discuss his or her responsibilities as a Horizon NJ Health member and seek to find a resolution to the situation.

Member Services 1-844-444-4410

24 hours, seven days a week

A healthy relationship between a provider and a member is important. If the provider believes that he/she cannot have this with a member, the provider may ask that the member receive services from another provider. Other circumstances in which a provider may request that a member be changed to another provider include:

  • Inability to solve conflicts between the member and his or her provider
  • If a member fails to comply with health care instructions, where such non-compliance prevents the physician from safely or ethically proceeding with the member's health care services
  • If a member has taken legal action against the provider

Horizon NJ Health Policies and Procedures

Because Horizon NJ Health's policies and procedures are intended to comply with federal and state requirements for the Medical Assistance program, providers are responsible for abiding by federal and state laws, regulations and program requirements, including the provisions of the contract between Horizon NJ Health and the New Jersey Department of Human Services.

Medically Necessary Services

The Division of Medical Assistance and Health Services (DMAHS), through regulation NJAC 10:74-1.4, defines medically necessary services as set forth below:

Medically necessary services are services or supplies necessary to prevent, diagnose, correct, prevent the worsening of, alleviate, ameliorate or cure a physical or mental illness or condition; to maintain health; to prevent the onset of an illness, condition or disability; to prevent or treat a condition that endangers life or causes suffering or pain or results in illness or infirmity; to prevent the deterioration of a condition; to promote the development or maintenance of maximal functioning capacity in performing daily activities, taking into account both the functional capacity of the individual and those functional capacities that are appropriate for individuals of the same age; to prevent or treat a condition that threatens to cause or aggravate a handicap or cause physical deformity or malfunction, and there is no other equally effective, more conservative or substantially less costly course of treatment available or suitable for the enrollee.

The services provided, as well as the type of provider and setting, must be reflective of the level of services that can be safely provided, must be consistent with the diagnosis of the condition and appropriate to the specific medical needs of the enrollee and not solely for the convenience of the enrollee or provider of service and in accordance with standards of good medical practice and generally recognized by the medical scientific community as effective. Course of treatment may include mere observation or, when appropriate, no treatment at all. Experimental services or services generally regarded by the medical profession as unacceptable treatment are not medically necessary for purposes of this contract.

Medically necessary services provided must be based on peer-reviewed publications, expert pediatric, psychiatric and medical opinion and medical/pediatric community acceptance.

In the case of pediatric enrollees, this definition shall apply with the additional criteria that the services, including those found to be needed by a child as a result of a comprehensive screening visit or an inter-periodic encounter (whether or not they are ordinarily covered services for all other Medicaid enrollees) are appropriate for the age and health status of the individual, and that the service will aid the overall physical and mental growth and development of the individual and the service will assist in achieving or maintaining functional capacity.

The Health Claims Authorization, Processing and Payment Act (HCAPPA) defines medical necessity or medically necessary as follows:

“Medical necessity” or “medically necessary” means or describes a health care service that a health care provider, exercising his prudent clinical judgment, would provide to a covered person for the purpose of evaluating, diagnosing or treating an illness, injury, disease or its symptoms and that is in accordance with the “generally accepted standards of medical practice;” clinically appropriate in terms of type, frequency, extent, site and duration, and considered effective for the covered person's illness, injury or disease; not primarily for the convenience of the covered person or the health care provider; and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that covered person's illness, injury or disease.

Horizon NJ Health believes that the DMAHS definition, which we are mandated to use by the State Contract and NJAC 10:74-1.4, incorporates the language and principles of the HCAPP definition. Therefore, Horizon NJ Health's Utilization Management (UM) program will function under the definitions in the same way as it has previously, utilizing the language from DMAHS found at NJAC 10:74-1.4. Furthermore, our medical policies and UM criteria used to help Horizon NJ Health reach decisions about medical necessity for coverage purposes reflect compliance with both definitions.

