www.HorizonBlue.com
September/October 2012
Blue Review
A newsletter for participating physicians and other health care professionals,
acute care facilities and ancillary staff
Educate your patients on
nutrition and remind them that
sensible diet choices lead to a
longer and healthier life.
Electronic Claims
Submission
Helping members
make informed
health care decisions
September/October 2012
Table of Contents
Ease of navigating the health care system
Access to effective and safe care
1 Electronic Claims Submission
2 Take advantage of the proposed delay to ICD-10
3 Need to correct a claim? Just call us!
Claims system consolidation update
4 Electronic Fund Transfer (EFT) requirement
6 Do you need to use a Type 2 NPI?
7 Rendering, referring and admitting NPI information required
8 Claims editing updates
10 How to submit medical attachments through NaviNet
11 Changes to ancillary claims processing
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21
22
24
Addressing health care costs
12 Working to stop fraud, waste and abuse
Healthier members ...
healthier communities
13 September calendar
October calendar
14 Better outcomes through better communication
15 Childhood and adolescent well visits
16 Helping patients understand vaccines and immunizations
18 Our Chronic Care Program
You can access our hospital,
physician and ancillary provider
office manuals online.
Log in to www.NaviNet.net and select Horizon
BCBSNJ within the Plan Central dropdown menu.
Mouse over References and Resources and
click Provider Reference Materials.
Click the link to the appropriate office
manual within the User Guides section.
Updated versions of our physician and ancillary
provider office manuals will be available
later this year.
2012 Radiology/Imaging Network Update
Formulary reminder
Advantage formulary: New class added
Formulary changes announced
LabCorp update
New online resource: Magellan introduces
Behavioral Health Toolkit for medical professionals
Service excellence
25 Horizon Blue Cross Blue Shield of New Jersey names new
Executive Vice President, Healthcare Management
26 Prestigious award received for service to network hospitals
27 Save the date: 2012 Network Hospital Forums
28 New Medicare Advantage plan offered in 2013:
Horizon Medicare Blue Group (PPO)
30 Don’t miss our health care professional webinars!
31 Pharmacy benefits management contract transitions to
Prime Therapeutics, LLC
32 Help us maintain and present accurate information
about your practice
34 Review our credentialing and recredentialing policy online
35 Improving your online experience with our redesigned website
36 Dental benefits under Horizon Medicare Blue TotalCare
(HMO SNP)
38 Working together to improve HEDIS results
40 Helping members make informed health care decisions
41 At your service
Icons throughout the newsletter will alert
you to articles relevant to your area.
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Ancillary Facilities (Ambulatory Surgery Centers,
Dialysis Centers, Hospice Agencies, Rehabilitation
Centers, Skilled Nursing Facilities, etc.)
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Ancillary Professionals (Ambulance, Durable
Medical Equipment Suppliers, Home Infusion,
Orthotics, etc.)
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Acute Care Facilities
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Physicians and Other Health Care Professionals
Interacting with you is just another way we’re Making Healthcare Work.
Horizon Blue Cross Blue Shield of New Jersey
has joined active users on Facebook with our
own corporate page,
<www.facebook.com/HorizonBCBSNJ>.
You can stay up to date with the latest
company news and health and wellness
information. Follow us on TwitterTM,
<www.twitter.com/HorizonBCBSNJ>.
TM
See an introductory video explaining
how we’re transforming the health
care delivery system in New Jersey,
<www.youtube.com/BCBSNJ>.
Learn how your patients can stay
connected with Horizon Blue
Mobile anytime, anywhere,
<mobile.HorizonBlue.com>.
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Electronic Claims Submission
orizon Blue Cross Blue Shield of
New Jersey requires you to submit
claims electronically1 either through
an Electronic Data Interchange (EDI) vendor
or through NaviNet®.
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EDI
To enroll with an Electronic Data Interchange
(EDI) vendor, please call EMDEON at
1-866-369-8805.
If you are currently enrolled with an EDI
vendor and need help submitting your claims,
please contact your vendor or call EMDEON at
1-866-369-8805.
NaviNet
If you have a small claim volume
(i.e., less than 20 claims per month), you may
submit claims free of charge online through
NaviNet. To submit claims online, log in to
www.NaviNet.net, access Horizon BCBSNJ
within the Plan Central dropdown menu and:
• Mouse over Claim Management and click
CMS 1500 Claim Submission or
UB04 Claim Submission.
All participating offices are under a
contractual obligation to comply with the
electronic claims submission requirement.
We reserve the right to review the participation
status of offices that do not demonstrate an effort
to comply with this requirement. If you have
legitimate reasons why you cannot comply with
this requirement, please contact your Network
Specialist.
Thank you in advance for your cooperation.
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Coordination of Benefit claims can be submitted electronically via a
clearinghouse, but not through Horizon BCBSNJ’s website at this time.
Presently, claims that require medical attachments cannot be submitted
electronically. Medical records should only be sent when requested by
Horizon BCBSNJ. An unsolicited medical attachment, sent in with a hard
copy claim, violates the electronic claim submission requirement of your
agreement.
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Take advantage of the proposed delay to
ICD-10
n response to an announcement by the
Centers for Medicare & Medicaid Services
(CMS) to re-examine the timeline for ICD-10
implementation, the Department of Health and
Human Services (HHS) proposed a rule that
would extend the ICD-10 compliance deadline
until October 1, 2014.*
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Horizon Blue Cross Blue Shield of New Jersey’s
ICD-10 Program Management Office has refined
its ICD-10 Implementation Plan based on the
proposed one-year delay and continues to engage
providers and business partners critical to the
success of its transition to ICD-10.
In light of the challenges experienced in the
conversion to HIPAA 5010, we urge you to take
advantage of the proposed delay. Plans and
preparation for ICD-10 will take a long time to
complete, so try to do as much as possible during
this delay to ensure that your practice continues
to operate efficiently throughout the transition to
ICD-10.
What you can do now
Here are ways you can make the most of this
extra time:
• Conduct a thorough in-office analysis to
identify day-to-day processes that are
impacted by ICD-10, if you have not done
so already.
• Consider how ICD-10 coding changes will
impact your practice and think about a plan
to accommodate increased coding
requirements. The American Health
Information Management Association
(AHIMA) estimates that it will take almost
twice as long for a coder to code under
ICD-10, and that medical practices should
expect a permanent 10 to 25 percent loss of
coding productivity.
• Consider the impact of ICD-10 to your cash
flow caused by delays in claims submission
and reimbursement.
• Speak to your payers, billing service,
clearinghouse and software vendors
about their plans for ICD-10.
Stay up-to-date on ICD-10
We want to help you to stay up-to-date on
ICD-10. For guidelines to help you define an
ICD-10 implementation strategy, log in to
www.NaviNet.net, access Horizon BCBSNJ
within the Plan Central dropdown menu and:
• Click Provider Reference Materials.
• Then, click ICD-10.
Visit the following websites for tools
and information on ICD-10:
•
•
•
•
<www.cms.gov/icd10>.
<www.himss.org/icd10playbook>.
<www.ahima.org/icd10>.
<www.aapc.com/icd-10>.
If you have questions about ICD-10,
please contact your Network Specialist,
Hospital Relations Representative or
Ancillary Account Executive or e-mail
<[email protected]>.
* At time of publication, the final rule for ICD-10 compliance is still to be
announced. Some of the content in this article is from publicly available
sources and has been adapted by Horizon BCBSNJ to pertain to our network
participants.
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Need to correct a claim?
Just call us!
orizon Blue Cross Blue Shield of
New Jersey is pleased to announce a
change to our process for handling
corrected claims.
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As of June 2012, physician and institutional
services representatives can now accept missing
or corrected claim information over the
telephone. You are no longer required to submit
the information for most corrected claim
situations in writing.*
Inquiry Request and Adjustment Form (579)
still available
If you prefer, you may still submit corrected
claim requests by mail using our Inquiry
Request and Adjustment Form (579).
This online form is a “fill-able” PDF, which
allows you to complete the required fields
online and then print the form for submission.
Doing so allows us to use Optical Character
Recognition (OCR) software to speed our ability
to assign, investigate and resolve your inquiries.
To access the Inquiry Request and
Adjustment Form (579), visit
www.HorizonBlue.com/Providers and access
the Forms section.
If our claim investigation results in a change to
the claim reimbursement amount, Horizon
BCBSNJ will send an Explanation of Payment
(EOP) to the billing address we have on file. If
the claim adjustment does not result in a change
in the claim payment amount, we will respond
directly to the name and address on the 579 form.
If you have questions, please call the
appropriate contact listed below. Representatives
are available to help you Monday through Friday,
between 8 a.m. and 5 p.m., Eastern Time.
If you are a …
Call …
At …
Physician or
other health care
professional
Physician Services
1-800-624-1110
Representative
at an acute care
or ancillary facility
Centralized Service
Center
1-888-666-2535
Do not use the 579 form for initial
claims submissions.
* This new process does not pertain to claims processed by
CareCore National, LLC for radiology services. Please use our 579 form
to add multiple bill lines not included in the original claim submission.
Claims system consolidation update
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orizon Blue Cross Blue Shield of New Jersey continues to transition plans, groups and
members to the NASCO Processing System (NPS). These transition efforts do not impact
the benefits of the groups and members involved.
New ID card prefixes
New ID cards, which include new prefixes, are issued to members and their dependents prior to their transition to the
NPS. Remember to:
• Ask your Horizon BCBSNJ patients to present their current ID card at each visit. Photocopy both sides of the ID card.
• Use the new prefix to ensure proper eligibility and claim processing.
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Electronic Fund Transfer (EFT) requirement
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orizon Blue Cross Blue Shield of New Jersey requires that all* participating physicians,
other health care professionals, ancillary professionals and ancillary facilities use EFT.
