Breastfeeding is a key source of nutrition for infants. As a reminder, no authorization, prescription or referral is needed for Manual or Standard Electric breast pumps. For more information on breast pumps for members, refer to Section 13.16 of the Provider Administrative Manual.

Getting the right behavioral health care is important. It is important to ensure our members are receiving safe, effective and coordinated care especially for behavioral health care. The Quality Management Program does reviews of randomly selected behavioral health outpatient providers. Patient treatment records are reviewed according to best clinical practice guidelines in addition to medical record-keeping standards outlined in the Provider Administrative Manual.

This process helps monitor and evaluate the care our members receive, and identify areas of strength and opportunities for improvement. Providers who score below 80 percent must submit a corrective action plan. These providers will also be reviewed again at a future date to ensure compliance standards are met.

2020 Results

In 2020, 242 member records, submitted by 49 behavioral health providers, were reviewed. Here are the results:

These results demonstrate an opportunity for improvement in the coordination of care between medical and behavioral health services. To achieve optimal care, we encourage you to discuss with patients the importance of sharing information among all doctors and health care professionals involved in their care. You can also get authorization from patients to release information and coordinate care between health care professionals.

All providers that participate in a Medicaid Managed Care Organization (MCO) are required to register with the state of New Jersey under the 21st Century Cures Act. Compliance is mandatory. Learn more about this mandate.

As more people get vaccinated and continue healthy practices, such as, social distancing and frequent hand washing, we are turning a corner to a “new normal”. But as we all move into a “new normal”, the hardships and struggles may still continue to affect everyone's lives.

Adults may be able to discuss their feelings of anxiety, stress and loss when questioned during office visits. However, young children and teens, who are experiencing stress, fear, grief and isolation, may not know how to express their feelings. Some may not understand their feelings or even know they are experiencing sadness and anxiety.

There are many resources available to help you when screening for mental and behavioral health issues in children and teens in the primary care setting. The American Academy of Pediatrics (AAP) recommends annual psychosocial/behavioral assessments for children and teens as part of their Bright Futures/AAP Recommendations for Preventive Pediatric Health Care.

Our Horizon Behavioral Health team is here to help support your patients in getting the treatment and care they may need. If your patient needs help, our dedicated care team is available 24/7 by calling 1-800-626-2212.

Additional resources:

• Bright Futures/AAP Recommendations for Preventive Pediatric Health Care
• Mental Health Screening and Assessment Tools for Primary Care
• The Survey of Well-being of Young Children (SWYC)
• Pediatric Symptom Checklist
• National Suicide Prevention Lifeline: 1-800-273-8255 (TTY) 711; Spanish: 1-888-628-9454
• Crisis Text Line: Text HOME to 741741

Pressure ulcers may be caused by pressure, shear, friction or a combination of all three. Once a pressure ulcer develops, care is complex and costly. Given the aging population and increase in co-morbidities associated with higher risk, such as diabetes, obesity and hypertension, it's expected that chronic wounds will continue to rise and challenge health care providers and systems.

The majority of pressure ulcers can be prevented. There are several risk-assessment tools available that can be used to assess a person's risk for developing a pressure ulcer.

Helpful resources:

• Braden Scale
• Common Questions about Pressure Ulcers

Do you have questions about our insurance and need to contact someone from Horizon NJ Health? If yes, review the list of our Professional Contracting and Servicing Staff on our Contact Us page.

Changes were recently made to our drug formulary. This formulary guide includes an explanation and listing of step therapy, quantity/age limits, and drugs requiring prior authorization. More information can be found on Pharmacy Medical Necessity Determination and Pharmacy Utilization Management Programs. Paper copies of the formulary are available upon request by calling Pharmacy Services at 1-800-682-9094.

Please note that our maximum days’ supply limit is 30 days. If, for medical reasons, members cannot be changed to preferred medications, please call our Pharmacy Department to request a prior authorization at 1-800-682-9094.

Please review the recent changes to our formulary.

Updated Formulary List

We encourage using generic drugs before using brand name drugs when appropriate. Generic drugs are the same as brand name drugs in quality, strength, purity and stability, as required by the U.S. Food and Drug Administration.

The following generic drugs are currently on the market or are expected to be on the market within the next three months:

Generic Drugs

There may be instances when you are overpaid for certain services. The Affordable Care Act requires providers to report and return overpayments to us within 60 days of self-identifying the overpayment.