Clinical Practice Guidelines

Clinical practice guidelines are initiated and then re-evaluated biannually by Horizon NJ Health or more frequently in the event that new scientific evidence or national standards are published or such national guidelines change during the time period between biannual reviews. References to these guidelines are available on the Horizon NJ Health website or Appendix A of this manual.


Primary Care Providers do not need to provide referrals for in-network specialist services. As a reminder, Horizon NJ Health members must:

  • Use in-network doctors and health care providers for all services.
  • Request authorization for out-of-network specialist services.

Out-of-Network Referrals

Occasionally, a member's needs cannot be provided through the Horizon NJ Health network of physicians and health care professionals. When the need for out-of-network services occurs, the physician must contact the Utilization Management department. The Utilization Management department, in collaboration with the recommendations of the PCP, will arrange for the member to receive the necessary medical services with a specialty care physician. Every effort will be made to locate an in-network specialty care physician. Members who seek self-initiated care from a nonparticipating physician or a non-covered service will be responsible for the cost of the care.

Utilization Management Department

Confidentiality Statement

The provider agrees and understands that all information, records, data and data elements collected and maintained for the operation of the provider, Horizon NJ Health and the Department of Human Services of the State of New Jersey and pertaining to Horizon NJ Health members, shall be protected from unauthorized disclosure, in accordance with the provisions of 42 CFR Part 1396 (a)(7) (Section 1902 (a)(7) of the Social Security Act), 42 CFR Part 431, subpart F, N.J.S.A. 30:4D-7 (g) and N.J.A.C 10:49-9.7, and any and all applicable state and federal laws and regulations. Access to such information, records, data and data elements shall be physically secured and safeguarded and shall be limited to those who perform their duties in accordance with provisions of the your Agreement with Horizon NJ Health including the Department of Health and Human Services and to such others as may be authorized by DMAHS in accordance with applicable law. For Horizon NJ Health members who are eligible through the Division of Child Protection and Permanency, records must be kept in accordance with the provision under N.J.S.A 9:6-8.10a and 9:6-8.40 and any and all applicable state and federal laws and regulations, consistent with the need to protect the members' confidentiality.

Enrollee-Specific Information

With respect to any identifiable information concerning Horizon NJ Health members that is obtained by the provider, it: (a) shall not use any such information for any purpose other than carrying out the express terms of your Agreement with Horizon NJ Health; (b) shall promptly transmit to Horizon NJ Health and DMAHS all requests for disclosure of such information; (c) shall not disclose, except as otherwise specifically permitted by Horizon NJ Health, any such information to any party other than DMAHS without Horizon NJ Health or DMAHS's prior written authorization specifying that the information is releasable under Title 42 CFR, Section 431, 300et seq.; and (d) shall, at the expiration or termination of your Agreement with Horizon NJ Health, return all such information to Horizon NJ Health and/or DMAHS or maintain such information according to written procedures set by DMAHS for this purpose.


The provider shall instruct his or her employees to keep confidential information concerning the business of Horizon NJ Health or DMAHS, its financial affairs, its relations with members and its employees, as well as any other information that may be specifically classified as confidential by law.

Medical records and management of information data concerning Medicaid beneficiaries enrolled pursuant to your Agreement with Horizon NJ Health shall be confidential and disclosed to other persons within the provider's organization only as necessary to provide medical care and quality peer or grievance review of medical care under the terms of your Agreement with Horizon NJ Health.

The provisions of this section shall survive the termination of your Agreement with Horizon NJ Health and shall bind the provider, so long as the physician and health care professional maintain any individually identifiable information relating to Medicaid/NJ FamilyCare beneficiaries.

Affirmative Statement

The provider is encouraged to freely communicate with members regarding available treatment options, including medication treatment that may or may not be a covered benefit under Horizon NJ Health.