Our online EFT training course provides step-by-step instructions on what you need to
do to complete the EFT registration process.
To access this online course, registered NaviNet® users may log in to www.NaviNet.net and
select Horizon BCBSNJ within the Plan Central dropdown menu:
• Mouse over References and Resources and click Provider Reference Materials.
• Click Educational Classes.
• Click Electronic Funds Transfer.
If you have questions, please contact your Network Specialist or Ancillary Reimbursement Analyst.
EFT Penny Test
Some offices have expressed confusion about one very important step in the EFT
registration process – confirming the penny test deposits. Here’s how it works:
A few days after you submit your bank information through NaviNet, we will perform
two test deposits (of less than a dollar) into your account to ensure that we have the
correct account information. Your EFT registration is NOT complete until you log in to
NaviNet and systemically confirm that the test deposits were successful.
To complete the EFT registration process, you MUST:
• Access your bank account and check that the test deposits were received.
• Make a note of the amounts deposited.
• Access NaviNet to confirm the test deposits were successful. Log in to
www.NaviNet.net and:
– Select Horizon BCBSNJ within the Plan Central dropdown menu.
– Mouse over Claim Management and click EFT Registration.
If within a week of completing the initial stage of EFT enrollment you do not receive the
test deposits, please contact the Horizon BCBSNJ e-Service desk at 1-888-777-5075 or
e-mail <[email protected]>.
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For participating physicians, other
health care and ancillary professionals:
EFT registration is performed through NaviNet® .
To register for EFT, log in to www.NaviNet.net,
access the Horizon BCBSNJ Plan Central page
and:
• Mouse over Claim Management and click
EFT Registration.
• Click Enroll.
You must confirm receipt of test deposits within
30 days to complete your EFT registration.
If you’re not registered with NaviNet , please visit
www.NaviNet.net and click Sign up.
For ancillary facilities:
To start the EFT registration process, please
complete our EFT Application for Ancillary
Facilities form and mail it to:
Horizon BCBSNJ
Attn.: Angela Gazzillo, WL-03A
Ancillary Reimbursement
1427 Wyckoff Road
Wall, NJ 07727-3918
To access the EFT Application for Ancillary
Facilities (5922) form, visit
www.HorizonBlue.com/Providers and access
the Forms section.
If you have questions about this form or the process
for ancillary facilities, please contact your
Ancillary Reimbursement Analyst.
* Oral surgeons and others who perform dental services are exempt from our EFT
requirement. Our Dental Explanations of Payment (EOPs) are not available in
electronic format. To ensure that oral surgeons and others who perform dental
services continue to receive Dental EOPs, we ask that these practitioners not register
for EFT until further notice.
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How to register for EFT
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6
Do you need to use a Type 2 NPI?
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or more than four years, Horizon Blue Cross Blue Shield of New Jersey has required physicians
and other health care professionals who conduct standard transactions or submit claims to a
third-party vendor for processing to include their National Provider Identifier (NPI) information.
Practices that are incorporated or established
as a partnership or corporation Limited Liability
Company (LLC) are required to include both
Type 1 (Individual) NPI information and Type 2
(Organization) NPI information on claim
submissions.
If you are unsure of which types of practices
are required to submit Type 1 and Type 2 NPI
information, please review the following
questions and answers.
Q: Does a physician or other health care
professional who has a sole proprietorship
need to obtain and use two NPI numbers?
A: No. A sole proprietorship is a form of
business in which one person owns all of
the assets of the business and is solely liable
for all the debts of the business in an
individual capacity. Sole proprietorships
are not considered organization health care
providers for purposes of the NPI Final Rule
and thus cannot obtain a Type 2
(Organization) NPI.
Q: Does a sole practitioner who is
incorporated need to obtain and use
two NPIs?
A: Yes. A sole provider who is incorporated
needs to obtain both a Type 1 (Individual)
NPI and a Type 2 (Organization) NPI. If a
practitioner incorporates him/herself as a
health care provider, that corporation/
organization is required to obtain and use
a Type 2 (Organization) NPI.
Q: Does a physician or other health care
professional who has formed an LLC
need to obtain and use two NPIs?
A: It depends on how the LLC is set up.
• Practitioners who form a single-member
LLC (i.e., disregarded entities) are only
eligible for a Type 1 (Individual) NPI.
• Providers classified as a partnership or
corporation who have formed an LLC
are required to obtain both Type 1
(Individual) and Type 2 (Organization)
NPIs.
Q: If I am incorporated, how should I submit
electronic claims?
A: When submitting electronic claims, you must
ensure the appropriate 837P Billing Loop.
Below are Horizon BCBSNJ Billing Loop
(2010AA) requirements. Please share these
requirements with your clearinghouse,
practice management system vendor,
third-party vendor and/or information
technology department to ensure accurate
processing of your electronic transactions.
When billing as a corporation/organization:
• Data element NM102 is equal to 2.
• The group’s NPI is submitted in data
element NM109.
• The Group Billing Provider Tax ID number
is submitted in data element REF01 with
the qualifier of EI.
• The group’s nine-digit Tax ID Number is
submitted in data element REF02.
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When billing as a sole proprietor:
• Data element NM102 is equal to 1.
• The individual provider’s NPI is submitted in the data element NM109.
• The Individual Billing Provider Tax ID number is submitted in data element REF01 with
the qualifier of EI.
• The individual’s nine-digit Tax ID number is submitted in data element REF02.
If you have any questions, please call your Network Specialist.
Don’t have an NPI?
To apply for an NPI from the Centers for Medicare & Medicaid Services:
Visit https://nppes.cms.hhs.gov or call 1-800-465-3203.
7
To register your NPI with us:
• Visit <www.HorizonBlue.com/Providers> and access the Forms section.
• Select the appropriate form:
- National Provider Identifier (NPI) Collection Form for Individual
Practitioner/Physician (19418).
- National Provider Identifier (NPI) Collection Form for Facility/Group/Practice (19419).
• Complete the form and fax it to 1-973-274-4416.
Rendering, referring and admitting
NPI information required
orizon Blue Cross Blue Shield of
New Jersey is capturing National Provider
Identifier (NPI) information on claims
submissions to identify rendering, referring and
admitting physicians.
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Please ensure that all electronic and paper
copy claim submissions include this important
NPI information, as appropriate.
If you have technical questions about NPI
or questions regarding electronic transactions,
please call our e-Service Desk’s Electronic Data
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Interchange (EDI) team at 1-888-334-9242,
Monday through Friday, between 7 a.m. and
6 p.m., Eastern Time. Or, you may e-mail your
inquiry to <[email protected]>.
Include rendering, referring
and admitting physician NPI
information on all claim
submissions.
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Claims editing updates
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orizon Blue Cross Blue Shield of New Jersey continues to enhance its claims auditing for
professional and facility claims.
On or about October 29, 2012, the claim edits listed in the chart below will be applied to help
ensure claim payments are accurate and consistent with standard business practices.
Edit Type
This Edit…
Supplies –
Same-Day Surgery
Denies claim lines for supplies and/or materials when billed for the same member, by the same
provider, on the same date of service as a surgical procedure.
Outpatient Consultations
Denies claim lines for an outpatient consultation when another outpatient consultation was billed
for the same member, by the same provider, with at least one matching diagnosis within the
previous six months.
Inpatient Consultations
Denies claim lines for an inpatient consultation when another inpatient consultation was billed for
the same member, by the same provider, with at least one matching diagnosis within a
five-day period.
Obstetrics Package
Evaluates claim lines to determine if any global obstetric care codes were submitted with
another global OB care code or a component code (e.g., antepartum care, postpartum care or
delivery-only services) during the average length of time of the typical pregnancy and postpartum
period as applicable (280 and 322 days, respectively).
CMS Always Bundled
Denies claim lines for procedure codes indicated as “always bundled” by CMS when billed with
any other procedure not indicated as “always bundled” for the same member, by the same provider,
on the same date of service. This edit allows bundled codes if billed alone or if billed only with
other procedure codes indicated as “always bundled.”
Custom Medical Policy
Denies claim lines for services or supplies that are considered experimental/investigational,
cosmetic and/or “not medically necessary” according to Horizon BCBSNJ’s medical policies.
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New and revised medical policies
In compliance with Health Claims Authorization, Processing and Payment Act (HCAPPA)
requirements, we post online new policies and existing policies that have major revisions at least
30 days in advance of the policies’ effective dates. New policies and those existing policies that have
major revisions are identified with an asterisk to help you easily locate and review them.
To review our current, new and revised policies:
• Log in to www.NaviNet.net and select Horizon BCBSNJ within the Plan Central dropdown menu
and:
• Mouse over References and Resources and click Provider Reference Materials.
• To review a particular new or revised policy, simply click the link to the information you need
within the Medical Policy Updates section.
Medical Policy Manual
You can quickly access our entire Medical Policy Manual online. Log in to www.NaviNet.net and
select Horizon BCBSNJ within the Plan Central dropdown menu and:
• Click Medical Policies and PreCert.
• Click Medical Policy Manual.
If you have questions, please contact your Network Specialist, Hospital Relations Representative or
Ancillary Account Executive.
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Medical Policies are available online
We post our medical policies online to make it easy for you to access the information you need.
We encourage you to regularly review these policies.
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How to submit medical attachments
through NaviNet
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ou can submit medical attachments for certain claims online through NaviNet®. This feature
expedites our processes by providing us quicker access to required medical information.
To submit medical attachments to us through NaviNet, registered users may log in to
www.NaviNet.net select Horizon BCBSNJ within the Plan Central dropdown menu and:
• Mouse over Claim Management and click Claim Status Inquiry.