Please send details of the overpayment, including a check written to ‘Horizon NJ Health’ and the claim ID(s), to:

Horizon NJ Health
Claims Services
PO Box 24077
Newark, NJ 07101-0406

If you have any questions, please call Provider Services at 1-800-862-9091, weekdays, from 8 a.m. to 5 p.m.

Providing access to care is important to your practice. We have adopted the following appointment scheduling standards to ensure timely access to quality medical care. Compliance with these standards will be audited by periodic onsite reviews of physician offices and phone calls.

Medical appointments

• Emergency services: immediately
• Urgent care: within 24 hours
• Symptomatic acute care: within 72 hours
• Routine care: within 28 days
• Specialist referrals: within four weeks or sooner, as medically indicated
• Urgent specialty care: within 24 hours of referral
• Baseline physicals for new adult enrollees: within 180 calendar days of initial enrollment
• Baseline physicals for new child enrollees and adult clients of Division of Developmental Disabilities (DDD): within 90 days of initial enrollment or in accordance with Early and Periodic Screening, Diagnostic and Treatment (EPSDT) guidelines
• Prenatal care: within three weeks of a positive pregnancy test (home or laboratory), within three days of identification of a high-risk pregnancy, within seven days during first and second trimester and within three days in third trimester
• Routine physicals: within four weeks for routine physicals for school, camp, work or similar
• Lab and radiology services: within three weeks for routine care and 48 hours for urgent care
• Wait time in office: less than 45 minutes
• Initial pediatric appointments: within three months of enrollment

Dental appointments

• Emergency dental treatment: no later than 48 hours, as condition warrants
• Urgent care appointments: within three days of referral
• Routine non-symptomatic appointment: within 30 days of referral

Mental health/Substance Use Disorder appointments (DDD, MLTSS and FIDE-SNP only)

• Emergency services: immediate; urgent care within 24 hours
• Routine care: within 10 days of request
• Waiting time in office: less than 45 minutes

We follow clinical and preventive guidelines for the care we give to our members. These guidelines are determined by evidence-based medicine and rigorous review of published medical literature. For more details, review our list of Clinical Practice Guidelines.

Members have rights, responsibilities and choices in the care they receive. To find member rights and responsibilities, please direct members to their Member Handbook or select one of the options below, depending on the line of business.

• Medicaid Member Rights & Responsibilities
• FIDE SNP Member Rights & Responsibilities

We know you have to talk with many of your patients about the dangers of falling. Falls are a threat to the health of older adults and can reduce their ability to remain independent. There are proven ways to reduce and prevent falls, even for adults age 65 years and older.

To prevent falls, please encourage your patients to:

• Do strength and balance exercises
• Have their eyes checked
• Make a fall-safe home by getting rid of items they can trip over and installing grab bars and rails

Resource: CDC

When your office has routine and non-urgent utilization or medical management determination-related inquiries, our Utilization Management (UM) staff is accessible to you by:

• Visiting NaviNet
• Calling 1-800-682-9094, weekdays, from 8 a.m. to 5 p.m., Eastern Time (ET)

A registered nurse or physician (medical director) is available during and after business hours by phone 24/7 to render urgent medical management determinations or to address inquiries.

Getting information about UM Decisions

When UM decisions are made, members are notified about their approval or denial by mail. This notification includes information about appeal rights. Prior authorizations are valid only for the dates requested. If you disagree with any medical necessity decisions or want more information on the UM criteria, please see Section 10 of the Provider Administrative Manual regarding appeal rights, or call our UM Medical Appeals Department at 1-800-682-9094 ext. 89606, weekdays, from 8 a.m. to 5 p.m. ET.

UM ethical standards

We do not compensate those responsible for making UM decisions in a manner that provides incentive to deny or approve coverage for medically necessary and appropriate covered services. We also do not offer our employees performing UM review incentives to encourage denials of coverage or services that are medically necessary, and do not provide financial incentives to hospitals, physicians and other health care professionals to withhold covered health care services that are medically necessary and appropriate.

Do you have a patient with complex medical conditions who needs help getting appropriate medical care? If so, refer them to our Case Management team.

Your patients' caregivers play an important role in your patients' lives. These caregivers may also need help caring for loved ones. Read more to find community resources you can provider to caregivers.