Horizon NJ Health distributes a statement to providers and employees who make UM decisions affirming the following:

  • UM decision-making is based only on appropriateness of care and service and existence of coverage
  • Horizon NJ Health does not specifically reward providers or other individuals for issuing denials of coverage or care
  • Financial incentives for UM decision-makers do not encourage decisions that result in under-utilization

Non-Discrimination Statement

The provider shall comply with the following requirements regarding non-discrimination:

  • The provider shall accept assignment of a Horizon NJ Health member and not discriminate against eligible members because of race, color, creed, religion, ancestry, marital status, sexual orientation, national origin, age, sex or physical or mental handicap, in accordance with Title VI of the Civil Rights Act of 1964, 42 USC Section 2000d, Section 504 of the Rehabilitation Act of 1973, 29 USC Section 794, the Americans with Disabilities Act of 1990 (ADA), 42 USC Section 12132, and rules and regulations promulgated pursuant thereto, or as otherwise provided by law or regulation.
  • ADA Compliance. In providing health care services, the provider shall not directly or indirectly, through contractual, licensing or other arrangements, discriminate against Medicaid/NJ FamilyCare beneficiaries who are “qualified individuals with a disability” covered by the provisions of the ADA.
  • A “qualified individual with a disability” is defined as an individual with a disability who, with or without reasonable modifications to rules, policies or practices; the removal of architectural, communication or transportation barriers; or the provision of auxiliary aids and services, meets the essential eligibility requirements for the recipient of services or the participation in programs or activities provided by a public entity.
  • Horizon NJ Health shall submit a written certification to DMAHS that it is conversant with the requirements of the ADA, is in compliance with the law and has assessed its provider network and certifies that the providers meet ADA requirements to the best of the provider's knowledge. The provider warrants that he or she will hold the state harmless and indemnify the state from any liability, which may be imposed upon the state as a result of any failure of the provider to be in compliance with the Act. Where applicable, the provider must abide by the provisions of section 504 of the federal Rehabilitation Act of 1973, as amended, regarding access to programs and facilities by people with disabilities.
  • The provider shall not discriminate against eligible persons or members on the basis of their health or mental health history, health or mental health status, their need for health care services, amount payable to the provider, or the eligible person's actuarial class or pre-existing medical/health conditions.
  • The provider shall not discriminate against an enrollee or attempt to disenroll an enrollee for filing a grievance/appeal.
  • The provider shall comply with the Civil Rights Act of 1964 (42 USC 2000d), the regulations (45 CFR Parts 80 & 84) pursuant to that Act, and the provisions of Executive Order 11246, Equal Opportunity, dated September 24, 1965, the New Jersey antidiscrimination laws including those contained within N.J.S.A. 10:2-1 through N.J.S.A. 10:2-4, N.J.S.A. 10:5-1 et seq. and N.J.S.A. 10:5-38, and all rules and regulations issued thereunder, and any other laws, regulations or orders that prohibit discrimination on grounds of age, race, ethnicity, mental or physical disability, sexual or affectional orientation or preference, marital status, genetic information, source of payment, sex, color, creed, religion or national origin or ancestry. There shall be no discrimination against any employee engaged in the work required to produce the services covered by your Agreement, or against any applicant for such employment because of race, creed, color, national origin, age, ancestry, sex, marital status, religion, disability or sexual or affectional orientation or preference.
  • Horizon NJ Health and the provider shall not discriminate with respect to participation, reimbursement or indemnification as to any provider, who is acting within the scope of the provider's license or certification under applicable state law, solely on the basis of such license or certification. This paragraph shall not be construed to prohibit Horizon NJ Health from including the provider, only to the extent necessary to meet the needs of the organization's members or from establishing any measure designed to maintain quality and control costs consistent with the responsibilities of the organization.
  • Scope. This non-discrimination provision shall apply to, but not be limited to, the following: recruitment, hiring, employment upgrading, demotion, transfer, layoff or termination, rates of pay or other forms of compensation and selection for training, including apprenticeship included in PL 1975, Chapter 127.
  • Grievances. The provider agrees that copies of all grievances alleging discrimination against enrollees because of race, color, creed, sex, religion, age, national origin, ancestry, marital status, sexual or affectional orientation or physical or mental handicap shall be forwarded to DMAHS for review and appropriate action within three business days of receipt by the provider.