• Search for and locate the claim in question.
• Click the claim number to proceed to the Claims Detail screen.
• Click Submit Attachments within the Claims Detail screen.
• Within the Submit Attachments for Pre-Existing Condition screen that displays, select the
appropriate Attachment Type. We can accept attachments in the following formats: JPEG, JPG,
TIFF, TIF or PDF.
• Click Browse then locate and attach the appropriate file(s) from your computer. A maximum of
five attachments may be uploaded per submission. Each submission cannot exceed 10MB
(combined size) for all attachments.
• Click Submit Attachments.
• Record the Confirmation Number that is generated for easier and faster follow up with
Horizon BCBSNJ.
You can submit attachments for claims that are pended for more than seven days or finalized with
$0 paid. NaviNet will display an informational icon and message to let you know if you can submit an
online medical attachment.
If you need help with online medical attachments, please call the e-Service Help Desk at
1-888-777-5075. Representatives are available Monday through Friday, between 7 a.m. and 6 p.m.,
Eastern Time.
Attachment Types
You are able to submit any of the following types of medical attachments to us through NaviNet:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Ambulance Report.
Anesthesia Report.
Coordination of Benefits (COB) Questionnaire.
Complete Medical Record.
Consultant/Consultation Report.
Discharge Summary.
Durable Medical Equipment (DME)
Order/Letter of Medical Necessity.
Emergency Room Report.
Entire Psychiatric Record,
except Psychotherapy Notes.
History and Physical.
Laboratory Report.
Letter/Form of Medical Necessity.
Medication Report.
Occupational, Physical or Speech
Therapy Progress Notes.
• Occupational, Physical or Speech
Therapy Report.
• Operation Report.
• Pathology Report.
• Photos/X-rays.
• Physician/Nursing/Office Notes.
• Prescriptions/Orders.
• Psychiatric Assessment/Evaluation.
• Psychiatric Progress Notes.
• Psychiatric Team Conference Notes.
• Psychological Testing.
• Radiology Report.
• Sleep Study.
• Substance Abuse Record, except
Substance Abuse Therapy Notes.
• Treatment Plan.
Changes to Ancillary Claims Processing
orizon Blue Cross Blue Shield of
New Jersey is committed to providing our
members with access to effective and safe
care, while continuously improving our operating
efficiencies. Effective October 14, 2012, there will
be a change in how you will be required to file, and
how all Blue Plans, including Horizon BCBSNJ, will
process certain ancillary claims. The contiguous
county rules do not apply to the ancillary services
and products explained below.
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This change will impact where you file and how
we process these ancillary claims for all Horizon
BCBSNJ members, except for traditional Medicare
enrollees and FEP® plan members. You should
continue to submit your ancillary claims for
traditional Medicare enrollees and FEP members
as you do today.
Independent clinical lab – Effective
October 14, 2012, independent clinical laboratory
claims must be sent to the Blue Plan in the state
where the referring physician is located.
For example, if the referring physician is located
in New Jersey, send the claim to Horizon BCBSNJ
and the claim will process according to the lab’s
participating status with Horizon BCBSNJ.
However, if the referring physician is located in
Pennsylvania, the claim must be sent to the
Blue Plan in Pennsylvania and will process
according to the lab’s contractual relationship
with the Pennsylvania Blue Plan and consistent
with the member’s Home Plan benefits.
Durable Medical Equipment (DME) –
Effective October 14, 2012, claims for DME services
must be sent to the Blue Plan in the state in which
the equipment was delivered or purchased. The
claim will process according to the DME provider’s
contractual relationship with the Blue Plan.
For example, if the equipment is purchased from
a New Jersey DME retail store or delivered to a
New Jersey address, that claim must be sent to
Horizon BCBSNJ and will process according to the
DME provider’s contractual relationship with
Horizon BCBSNJ. However, if the equipment is
purchased by or delivered to a Horizon BCBSNJ
member in Pennsylvania, the claim must be sent to
the Pennsylvania Blue Plan and will process based
on the DME provider’s contractual relationship
with that Pennsylvania Blue Plan and consistent
with the member’s Home Plan benefits.
Specialty Pharmacy – Effective
October 14, 2012, specialty pharmacy claims must
be sent to the Blue Plan in the service area where
the ordering physician is located. The claim will
process according to the pharmacy’s relationship
with that Blue Plan.
For example, if the ordering physician is located
in New Jersey, send the claim to Horizon BCBSNJ
and the claim will process according to the
pharmacy’s participating status with Horizon
BCBSNJ. However, if the ordering physician is
located in Pennsylvania, the claim must be sent to
the Blue Plan in Pennsylvania and will process
according to the pharmacy’s contractual
relationship with the Pennsylvania Blue Plan and
consistent with the member’s Home Plan benefits.
Please refer your Horizon BCBSNJ patients
to in-network health care professionals
whenever possible and ensure you follow our
Out-of-Network Consent Policy. To find a
participating health care professional, visit
<www.HorizonBlue.com/Directory>.
Refer to participating providers
Please be sure you refer your patients to a
participating ancillary provider based on the above
guidelines. This change in claims processing may
impact your Horizon BCBSNJ’s patients’
out-of-pocket costs if they have out-of-network
benefits. For patients with no out-of-network
benefits, claims will be denied if they are not
referred to an in-network provider and the member
will be responsible for payment in full.
For more information about how independent
clinical lab, DME and specialty pharmacy claims
will be processed, please call Physician Services at
1-800-624-1110.
The referring physician is the physician that orders
or prescribes the care for the patient.
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Addressing health care costs
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Working to
stop fraud,
waste and abuse
ealth care fraud, waste and abuse
are national problems that affect
us all. According to the Federal
Bureau of Investigation (FBI), $80 billion
of the roughly $2.7 trillion the United States
spends on health care annually is lost to
fraud each year1.
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Health care fraud, waste and abuse can take
many forms, including:
• Billing for services that were not rendered.
• Upcoding: Charging for a more complex
service than what was actually provided.
• Medical identity theft: Patients presenting
stolen or counterfeit health insurance
information to receive services.
• Providing less than the fully prescribed
medication quantity to a member, but
billing for the fully prescribed amount.
We take health care fraud, waste and abuse
seriously. Each day, Horizon Blue Cross
Blue Shield of New Jersey’s Special Investigations
Unit works to uncover fraudulent activities and
recover monies paid as a result of such activity.
Participating physicians, other health care
professionals and facility staff are responsible for
ensuring that they have policies and procedures
in place to address fraud, waste and abuse.
Horizon BCBSNJ does not permit reprisal against
those who make good faith reports of potential
fraud, waste or abuse.
If you suspect that a member, health care
professional or employee of a health care facility
is committing fraud, please call our Special
Investigations Unit’s anti-fraud hotline at
1-800-624-2048.
As a Medicare Advantage and Medicare Part D
plan sponsor, we also work closely with the
Centers for Medicare & Medicaid Services (CMS)
to investigate and prosecute all instances of
fraud, waste and abuse involving those lines of
business. Our dedicated Medicare Part D fraud,
waste and abuse hotline is 1-888-889-2231.
You may also call Medicare Drug Integrity
Contractors at 1-877-7SafeRx (1-877-772-3379)
to report suspected fraud, waste and abuse
related to the Medicare Part D program.
Reminding our network about heath care
fraud, waste and abuse is one of the ways
Horizon BCBSNJ is addressing health care costs.
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The Federal Bureau of Investigation,
<www.fbi.gov/about-us/investigate/white_collar/health-care-fraud>.
Fraud, waste and abuse training
information
In May 2012, CMS developed a web-based training
module that can be used for compliance training on
the topic of fraud, waste and abuse. We encourage
you to complete this web-based training course.
To access the training, visit www.cms.gov and:
• Click Outreach and Education.
• Under Medicare Learning Network (MLN),
click MLN Products.
• Click Provider Compliance and scroll down to
Downloads, then click Medicare Parts C and
D Fraud, Waste and Abuse Training.
September calendar
National Childhood Obesity Awareness Month
Over the past 30 years, the rate of childhood obesity has more than tripled. During this month, we encourage you
to talk to parents/guardians of your young patients about the importance of healthy lifestyle habits, including healthy
eating, physical activity, and how to lower the risk of becoming obese and developing related diseases.
Source: <http://www.cdc.gov/healthyyouth/obesity/facts.htm>.
National Ovarian Cancer Month
September is National Ovarian Cancer Month and it is a great opportunity to discuss with your female patients the
early warning symptoms of this cancer.
Ovarian cancer is the eighth most common cancer among women nationally and it often goes undetected because its
early symptoms are not always evident. Since there is no simple or reliable screening test for ovarian cancer, it is
important to educate your female patients about the possible signs of ovarian cancer and to encourage them to pay
attention to any of the symptoms. Make your patients aware that early detection improves chances of effective
treatment.
Source: <http://www.cancer.org/cancer/ovariancancer/OverviewGuide/index>.
Prostate Cancer Awareness Month
The American Cancer Society recognizes September as Prostate Awareness month. It’s a good time to increase your
male patients’ understanding of this disease and help educate them about maintaining their prostate health.
Prostate cancer is the second leading cause of cancer death among men; when detected early, it also can have some
of the highest survival rates. Beginning at 50 years of age, men at average risk should start talking to their doctors about
prostate health. Men at higher risk should talk to their doctor about prostate testing earlier – African Americans,
beginning at 45 years of age and men who’ve had a first-degree relative diagnosed with prostate cancer, beginning at
40 years of age. For all men, information should be provided about what is known and what is uncertain about the benefits
and limitations of early detection tests and treatments so they can make informed decisions about testing.
Source: <http://www.cancer.org/MyACS/Eastern/AreaHighlights/newsroom-prostate-awareness>.