Indemnification and Hold Harmless

As required by the New Jersey Medicaid program, at all times during the term of your Agreement, the provider shall indemnify, defend and hold the State of New Jersey and members harmless from and against all claims, damages, causes of action, cost or expense, including reasonable attorney's fees, to the extent such actions were caused by any negligent act or other wrongful conduct by the provider or provider's employee(s) arising with respect to the provider's services to members.

Billing Members

The provider agrees that under no circumstances (including, but not limited to, nonpayment by Horizon

NJ Health, insolvency of the managed care plan or breach of agreement) will the provider bill, charge or seek compensation, remuneration or reimbursement from or have recourse against enrollees, or persons acting on their behalf, for covered services, except for applicable copayments as designated by Horizon NJ Health.

However, a provider may charge DMAHS for Medicaid services not included in Horizon NJ Health's benefits package under this contract on a New Jersey Medicaid fee-for-service basis.

The provider may charge members when they seek care on their own for non-covered services. The provider is required to notify the member in writing before the service is rendered and receive the member's agreement to pay for all or part of the provider's charges.

The provider agrees that this provision shall survive the termination of your Agreement with Horizon NJ Health regardless of the reason for termination, including insolvency of Horizon HMO or Horizon NJ Health, and shall be constructed to be for the benefit of Horizon HMO and the members. The provider agrees that this obligation supersedes any oral or written contrary agreement now existing or hereafter entered into between the provider and the members, or persons acting on their behalf, insofar as such contrary agreement relates to liability for payment for or continuation of covered services, provided under the terms and conditions of this continuation of benefits provision.


The use of thorough screening of credentialing criteria is an important step in maintaining the quality of the Horizon NJ Health provider network.

Horizon NJ Health also uses strict standards for the credentialing of its provider network following guidelines of an external accrediting organization. Evaluation of a credentialing application includes review of the following:

  • Accreditation
  • Current state licensure
  • Medicare/Medicaid certification
  • Medicare/Medicaid sanction activity
  • Professional liability coverage (malpractice)
  • Satisfactory history of malpractice claims and settlements

In addition, site visits may be conducted to ensure that our members are receiving treatment in an appropriate, clean and safe environment that adheres to Occupational Safety and Health Administration and Clinical Laboratory Improvement Amendments standards and respects member privacy.

Updates to all credentialing information must be reported as changes occur. Copies of provider credentialing information are kept on file and must be updated every three years at recredentialing. Please send copies of these documents, since they are required.


Recredentialing of providers will be conducted by Horizon NJ Health every three years. This process will include an update of all credentialing information, as well as the following:

  • Correspondence between the medical management program and the provider
  • Actions of the utilization and quality improvement committees
  • Economic and medical utilization data
  • Compliance with Horizon NJ Health policies and procedures
  • Patient satisfaction or complaint response information
  • Other pertinent data recommendations will be made to the medical director if any change in participation status is deemed necessary


Subrogation by Horizon NJ Health operates in compliance with the requirements of Department of Health and Senior Services Bulletin No. 01-11 and the New Jersey Supreme Court ruling Perreira v. Rediger et al., A-145-99.

To help control health care costs, Horizon NJ Health is obligated to attempt to recover payments made for medical services that result from injuries caused by the negligence or wrongful acts of another person.

Subrogation clauses in the State Contract permit the State of New Jersey to recover benefit payments from a third party who is determined to be liable.

Since subrogation cases are often not settled until months after an accident, Horizon NJ Health will not delay claim payment until litigation is final or a settlement is reached. Payment will be made and recovery will be pursued by the State of New Jersey.

If a member is injured or becomes ill through the act of a third party, Horizon NJ Health is responsible for providing care to that individual and then identifying that individual to the New Jersey Department of Human Services.

In cases where there is a legal cause of action for damages, the Department of Human Services has the sole and exclusive right to pursue and collect payments when a legal cause of action for damages is instituted on behalf of a Medicaid enrollee against a third party or when the state receives notice that legal counsel has been retained by or on behalf of any enrollee.