October calendar
National Breast Cancer Awareness Month
Early detection of breast cancer offers the best chance for survival. This is a great time to remind your patients about
scheduling a mammogram. Most Horizon Blue Cross Blue Shield of New Jersey members do not need a referral from their
Primary Care Physician or their Ob/Gyn for routine mammography services performed at a participating facility. However,
please give the member a prescription to present to the facility and ask them to call CareCore National LLC’s Scheduling Line
at 1-866-969-1234 to schedule a mammography appointment. Horizon BCBSNJ covers annual mammograms for women
ages 40 years and older.
Source: <http://www.cancer.org/Cancer/BreastCancer/MoreInformation/BreastCancerEarlyDetection/index>.
Source: National Health Information Center, <www.healthfinder.gov/nho/nho.asp>.
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Better outcomes through
better communication
ffective communication helps to improve
health care outcomes by ensuring that
patients better understand the
information, advice and instructions that you
provide. The ease with which patients can voice
their concerns and questions to you is an equally
important part of effective communication.
Establishing relationships with your patients that
are based on open communication makes it more
likely that patients will adhere to your treatment
plans and get the full benefit of your care.
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Through focus group sessions, our members
offered the following suggestions to help improve
communication with their health care
professionals:
• Before an appointment, become familiar
with your patient’s medical history,
including past tests, major illnesses,
allergies, medications and family history.
• Actively listen to your patient’s concerns
and answer questions in a manner and
language your patient can understand.
• Encourage your patient to participate in
health care decision-making and
treatment options (to the extent possible).
• Ensure that your patient understands the
medications you prescribe (e.g., directions
for use and any possible side effects).
• Summarize your plan of treatment, tests
and any follow-up care you are
recommending. Then ask your patient
to sum up, in his or her own words, the
information you conveyed to them.
We appreciate all that you do to help your
patients, our members, take a more active role
in their health.
Communicate the importance
of exercise and physical
activity.
• Ask patients if they exercise regularly.
• Encourage patients, especially older adults
who do not exercise, to begin a program of
activity.
• Help patients determine their optimum level of
activity and discuss increasing or maintaining
levels of physical activity to improve their
health.
Childhood and adolescent well visits
T
horough well-child care sets the stage for a lifetime of good health. Horizon Blue Cross
Blue Shield of New Jersey appreciates your help in raising awareness about the importance
of scheduling well visits.
During well-visit exams, be sure to:
• Calculate and record the body mass index (BMI) at ages 24 and 30 months and then
annually starting at age 3 years.
• Check immunization status and administer age-appropriate immunizations or catch up
on overdue immunizations.
• Talk to parents and guardians about protecting older children from Human
Papillomavirus (HPV).
– For females ages 11 through 18 years, either HPV4 or HPV2 is recommended in a
three-dose series, if not previously vaccinated.
– For males ages 11 through 18 years, HPV4 is recommended in a three-dose series,
if not previously vaccinated.
For more information about HPV vaccine, prevention, treatment and patient information
visit, <http://www.cdc.gov/std/hpv/>.
Immunization Documentation
Following well-visit exams, please ensure that your office staff documents immunization information in
the New Jersey Immunization Information System (NJIIS). New Jersey law mandates that all providers who
administer vaccines to children under age 7 years register to use the NJIIS and enter immunizations within
30 days of administration. Though not mandated, it is also beneficial to document immunizations in the NJIIS
for children age 7 years and older and for adults. For information about the NJIIS, please visit
<https://njiis.nj.gov/njiis/>.
Thank you for all you do to help our members
get and stay healthy.
Sources:
BMI calculator for children and teens, <http://apps.nccd.cdc.gov/dnpabmi/>.
New Jersey Immunization Information System, <www.njiis.nj.gov>.
American Academy of Pediatrics, Recommendations for Preventive Pediatric Healthcare, 2008,
<http://brightfutures.aap.org/pdfs/AAP%20Bright%20Futures%20Periodicity%20Sched%20101107.pdf>.
Sexually Transmitted Diseases (STDs), Human Papillomavirus (HPV), <http://www.cdc.gov/std/hpv/>.
Centers for Disease Control and Prevention, Vaccines and Immunizations, Immunization Schedules, Adolescent Schedule 2012,
<http://www.cdc.gov/vaccines/recs/schedules/>.
Centers for Disease Control and Prevention, Immunization Schedules, Childhood Schedule.2012,
<http://www.cdc.gov/vaccines/schedules/downloads/child/0-6yrs-schedule-pr.pdf>.
New Jersey Department of Health and Senior Services, Vaccine Preventable Disease Program, <http://nj.gov/health/cd/documents/njiis_mandate_faq.pdf>.
Centers For Disease Control and Prevention, <http://www.cdc.gov/>.
Recommendations and Guidelines: Advisory Committee on Immunization Practices, <http://www.cdc.gov/vaccines/recs/acip/default.htm>.
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Helping patients understand
vaccines and immunizations
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e are sure that you have met patients or parents of children who have objections or
concerns about the Centers for Disease Control and Prevention (CDC) recommended
immunization practices.
We appreciate all you do to help convey the
facts about immunizations to your patients. To
help you in this effort, below are some questions
and answers about common misconceptions
regarding vaccines and immunizations from the
CDC.
Misconception: Diseases had already begun to disappear
before vaccines were introduced because of better
hygiene and sanitation.
Fact: While improved hygiene and sanitation
certainly played a part in reducing the incidence
of many diseases, statistics clearly show a
dramatic drop in the number of cases for
immunization-preventable diseases after the
introduction of a vaccine.
For example:
• A newly licensed measles vaccine became
available in 1963. Before the vaccine there
were between 300,000 and 800,000 cases
of measles reported annually. By 1968,
there were only about 22,000 reported
cases of measles. By 1998, the number of
cases averaged about 100 or fewer cases
per year.
• There was an 85 percent drop in reported
chickenpox cases after the introduction of
the varicella vaccine in 1995. Chickenpox
infection rates would have dropped long
before 1995 if improved hygiene and
sanitation were responsible for the drop in
cases.
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Fact: Although no vaccine is 100 percent
effective, most routine childhood vaccines
are effective for 85 percent to 95 percent of
recipients, and most people have been
vaccinated. When there is an outbreak of
a vaccine-preventable disease, 5 percent to
15 percent of the vaccinated and 100 percent of
the unvaccinated people may become infected.
More vaccinated than unvaccinated people may
become infected but that’s only because there
are so many more vaccinated individuals.
Misconception: Since many diseases have completely
or at least nearly disappeared from the United States,
many parents think it is no longer necessary for their
children to be vaccinated against certain diseases.
Fact: Diseases like polio have not disappeared
from other countries and may even be
widespread in other parts of the world. Polio
could easily begin infecting unprotected
individuals if it were re-introduced to this
country. Measles is another example of a disease
that is not prevalent in the U.S. today. However,
visitors to or from other countries could easily
spread measles to unprotected Americans.
Misconception: A child’s immune system can be
“overloaded” if the child receives multiple vaccines
at once.
Fact: After a number of safety studies, the
Advisory Committee on Immunization Practices
(ACIP) and American Academy of Pediatrics
(AAP) recommend simultaneous administration
of all routine childhood vaccines, when
appropriate. Available scientific data show that
simultaneous vaccination with multiple vaccines
has no adverse effect on the normal childhood
immune system. An upper respiratory viral
infection exposes a child to four to 10 antigens,
and a case of “strep throat” to 25 to 50 antigens.
And, there is an abundance of bacteria in the
mouth and nose that expose children to many
more antigens than they’re exposed to from
immunizations.
Misconception: Vaccines contain thimerosal, which
causes autism.
Fact: There are no valid studies that show
thimerosal causes autism. The use of thimerosal
has been greatly reduced since 1999, yet the rates
for autism have increased since 1999.
We appreciate all you do to help your patients,
our members, get and stay healthy.
Misconception: Natural immunity is better than
vaccine-acquired immunity.
Fact: While it’s true that natural
immunity lasts longer in some cases
than vaccine-induced immunity can, the
risks of natural infection outweigh the risks
of immunization for every recommended
vaccine.
For example:
A “natural” measles infection causes
encephalitis in one of every 1,000 infected
individuals and kills two in every
1,000 infected individuals. The MMR (measles,
mumps and rubella) vaccine, however, results
in encephalitis or a severe allergic reaction
only once in every million vaccinated
individuals. The World Health Organization
has estimated that the disease still causes
nearly 200,000 deaths each year worldwide.
Sources:
Centers for Disease Control and Prevention,
<www.cdc.gov/vaccinesafety/concerns/thimerosal/index.html>.
<www.cdc.gov/vaccines/vac-gen/6mishome.htm>.
The History of Vaccines,
<www.historyofvaccines.org/content/articles/
misconceptions-about-vaccines>.
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Misconception: The majority of people who get diseases
have been vaccinated.
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Our Chronic Care Program
orizon Blue Cross Blue Shield of New Jersey offers a special, no-cost program to our eligible
members who have chronic conditions. Our Chronic Care Program provides members with
tools and information to help them better manage their health, decrease their risk for
complications and improve their quality of life.
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Chronic Care Program Case Managers encourage members to take more responsibility for their
health, to work with you to develop an action plan that best meets their needs and to follow the
treatment plan you develop for them.
Chronic Care Program Case Managers review clinical metrics and keep you informed of any
changes in your patient’s status. You will also be notified when one of your patients enrolls in the
Chronic Care Program, elects to opt out of the program or cannot be reached to discuss his or her
program eligibility.
We welcome your feedback about this program. If you have suggestions about how we can better
work together for the good of your patients, please call us at 1-888-333-9617, Monday through Friday,
between 8 a.m. and 5 p.m., Eastern Time.