If services are provided to a member who is ill or injured as the result of a third party action, the provider must notify Horizon NJ Health. Even after a claim has been made, the provider should notify Horizon NJ Health of any lawsuits or legal action for which they are aware and that are related to the injury or condition treated. For questions, contact MLTSS Provider Services at 1-855-777-0123.

Treatment of Minors Policy

Provider agrees to provide medical treatment to minors in accordance with applicable law; and, to the extent required, treatment will be in accordance with the wishes of parent(s) or other person(s) having legal responsibility for the minor's medical care.

Under certain circumstances, New Jersey law authorizes minors to make health care decisions on their own behalf. Horizon NJ Health will not deny access to medical care in the following situations:

  • Minors presenting themselves for family planning services, maternity care or sexually transmitted diseases (STD) services
  • Minors 14 years or older presenting themselves for drug/alcohol or mental health treatment

Americans with Disabilities Act

All physicians and health care professionals agree to comply with the Americans with Disabilities Act of 1990 (ADA), all amendments to that act and all regulations promulgated thereunder. Horizon NJ Health is required by the State of New Jersey to conduct a formal ADA physician survey. Horizon NJ Health also conducts a special needs survey. If you have not completed either survey, please do so at your earliest convenience.

The surveys will provide handicap accessibility information regarding your practice facility or business location and information regarding your experience in treating members with special facility or business needs. Your responses will provide helpful information to special needs members, their families and caretakers, including other physicians who might require this information.

You will find ADA survey and special needs survey forms on the Horizon website. Please follow the directions below to complete the surveys. The surveys will take approximately 10 minutes to complete.

ADA Provider Survey

  • Read the survey thoroughly
  • Answer each question appropriately
  • Sign and date the survey
  • Please use black or blue ink

Note: If you have 15 or fewer employees at your location, please complete only questions 1-4 (a-g) and sign Statement II on page 6 of the survey.

Special Needs Survey

  • Read the survey thoroughly
  • Answer each question appropriately
  • Sign and date the survey
  • Please use black or blue ink

The surveys are considered complete once you have recorded your responses to all applicable questions, and signed and dated both surveys. Providers specializing in the treatment of members with developmental disabilities must have adequate support staff to meet the needs of these patients.

Once you have completed and signed the ADA provider survey and the special needs survey, please fax the forms to 1-609-583-3004 or mail the forms to the following address:

Horizon NJ Health
Attn: Provider Contracting & Strategy Department
1700 American Blvd.
Pennington, NJ 08534

Find out more about ADA on the Department of Justice website or call them at 1-800-514-0301.

If you have any questions regarding this survey, you may call our Provider Services at 1-800-682-9091. A Provider Services Representative is available to assist your office weekdays from 8 a.m. to 5 p.m.

Domestic Violence Reporting

The health care provider is a primary source in identifying members who may have been subjected to domestic violence. Domestic violence includes both abuse and battery. Abuse is a pattern of coercive control that one person exercises over another. Battery is a behavior that physically harms, arouses fear, prevents a partner from doing what they wish or forces them to behave in ways they do not want.

State law requires the reporting of child abuse. Reporting can be done anonymously. Report any injuries from firearms and other weapons to the police. Immediately report any suspected child abuse or neglect to the Division of Child Protection and Permanency at 1-877-NJABUSE (1-877-652-2873). Calls can be received 24 hours a day, seven days a week.

The provider is responsible to report suspected cases of elder or partner abuse, neglect or exploitation that occurs in the community. Immediately report any suspected elder or partner abuse to the state's Department of Adult Protective Services at 1-609-588-6501.

State law provides immunity from any criminal or civil liability as a result of good faith reports of child abuse or neglect. Any person who knowingly fails to report suspected abuse or neglect may be subject to a fine up to $1,000 or imprisonment up to six months. To help identify domestic violence, the below questions have been developed by the Family Violence Prevention Fund.

Domestic Violence Screening Tools

Framing Statements:

  • Because violence is so common in many people's lives, I've begun to ask all my patients about it.
  • I'm concerned that your symptoms may have been caused by someone hurting you.
  • I don't know if this is a problem for you, but many of the women I see as patients are dealing with abusive relationships. Some are too afraid or uncomfortable to bring it up themselves, so I've started asking about it routinely.

Direct Verbal Questions:

  • Are you in a relationship with a person who physically hurts or threatens you?
  • Did someone cause these injuries? Was it your partner/husband?
  • Has your partner or ex-partner ever hit you or physically hurt you? Has he ever threatened to hurt you or someone close to you?
  • Do you feel controlled or isolated by your partner?
  • Do you ever feel afraid of your partner? Do you feel you are in danger? Is it safe for you to go home?
  • Has your partner ever forced you to have sex when you didn't want to? Has your partner ever refused to practice safe sex?

Change in Address

A Horizon NJ Health for change of information form must be completed and request in advance when a participating physician or provider changes phone numbers, practice locations, billing address, tax ID or any operational changes, such as business hours.

The guide for updating information can be found on our Demographic Updates web page. Requests may be submitted to, or mailed to:

Horizon BCBSNJ
3 Penn Plaza East
Mail Station PP 14 C
Newark, NJ 07105

Please allow 30 days for processing time.

Workers' Compensation

Workers' compensation covers any injury or illness that is the result of a work-related accident. Employers purchase the insurance. You should always bill the workers' compensation carrier for work-related illnesses or injuries.

Payment will not be made for services provided to a member for any injury, condition or disease if payment is available under workers' compensation laws.

Financial Disclosure

If you have annual revenues from Horizon NJ Health in excess of $25,000, you agree to cooperate with Horizon NJ Health in the disclosure of significant business transactions between you and Horizon NJ Health. Transactions to be reported include any sale, exchange or leasing of property, any furnishing for consideration of goods, services or facilities (but not employee salaries) and any loans or extensions of credit.

Corrective Action

Horizon NJ Health is committed to working cooperatively with participating physicians to resolve any identified areas of noncompliance with administrative or quality standards. In order to prevent and avoid such noncompliance, all attempts will be made to educate our physicians on our policies and procedures.

Steps in the corrective action process include, but are not limited to, the following:

  • Provider notification of Horizon NJ Health standards and clinical practice guidelines. (See Appendix A Preventive and Clinical Guidelines.)
  • Provider is monitored against these guidelines.
  • Administrative or quality-of-care issues are identified by Horizon NJ Health staff and reviewed by the medical director.
  • Medical director identifies deficiencies that need to be reviewed by the Peer Review Committee (hereafter identified as the “committee.”)
  • If the committee or medical director identifies a concern, the provider is notified and given the opportunity to respond before a final determination is made.

The Corrective Action Program contains important safeguards for the provider to ensure that all decisions are made fairly with the goal of improving quality of care and service to our members.

Sanctions and Appeals of Sanctions

It is the goal of Horizon NJ Health to resolve identified provider deficiencies in a fair manner, which allows an opportunity for provider education and fair due process, where indicated. When non-compliance significantly affects the quality of care provided to the member, Horizon NJ Health may impose sanctions through the Corrective Action Program. Sanctions will only be imposed after a thorough review of the issue.

Severity Levels of Sanctions

Level Zero: No quality-of-care or service issue and/or no evidence of failure to comply with documented administrative policies and procedures.

Level One: Includes failure to comply with documented administrative policies and procedures of, and contractual obligations with, Horizon NJ Health (i.e., EPSDT, Case Management, Quality Management, Claims, Recipient Restriction, Pharmacy, Provider Services and Grievances).

Examples include but are not limited to:

  • Failed site evaluation
  • Failed medical record review
  • Failure to precertify procedures
  • Failure to comply with complaint protocol

Level Two: Will be imposed upon providers who have greater than five occurrences of Level One sanctions or for activities that are documented quality-of-care concerns.