For more information about the Chronic Care Program or to enroll one of your eligible
patients, please call us at 1-888-333-9617, Monday through Friday, between 8 a.m. and
5 p.m., Eastern Time.
We know that by working together, we will provide our members, your patients, with the
support they need to successfully manage their health.
2012 Radiology/
Imaging Network Update
orizon Blue Cross Blue Shield of
New Jersey is committed to providing
our members with access to safe,
high-quality and effective care. With that
commitment in mind, we have changed the way
we contract with radiologists and the facilities
where they practice. Horizon BCBSNJ has
made the decision to terminate our contracts
with individual radiologists and extend Horizon
Ancillary Agreements to those New Jersey
freestanding radiology centers that are
multi-modality and meet all applicable
equipment standards and credentialing criteria.
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As a result, upon completion of our review
and evaluation, some of the radiology centers
currently listed in our online Provider Directory
may not be included in the new Horizon
Ancillary Radiology Network. We will continue
to keep you updated on our progress and final
determinations.
As you know, when members use a
participating facility or health care professional,
they maximize their benefits and minimize their
out-of-pocket costs.
Access to effective and safe care
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We remind you that as a participating
physician, you are required to adhere to our
Out-of-Network Consent Policy * which
requires that you, whenever possible, refer
your Horizon BCBSNJ patients to participating
physicians, other health care professionals or
facilities (including freestanding radiology
imaging centers) unless the member has, and
wishes to use, his or her out-of-network
benefits, understands that a much greater
member liability may be involved and signs a
completed copy of our Out-of-Network
Consent Form.
To access our Out-of-Network Consent
Policy , registered NaviNet® users may log in
to www.NaviNet.net, select Horizon BCBSNJ
within the Plan Central dropdown menu and:
• Mouse over References and Resources
and click Provider Reference Materials.
• Click Additional Information.
• Click Out-of-Network Consent Policy.
To access our Out-of-Network Consent Form,
in English and Spanish, visit
www.HorizonBlue.com/Providers and access
the Forms section.
If you have questions, please contact your
Network Specialist.
* The Out-of-Network Consent Policy does not apply to Horizon EPO,
Horizon HMO, Horizon Medicare Blue Value (HMO) or Horizon
Medicare Blue TotalCare (HMO SNP) members. Members enrolled in
these plans do not have out-of-network benefits.
Access to effective and safe care
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Formulary reminder
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orizon Blue Cross Blue Shield of New Jersey reminds you that the following
therapies are part of our formulary:
Pegasys is the Preferred pegylated interferon therapy for the treatment of hepatitis C.
Avonex, Copaxone and Rebif are the Preferred multiple sclerosis (MS) therapies.
The benefits of using a Preferred product include:
• Lower out-of-pocket responsibility for your patient’s prescription drug therapy.
• Comprehensive patient support services through the specialty pharmacy network
and manufacturer patient support programs.
• Financial assistance through manufacturer programs for patients who may need
help paying for their prescribed medication or making their copayments.
Horizon BCBSNJ recognizes that patient-specific variables, as well as other factors that
are not available to us, may affect your prescribing decision. However, we encourage you
to support our Preferred formulary, when clinically appropriate, for your new and existing
Horizon BCBSNJ patients and for those Horizon BCBSNJ patients not responding to their
current therapy.
If you have questions or would like a paper copy of a particular medical policy, please
contact your Network Specialist.
For more information about our hepatitis C or multiple
sclerosis medical polices, please log on to
www.NaviNet.net and select Horizon BCBSNJ within the
Plan Central dropdown menu.
• Mouse over Reference and Resources and click
Provider Reference Materials.
• Click Utilization Management.
• Click the link under Medical Policies and Guidelines.
• Review the Medical Policy disclaimer statement and
click the link: If you have read and agree
with the previous statement, you may access Horizon
BCBSNJ’s Medical Policies by clicking HERE.
This article contains brand name products that are registered trademarks of brand manufacturers that are not
affiliated with either Horizon Blue Cross Blue Shield of New Jersey or the Blue Cross and Blue Shield Association.
Advantage formulary: New class added
s of August 1, 2012, Horizon Blue Cross Blue Shield of New Jersey added a new class to our
Advantage Formulary – acne medications.
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The Advantage Formulary is designed to drive generic and Preferred brand use. The addition of
the acne class to the Advantage Formulary means that members using acne medications must try a
generic alternative or receive prior authorization before a non-Preferred drug will be covered.
The acne medications included in our Advantage Formulary are:
•
•
•
•
•
Acanya.
Akne-Mycin.
Azelex.
Duac.
Neobenz Micro.
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­ ith the addition of this new class, there will be a total of 15 therapeutic categories in our
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Advantage Formulary:
•
•
•
•
•
•
•
•
Acne medications.
Alzheimer’s drugs.
Benign prostatic hypertrophy.
Bisphosphonates.
Certain antidepressants.
Fibrates.
Insomnia agents.
Migraine medications.
Access to effective and safe care
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•
•
•
•
•
•
•
Nasal steroids.
Non-sedating antihistamines.
NSAIDs.
Opthalmic prostaglandins for glaucoma.
Proton pump inhibitors.
Statins.
Urinary antispasmodics.
Access to effective and safe care
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Formulary changes announced
F
ormulary changes are determined by Horizon Blue Cross Blue Shield of New Jersey’s Pharmacy
and Therapeutics (P&T) Committee.
Our P&T Committee is a group of physicians and pharmacists who regularly review new and
existing prescription drugs to help ensure our members have access to safe and effective care. The
priority consideration for allocation of prescription drugs into Preferred and non-Preferred placement
is a quality review based on clinical efficacy, safety margins, side effects, drug-to-drug interactions
and dosage. The P&T Committee also takes into consideration second-line therapies, utilization
metrics, brands with a wide therapeutic index for drugs commonly used and safe generics.
Clinical decisions provide the framework for benefit designs that use tiers and/or formulary status
to determine patient cost sharing, as well as point-of-sale edits for patient safety and/or utilization
management. There is an emphasis on multi-source brands and brand name prescription drugs with
generic equivalents being placed in tier three and the generic being placed in tier one.
The following changes were determined at the P&T Committee’s most recent meeting in
June 2012.
Commercial Formulary
Changes effective July 1, 2012
Moved from
non-Preferred
to Preferred
status
Moved from
Preferred
to non-Preferred
status
New drugs
reviewed
and remaining
non-Preferred
status
Brand
Generic
Potiga
ezogabine
Kalydeco
ivacaftor
Brand
Generic
Renagel
(Effective August 1, 2012)
sevelamer HCL
Brand
Generic
Enlyte
multivitamin
Lorzone
chlorzoxazone
Duexis
ibuprofen/famotidine
Pedipirox-4 Nail
ciclopirox
Jentadueto
linagliptin/metformin
First lansoprazole solution
lansoprazole
First omeprazole solution
omeprazole
Edarbyclor
azilsartan/chlorthalidone
Ferriprox
deferiprone
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Brand
Generic
Potiga
Enlyte
Lorzone
Duexis
Pedipirox-4 Nail
Jentadueto
First lansoprazole solution
First omeprazole solution
Edarbyclor
Ferriprox
Kalydeco
ezogabine
multivitamin
chlorzoxazone
ibuprofen/famotidine
ciclopirox
linagliptin/metformin
lansoprazole
omeprazole
azilsartan/chlorthalidone
deferiprone
ivacaftor
NC = not covered
NP = covered, third tier
P = covered, second tier
Closed Plan
3 Tier
P
NC
NC
NC
NC
NC
NC
NC
NC
NC
SP
SP = specialty, fourth tier
Three tier closed-brand-formulary changes
Affected drugs will be removed from the formulary as of the effective date listed.
Name of Affected Drug
Alternative Formulary Drug
Effective Date
Valturna 150/160mg, 300/320mg
Withdrawn from market.
7/20/2012
Ancobon 250mg, 500mg tablets
Flucytosine 250mg, 500mg tablets
9/1/2012
Arixtra 2.5mg, 5mg, 7.5mg, 10mg injections
Fondaparinux 2.5mg, 5mg, 7.5mg, 10mg injections
9/1/2012
Avalide 150/12.5mg, 300/12.5mg,
300/25mg tablets
Irbesartan/Hydrochlorothiazide 150/12.5mg,
300/12.5mg, 300/25mg tablets
9/1/2012
Avapro 75mg, 150mg, 300mg tablets
Irbesartan 75mg , 150mg, 300mg tablets
9/1/2012
Boniva 150mg tablet
Ibandronate 150mg tablet
9/1/2012
Felbatol oral solution
Felbamate oral solution
9/1/2012
Gastrocrom oral solution
Cromolyn oral solution
9/1/2012
Geodon 20mg, 40mg, 60mg, 80mg tablets
Ziprasidone 20mg, 40mg, 60mg, 80mg tablets
9/1/2012
Plavix 75mg tablets
Clopidogrel 75mg tablets
9/1/2012
Prometrium 100mg, 200mg capsules
Progesterone 100mg, 200mg capsules
9/1/2012
Provigil 100mg, 200mg tablets
Modafinil100mg, 200mg tablets
9/1/2012
Seroquel 25mg, 50mg, 100mg,
200mg, 300mg, 400mg tablets
Quetiapine 25mg, 50mg, 100mg, 200mg,
300mg, 400mg tablets
9/1/2012
Surmontil 100mg tablets
Trimipramine 100mg tablets
9/1/2012
Stalevo 100mg, 150mg tablets
Carbidopa/Entacapone/Levodopa 100mg, 150mg tablets
9/1/2012
Tegretol XR 100mg tablets
Carbamazepine 100mg tablets
9/1/2012
Vancocin 125mg, 250mg tablets
Vancomycin 125mg, 250mg tablets
9/1/2012
Viramune 200mg tablets; oral solution
Nevirapine 200mg tablets; oral solution
9/1/2012
This article contains brand name products that are registered marks or registered trademarks of brand manufacturers that are not affiliated with either
Horizon Blue Cross Blue Shield of New Jersey or the Blue Cross and Blue Shield Association.
Access to effective and safe care
Medicare Formulary
Changes effective July 1, 2012
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Access to effective and safe care
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LabCorp update
New age-based test protocol for cervical cancer and STD screening
creening guidelines can be complex –
Laboratory Corporation of America®
Holdings’ (LabCorp) age-based test
protocol for cervical cancer and sexually
transmitted diseases (STDs) screening can
help individualize patient care.
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LabCorp has introduced an innovative,
age-based test protocol to aid physicians when
ordering cervical cancer and STD screening
tests. Clinicians can select a test number that
will individualize cervical cancer and STD
testing based on a patient’s age (from ages 21
to 64 years) as set forth in the American Congress
of Obstetricians and Gynecologists (ACOG)
guidelines.
LabCorp’s age-based test protocol follows the
current ACOG guidelines. As ACOG guidelines
evolve and change, if the test or age protocol is
affected, LabCorp will update its test protocol
accordingly.
This enhancement to LabCorp’s test menu is
part of LabCorp’s broad women’s health test
options, including tests that focus on both
screening and diagnosis of disease. In addition to
women’s health services, LabCorp offers a
comprehensive menu of individual tests and test
combinations to address specific patient needs.
LabCorp offers this age-based protocol as
an additional tool to help you manage your
patients’ testing needs. You can continue to
order individual cervical cancer and STD tests,
as appropriate for your patients’ signs and
symptoms.
If you have questions, please call your local
LabCorp Field Representative at 1-888-LabCorp
(522-2677), option 3, or visit www.LabCorp.com
for information about other services LabCorp
provides.
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New online resource:
Magellan introduces Behavioral Health Toolkit
for medical professionals
orizon Blue Cross Blue Shield of New Jersey network physicians and other health care
professionals can access Magellan Behavioral Health’s® new online resource that provides
information and screening tools needed to identify potential behavioral health concerns and
assist in making behavioral health referrals. To access the toolkit, visit
<www.MagellanPCPtoolkit.com>.
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Horizon Blue Cross Blue Shield of New Jersey
names new Executive Vice President,
Healthcare Management
n July 2, 2012, Kevin P. Conlin joined Horizon BCBSNJ as
Executive Vice President, Healthcare Management. Mr. Conlin
succeeds Christy Bell, who retired from the company in June.
Mr. Conlin’s areas of responsibility include managing Horizon BCBSNJ’s
physician and hospital networks; the company’s Health Affairs and
Pharmacy Services divisions; its Medicaid company, Horizon NJ Health, and
its Horizon Healthcare Innovations subsidiary.
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“Kevin Conlin brings decades of executive management
experience on the provider side of health care to
Horizon BCBSNJ,” Bob Marino, Chairman and CEO said. “As we continue our
collaborative effort with providers to transform the health care delivery system,
Kevin’s extensive experience in working with physicians and hospitals to bring
innovation to care delivery will help us succeed in improving health care quality
and health coverage affordability for our members. We are pleased to welcome
Kevin to our executive team.”
Prior to joining Horizon BCBSNJ, Mr. Conlin served as Executive Vice President at Coventry
Health Care where he headed the company’s medical management, national contracting and provider
relations area. He was instrumental in leading innovative partnerships with health systems and
physician groups in Patient-Centered Medical Homes (PCMHs). Mr. Conlin also spearheaded the
implementation of contracting with all providers and all medical management functions of the
Kentucky Medicaid business for Coventry.
Mr. Conlin has also served as President and CEO of Via Christi Health, a Kansas-based integrated
health system with eight hospitals, a health insurance company, senior care facilities, physician
practices and home-based and outpatient services. Before joining Via Christi Health, he was
President of Cross Country Consulting and President and CEO of Partners First, a subsidiary of
Ascension Health.
Mr. Conlin is a Rutgers University graduate, receiving his Bachelor’s Degree in Biological Sciences.
He holds a Master’s Degree in Health Administration from Duke University.
Service excellence
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Service excellence
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Pictured left to right: Ryan Lachowicz, Hilary Bodner, Jean Bayley, Jennifer Lewandowski, Jill VanRooyen.
Prestigious award received for service to
network hospitals
ith every hospital stay, there is a myriad of paperwork and administrative steps that
insurers and hospitals must handle flawlessly to ensure that patients can concentrate fully
on their treatment and getting well. In recognition of the excellent service we provide to
help hospital administrators complete these important tasks, Horizon Blue Cross Blue Shield of
New Jersey was awarded the 2011 John F. Coffey Memorial President’s Award by the New Jersey
Chapter of the American Association of Healthcare Administrative Management (AAHAM).
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“We are honored to receive this recognition from the New Jersey Chapter of AAHAM,” said
Michelle Merchant, Hospital Relations Manager, Horizon BCBSNJ. “The President’s Award
distinguishes Horizon BCBSNJ for its best practices for managing hospital accounting, billing,
registration and other related functions and our support of the New Jersey Chapter.”
The award was presented by 2011 Chapter President Kathleen Andreola during an educational
seminar that Horizon BCBSNJ hosted this past March with representatives of member hospitals.
“This prestigious award normally goes to an individual who goes above and beyond the call of duty
to help our association and our members excel,” Ms. Andreola said. “We felt that Horizon BCBSNJ’s
contributions as a team merited recognition for an entire company – a first for the John F. Coffey
Memorial President’s Award.”
“We have strong working relationships with our network, comprised of more than 70 hospitals,
and this award speaks volumes about how our collaboration is benefitting Horizon BCBSNJ’s
3.6 million members,” Ms. Merchant added.
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2012 Network Hospital Forums
H
orizon Blue Cross Blue Shield of New Jersey is pleased to announce dates and locations for
two upcoming network hospital information forums.
Horizon BCBSNJ’s Newark office: Horizon BCBSNJ’s Mt. Laurel office:
Wednesday, October 31, 2012
Registration: 8:30 a.m. to 9 a.m.
Session:
9 a.m. to 3 p.m.
3 Penn Plaza East
Newark, NJ 07101-2200
Wednesday, November 7, 2012
Registration: 8:30 a.m. to 9 a.m.
Session:
9 a.m. to 3 p.m.
250 Century Parkway
Mt. Laurel, NJ 08054
At the forums, key representatives from Horizon BCBSNJ service areas (including BlueCard®,
CareCore National, LLC, ICD-10, Centralized Service Center and Utilization Management) will
share program improvements, new policies and collaborative opportunities.
Personnel from patient accounts, patient access and utilization management are encouraged
to attend.
We value our relationships with our network hospitals and look forward to seeing you at one
of our 2012 Hospital Forums. Invitations will be e-mailed – be sure to check your inbox!
If you have questions, please contact your Hospital Account Executive or Hospital Relations
Representative.
Our Solution Center will be available
Our Solution Center provides a unique opportunity for you to speak directly with a Horizon BCBSNJ
representative. Last year, the Solution Center was a big hit with attendees. Attendees were able to bring
cases on site and have a representative help with research and on-site resolution.
We encourage you to bring your claims, inquiries and questions and meet directly with a
member of our staff.
Our Solution Center will include representatives from:
• Centralized Service Center, including Federal Employee Program,
State Health Benefits Program, BlueCard, etc.
• CareCore National, LLC.
• Utilization Management.
Our Solution Center will be open between 8:30 a.m. and 3 p.m.
Service excellence
Save the date:
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Medicare Advantage plan
offered in 2013:
Horizon Medicare Blue Group (PPO)
28
ffective January 1, 2013, Horizon Blue Cross Blue Shield of New Jersey will offer a
new Medicare Advantage (MA) plan – Horizon Medicare Blue Group (PPO). The plan
is pending final approval by the Centers for Medicare & Medicaid Services (CMS).
CMS issued its conditional approval for the new product in May and is expected to give final
approval by September. This plan will enable enrolled members to obtain services outside our
local service area at the in-network level of benefits by leveraging a Blue Cross and Blue Shield
Association (BCBSA) program, similar to the BlueCard® network arrangement. This
arrangement also makes Blue Plans’ provider networks available to other Blue Plans’
enrolled MA PPO members.
E
In our service area – the state of New Jersey – Horizon Medicare Blue Group (PPO) members
will receive care at the in-network level of benefits from participating Horizon Managed Care
Network physicians and other health care professionals.
Outside of our service area:
• Enrolled employer group members who reside or travel in another service area may
receive care at the in-network level of benefits as long as they use a practitioner
or facility that participates in that other Blue Plan’s “MA PPO” network.
• Enrolled employer group members who reside in a state where there is no Blue Plan
“MA PPO” network, will receive the in-network level of benefits in accordance with the
CMS Employer Group Waiver Plan policy.
• Enrolled consumer members who travel in another service area may receive care at the
in-network level of benefits as long as they use a practitioner or facility that participates
in that other Blue Plan’s “MA PPO” network. Consumer members must live in our
service area.
(continues on next page)
Network participation and reimbursement
For Horizon BCBSNJ, the MA PPO plan, like other MA plans, uses the Horizon Managed Care
Network.
When in the state of New Jersey, Horizon Medicare Blue Group (PPO) members and members
enrolled through other Blue Plans’ MA PPO plans:
• Access the in-network level of benefits when they receive care from physicians, other health
care professionals and facilities that participate in the Horizon Managed Care Network. In this
case, reimbursement for services provided to MA PPO members will be calculated at
our managed care rates.