Examples include but are not limited to:

  • Documented pattern of member complaints
  • Grossly negligent professional behavior
  • Quality-of-care and/or service concerns

Sanctions and Appeal Process

  1. The Quality Peer Review Committee (QPRC) will send the provider a letter outlining the decision and committee recommendations, including an action plan, if applicable. Actions that can be taken related to identified deficiencies include, but are not limited to:
    1. Individual provider education
    2. Educational seminars
    3. Request for a corrective action plan
    4. Site visit
    5. Freezing of patient panel and/or incentive payment
    6. Termination from the provider network
  2. Following the QPRC determination, the file is forwarded to the Quality Management Department and a copy of the resolution letter is placed in the file. If the provider does not respond within 30 days from the initial QPRC determination, a copy of the resolution letter is forwarded to Horizon Blue Cross Blue Shield of New Jersey's Credentialing Department to place in the provider's credentialing file. The requested corrective action plan(s) are tracked for receipt.
  3. A corrective action plan, if requested, is due within 30 days of receipt of our letter. When the plan is received, it will be reviewed by a medical director and forwarded to the next QPRC meeting. The QPRC determines if the plan is accepted. If it is accepted, the plan will be placed in the file and the case closed. If the plan is not accepted, a committee member will contact the provider, either by telephone or mail, to identify the areas of concern and await a response, which is due within 10 days. If no plan is received within 10 days, the case will be brought back to the QPRC for further action.
  4. If the provider does not agree with the determination of the QPRC regarding a Level One or Level Two Sanction, the provider may appeal the decision in writing to the Quality Management Department within 30 days of receipt of the determination to request a hearing.
  5. A Hearing Committee shall be established to preside over the hearing, which shall take place within 30 days. The committee shall consist of at least three people, at least one of whom must be a clinical peer in the same or substantially similar discipline and specialty as the health care professional. This peer may not be an employee of Horizon NJ Health, but shall be a participating provider who is not otherwise involved in the plan management. If the health care professional consents, the hearing may be conducted by conference telephone or any means of communication by which all persons participating in the hearing are able to hear each other. The decision of the committee shall be by majority vote.
  6. If applicable, after the close of the First Level Hearing, the provider is notified of the Hearing Committee's decision within 30 days. If the provider does not respond within 10 days to the First Level Hearing determination, a copy of the resolution letter is forwarded to Horizon Blue Cross Blue Shield of New Jersey's Credentialing Department to place in the provider's credentialing file.
  7. If the provider does not agree with the First Level Hearing decision, the provider has the right to submit a second level appeal request in writing, within 10 days, directly to either the chief medical officer if appealing a professional competency action, or the president/chief operating officer or designee if appealing an administrative action. The chief medical officer or the president/chief operating officer or designee shall then convene a Second Level Appeal Hearing Committee, which shall consist of at least three people who were not involved with the First Level Appeal. Furthermore, the Second Level Appeal Hearing Committee shall include at least one provider who is a clinical peer in the same or substantially similar discipline and specialty as the health care professional. This peer, as in the case of the First Level Hearing Committee, may not be an employee of Horizon NJ Health, but still may be a participating provider who is not otherwise involved in the plan management. The Second Level Appeal Hearing Committee shall conduct a hearing, as described in Section 6, and issue its decision with the exception that no further appeal rights following the Second Level Appeal shall be available, as described. As such, the decision reached through this Second Level Appeal process shall be final.
  8. At the conclusion of the Second Level Hearing, the provider is notified of the Second Level Hearing committee's decision within 30 days and a copy of the resolution letter is forwarded to Horizon Blue Cross Blue Shield of New Jersey's Credentialing Department to place in the provider's credentialing file. If formal sanctioning proceedings are implemented and the outcome is not in favor of the provider, the National Practitioner Data Bank may need to be notified depending on the severity of the deficiency and the associated sanction and corrective action.


Providers must notify Horizon NJ Health 90 days prior to their intent to terminate their contract. Written notifications must be sent by certified mail to:

Horizon NJ Health
Professional Contracting & Servicing Department
1700 American Blvd.
Pennington, NJ 08534

Horizon NJ Health will notify members of the provider termination at least 30 days prior to the termination date.