• Access the out-of-network level of benefits when they receive care from physicians and other
health care professionals who only participate in the Horizon PPO Network.
Note: PPO physicians or other health care professionals who have opted out of, or are excluded
from, Medicare are not eligible to receive payment for services rendered to a Medicare Advantage
member.
How to identify MA PPO members
You’ll recognize MA PPO members by the MA-in-the-suitcase logo on the member’s ID card.
MA PPO benefits
No Primary Care Physician selection or referrals are required for members enrolled in Horizon
Medicare Blue Group (PPO).
Horizon Medicare Blue Group (PPO) offers in-network and out-of-network benefits and covers all
Medicare Part A and Part B benefits, as well as additional supplemental benefits.
Horizon Medicare Blue Group (PPO) will be offered with and without Part D prescription drug
coverage. Group members may convert their Medicare Advantage coverage to Medicare Advantage
with Prescription Drug (MAPD) coverage – Horizon Medicare Blue Group w/Rx (PPO).
Making new plan options available to our customers is another way Horizon BCBSNJ is
Making Healthcare Work.
Service excellence
In addition to seeing Horizon Medicare Blue Group (PPO) members, you may also see members
enrolled through other Blue Cross and/or Blue Shield MA PPO plans who reside or travel in our
service area. These members will be extended the same contractual access to care. Services
provided to these members will be reimbursed at our negotiated rates.
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30
Don’t miss
our health care professional webinars!
H
orizon Blue Cross Blue Shield of New Jersey invites you to participate in our upcoming
webinars. Our webinars are valuable online resources designed to provide you with
important information about our products, policies and procedures and self-service tools.
How to participate
Registered users of NaviNet® may log in to www.NaviNet.net a few minutes before 10 a.m. on one
of the dates listed below.
From the Horizon BCBSNJ Plan Central page:
• Mouse over References and Resources and click Provider Reference Materials.
• Click Webinars.
• Click either Physician Orientation Webinar or Behavioral Health Webinar.
• Click Join Our Webinar Session.
Physician Orientation Webinar
Our Physician Orientation Webinar is available to our participating physicians, other health care
professionals and their office staff and billing offices.
You’ll learn:
• About Horizon BCBSNJ products.
• About the BlueCard® program.
• How to access content on our online Provider Reference Materials page.
• What you need to know about our recredentialing process.
• How to use our new online credentialing application.
• Tips on how to get the most from NaviNet.
2012 Physician Orientation webinar schedule
Webinar sessions will be held at 10 a.m. on: September 20
October 18
November 15
December 20
Behavioral Health Care Professional Webinar
Our new webinar is available to all participating behavioral health care professionals, including
their office staff and billing offices.
You’ll learn:
• About our new behavioral health access standards.
• Electronic Fund Transfer (EFT) enrollment.
• About Horizon BCBSNJ products.
• About the BlueCard® program.
• How to access content on our online Provider Reference Materials page.
• What you need to know about our recredentialing process.
• Tips on how to get the most from NaviNet.
2012 Behavioral Health Care Professional webinar schedule
Webinar sessions will be held at 10 a.m. on: September 26
October 24
If you have questions, please contact your Network Specialist.
November 28
December 26
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Pharmacy benefits management contract
transitions to Prime Therapeutics, LLC
H
orizon Blue Cross Blue Shield of New Jersey will transition its commercial membership
pharmacy benefits management (PBM) contract to Prime Therapeutics, LLC (Prime) from
CVS Caremark effective April 1, 2013.
After conducting a competitive bidding process designed to assure that we were receiving the best
PBM services available in the marketplace, Horizon BCBSNJ decided that Prime offers the best option
for PBM services.
Our new relationship with Prime will offer an integrated approach for medical and prescription
benefits. We believe this will result in an improved quality of care and service for our members.
Headquartered in Eagan, Minnesota (outside Minneapolis), Prime has been in business for
25 years. Prime was started by Blue Cross Blue Shield plans, for Blue Cross Blue Shield plans, and is
currently privately owned by 13 Blue Cross Blue Shield (BCBS) plans. Prime serves 19 BCBS plans
with more than 20 million pharmacy customers and 172,000 employer groups.
Horizon BCBSNJ will make every effort to minimize disruption to our commercial members who
will experience this change after the 2013 benefit year begins. Members will have access to the same
network of retail pharmacies, including CVS pharmacies. Horizon BCBSNJ will transition members’
mail-order prescriptions from CVS to Prime.
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P
Help us maintain and present accurate
information about your practice
I
t’s important that your practice information in our files is accurate, current and complete.
Inaccurate or incomplete information may cause problems and/or delays in the processing
of claims, referrals and reimbursement to your office.
The information in our files is also used to populate our online Provider Directory. Inaccurate or
outdated information in our files will misrepresent your practice to patients and referring physicians
searching our Provider Directory for a primary or specialty physician.
To ensure that your practice’s demographic information is correct, please regularly review your
demographic information and initiate any necessary updates.
Note: Although Horizon BCBSNJ works with Medversant to verify practitioner credentials as part
of our recredentialing efforts, Medversant does not forward changes to practice demographic
information that you may have conveyed to them. You must notify us directly of any and all changes
to your practice’s demographic information.
How to notify us of changes to your practice
Please fax notification to 1-973-274-4302 if any of the following changes occur:
•
•
•
•
•
You close your practice.
You move your practice out of the area.
A physician within your practice retires.
A physician within your practice dies.
You wish to terminate your Agreement(s) with Horizon BCBSNJ.*
You may also mail notification of the above-listed practice changes to the appropriate address listed
in the table below:
Practices located in …
• Northern New Jersey
(Bergen, Essex, Hudson, Hunterdon, Morris,
Passaic, Sussex, Union or Warren counties)
• New York
• Southern New Jersey
(Atlantic, Burlington, Camden, Cape May,
Cumberland, Gloucester, Mercer, Middlesex,
Monmouth, Ocean, Salem or Somerset counties)
May send notification to the attention
of their Network Specialist at …
Horizon BCBSNJ
Network Management
3 Penn Plaza East, PP-12K
Newark, NJ 07105-2200
Horizon BCBSNJ
Network Management
250 Century Parkway, MT-03N
Mount Laurel, NJ 08054-1121
• Pennsylvania
• Delaware
(continues on next page)
Online
We encourage all practices to update their
demographic information online. Registered
NaviNet® users may initiate demographic
changes, as well as check the status of a
previously submitted request online. To access
our Provider Data Maintenance tool, registered
users may log in to www.NaviNet.net and:
• Select Horizon BCBSNJ within the
Plan Central dropdown menu.
• Mouse over References and Resources and
click Provider Data Maintenance.
Our Provider Data Maintenance tool will
generate an e-mail to you to confirm our receipt
of your request and provide you with a reference
number when your request is completed.
By fax
You may also request that we update your
practice’s demographic information by
completing a copy of our Provider File Change
Request Form (9093) and faxing it, along with all
necessary supporting documents (e.g., W9,
NPPES letter, SS4, etc.) to 1-973-274-4302.
To access our Provider File Change
Request Form (9093), please visit
www.HorizonBlue.com/Providers and access
the Forms section.
If you have questions, please contact your
Network Specialist.
* Termination letters must be signed personally by the physician or other
health care professional and should be forwarded to the attention of your
Network Specialist. Your effective date of termination (unless another date
is agreed upon by you and Horizon BCBSNJ) will be 90 days following the
receipt of your termination from the Horizon Managed Care Network and
30 days from the Horizon PPO Network.
If you submit a request to terminate your Agreement, you are required to
notify us of any Horizon BCBSNJ members undergoing a course of treatment.
Please prepare a list of members and send it to your Network Specialist.
We, in turn, notify those members who are receiving a course of treatment
of your termination from our network(s) prior to the effective date of your
termination.
Service excellence
How to initiate other demographic updates
33
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34
Review our credentialing and recredentialing
policy online
orizon Blue Cross Blue Shield of
New Jersey has aligned our PPO
credentialing and recredentialing policy
with our managed care credentialing and
recredentialing policy, effective July 1, 2012.
H
This policy, the Horizon BCBSNJ Credentialing
and Recredentialing Policy for Participating
Physicians and Health Care Professionals, impacts
the standards of participation for our Horizon
PPO Network, but does not change any of the
standards of participation for our managed care
network.
We strongly encourage all participating
physicians and other health care professionals
to carefully review the standards for
participation and exceptions noted in this
policy.
Please log in to www.NaviNet.net, and select
Horizon BCBSNJ within the Plan Central
dropdown menu and:
• Mouse over References and Resources then
click Provider Reference Materials.
• Click Service.
• Click Horizon BCBSNJ Credentialing and
Recredentialing Policy for Participating
Physicians and Health Care Professionals.
If you have questions, please call our
Credentialing Department at 1-800-624-1110,
select the prompt for More Options, then select
the prompt for Credentialing and Recredentialing.
If you do not have access to the Internet and
would like a copy of this policy, please contact
your Network Specialist.
Improving your online experience
with our redesigned website
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orizon Blue Cross Blue Shield of New Jersey is committed to Making Healthcare Work for
all of our customers. As part of this commitment, Horizon BCBSNJ will be unveiling a
redesigned website in mid-September. Our improved website offers a number of valuable,
new online features for you and our members.
H
Improved features
Our redesigned website offers greater access
to the tools and information you need to work
more effectively with Horizon BCBSNJ and help
your patients, our members, get and stay healthy.
At the new www.HorizonBlue.com, you’ll
experience:
• Audience-specific home pages. Visitors to
our redesigned website are greeted by a
completely revamped homepage. From
there, you can navigate to a redesigned
provider-specific homepage that will enable
you to find only the information you’re
looking for and receive just the alerts that
affect providers.
• More information available digitally.
Valuable resources and information,
such as forms, our medical policies and our
pharmacy guidelines, will all be available
with just one click from the Provider
homepage.
• An in-line glossary. Browsing through the
immense volume of health care information
available at www.HorizonBlue.com is even
easier now that you can instantly read
definitions of key words simply by mousing
over the words.
The redesigned www.HorizonBlue.com
offers a fresh, more user-friendly experience to
help you get the information you need, plus
quicker and easier access to NaviNet® and
our Provider Reference Materials page.
For more information, please visit
<www.HorizonBlue.com>.
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36
Dental benefits under Horizon Medicare
Blue TotalCare (HMO SNP)
H
orizon Healthcare of New Jersey, Inc. offers Horizon Medicare Blue TotalCare (HMO SNP) –
a Special Needs Plan – to New Jersey residents who are eligible for both Medicare and
Medicaid coverage.
Under Horizon Medicare Blue TotalCare (HMO SNP), members are entitled to benefits covered
under Medicare Parts A, B and D, Medicaid, plus comprehensive dental services.
• Members enrolled in Horizon Medicare Blue TotalCare (HMO SNP) use the Horizon NJ Health
Dental Network for their dental needs. You do not have to accept Medicare to see Horizon
Medicare Blue TotalCare (HMO SNP) members.
• Horizon Medicare Blue TotalCare (HMO SNP) is a zero cost sharing plan. Enrolled members
have no copayment or coinsurance liability.
• Horizon Medicare Blue TotalCare (HMO SNP) has no annual maximum.
• The benefits offered to Horizon Medicare Blue TotalCare (HMO SNP) members are the same
as Horizon NJ Health special needs members in Plan A or Plan B. To access this information
sign in to www.HorizonBlue.com/Medicare and click Horizon Medicare Blue TotalCare.
Click Evidence of Coverage located on the left navigation bar.
Horizon Medicare Blue TotalCare (HMO SNP) members will present a Horizon Medicare
Blue TotalCare (HMO SNP) ID card. On the back of the ID card is the toll-free phone number for
Dental Services. When you call this number, select the prompt to connect you to our dental
department. Representatives are available to answer any questions you may have.
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Services
Dental
1-800-4-DENTAL (433-6825)
Care Management
1-888-333-9617
LabCorp
1-800-845-6167
Prior Authorization
Phone: 1-800-664-2583
Fax: 1-888-223-3527
37
Claims
Type of service
Service excellence
Horizon Medicare Blue TotalCare (HMO SNP) uses the same contact and mailing information
as other Medicare Advantage plans:
Claim submission address
Inquiry submission address
Professional
Horizon BCBSNJ
PO Box 1609
Newark, NJ 07101-1609
Horizon BCBSNJ
PO Box 199
Newark, NJ 07101-0199
Professional claims
submitted on a CMS
1500 form
Horizon BCBSNJ
PO Box 1609
Newark, NJ 07101-1609
Horizon BCBSNJ
PO Box 199
Newark, NJ 07101-0199
If you have any questions concerning dental benefits covered under Horizon Medicare
Blue TotalCare (HMO SNP), please call Horizon Healthcare Dental, Inc. at 1-800-4DENTAL
(1-800-433-6825).
Horizon Medicare Blue TotalCare (HMO SNP) is a dual eligible
special needs plan that is offered by Horizon Healthcare of
New Jersey, Inc. to New Jersey residents who are eligible for both
Medicare and Medicaid coverage*.
* This coverage is separate and distinct from the Horizon TotalCare Dental plan which is available to employer groups with 51 or more employees.
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38
Working together to improve
HEDIS results
hank you to the participating Ob/Gyn and
Primary Care Physician (PCP) offices that
provided the medical record data we
needed to complete and submit 2012 Healthcare
Effectiveness Data and Information Set (HEDIS®)
information based on services in 2011, to the
National Committee for Quality Assurance
(NCQA). We greatly appreciate your cooperation
and assistance.
T
Our 2013 HEDIS efforts are already underway
with your input and direction. Please review the
following information to help improve 2013
HEDIS results.
What is HEDIS?
HEDIS is a tool created by NCQA to help
improve health care quality throughout the
country. HEDIS is used by more than 90 percent
of America’s health plans to measure
performance on important dimensions of care
and service.
What do we do with HEDIS results?
We use HEDIS results to see where we need to
focus our improvement efforts to ensure that our
members continue to receive safe and
appropriate care.
Horizon BCBSNJ and other Blue Cross and/or
Blue Shield Plans also use select HEDIS results to
display physician quality measures within new
online tools. Members can access the Physician
Quality Measurement (PQM) Program
information online through the Blue National
Doctor & Hospital FinderSM available at
<www.HorizonBlue.com/Directory>.
This PQM Program information, based on
select HEDIS measures, helps members with
their health care decision making by providing
access to this important quality information.
How can you help improve 2013 HEDIS
results?
There are a number of things your office can
do to help support future HEDIS data collection
efforts and HEDIS results.
Use participating clinical laboratories.
Using participating laboratories eliminates the
need to review charts for test results during the
HEDIS data collection efforts.
As a participating physician or other health
care professional, you have agreed to adhere to
the policies and procedures in the Physician
Agreement, which includes referring your
Horizon BCBSNJ patients and/or sending their
testing samples to participating clinical
laboratories.
We remind you that Laboratory Corporation
of America® Holdings (LabCorp) is the only
in-network clinical laboratory services provider
for your Horizon BCBSNJ managed care patients
(i.e., members enrolled in Horizon HMO,
Horizon EPO, Horizon Direct Access, Horizon
POS or Horizon Medicare Advantage plans) and
a preferred provider of clinical laboratory
services for your Horizon PPO and Indemnity
patients.
Members enrolled in Horizon PPO and
Indemnity plans may also use our other
participating clinical laboratories or hospital
outpatient laboratories at network hospitals.
To view a list of our other participating clinical
laboratories, please visit www.HorizonBlue.com
and access our Provider Directory. Within the
Other Healthcare Services tab, select Laboratory Patient Centers or Laboratory - (Physician Access
Only) within the Service Type dropdown menu
and click Search.
(continues on next page)
Review and become familiar with our Clinical Practice Guidelines (CPGs). Please review our
CPGs online and consider this information when making decisions about the care and treatment you
provide to your patients.
To access Horizon BCBSNJ’s CPGs, log in to www.NaviNet.net, select Horizon BCBSNJ within the
Plan Central dropdown menu and:
• Mouse over References and Resources and click Provider Reference Materials page.
• Click Additional Information.
• Click Clinical Practice Guidelines.
Focus on key quality measures. We want to improve our results in the HEDIS measures and
CMS Quality Measures for Medicare star ratings listed below. These services will aid in the early
detection of illness and will ultimately help our members get and stay healthy. Please incorporate
these quality outcome measures into your day-to-day practice, as appropriate, and maintain the
required patient medical record documentation.
We will highlight other important measures in future issues of Blue Review.
HEDIS / Star
Measures
Eligible
populations
Medical record
documentation
Administrative
codes
Exclusions
Breast
Cancer
Screening (BCS)
Women age
40 to 69 years.
One or more mammograms
during the measurement
year or the year prior to
the measurement year.
(January 1, 2011 to
December 31, 2012).
Mammogram:
77055-77057
Women who had a
bilateral mastectomy
or for whom there
is evidence of
two unilateral
mastectomies.
Cervical Cancer
Screening (CCS)
Women age
21 to 64 years.
One or more Pap tests
within the last three
years (January 1, 2010 to
December 31, 2012).
Pap tests:
88141-88143, 88147,
88148, 88150,
88152-88155,
88164-88167, 88174,
88175
Exclusionary evidence in
the medical record must
include a note indicating
a hysterectomy with no
residual cervix. The
hysterectomy must have
occurred by December 31
of the measurement year.
Documentation of
“complete,” “total” or
“radical” abdominal or
vaginal hysterectomy
meets the criteria for
hysterectomy with no
residual cervix.
Chlamydia
Screening (CHL)
Women age
16 to 24 years
who were
identified as
sexually active.
At least one chlamydia test
during the measurement
year (January 1, 2012 to
December 31, 2012).
Chlamydia
screening:
87110, 87270, 87320,
87490-87492, 87810
Additional information
provided upon
request for CHL.
Service excellence
If you refer a Horizon BCBSNJ patient who has out-of-network benefits (or send his or her testing
sample) to a nonparticipating clinical laboratory, please ensure that you follow the guidelines of our
Out-of-Network Consent Policy.
39
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Helping members make informed
health care decisions
umerous market forces – including
national account clients, member
demand and the anticipated expansion
of the individual market due to health care
reform – have created a need for health plans
to offer consumer transparency tools that deliver
meaningful and understandable quality
information to members making health care
decisions.
N
Horizon Blue Cross Blue Shield of New Jersey
and other Blue Cross and/or Blue Shield Plan
members have access to new online quality and
transparency tools. In our online directory,
physicians who are recognized in Horizon
BCBSNJ’s Physician Quality Recognition
Program have an indicator next to their names.
In addition, Horizon BCBSNJ members will
soon be able to write reviews of their physicians
and read other patients’ reviews using the
Patient Review tool at <www.HorizonBlue.com>.
Members can write reviews of participating
physicians based on their patient experiences by
answering questions, such as:
• How would you rate your overall experience
and satisfaction with the physician’s
approach?
• Would you recommend this physician to
your friends and/or family?
• How well did the physician communicate
with you about your health concerns?
• How would you rate the physician’s
availability for your appointment?
• How would you rate the physician’s overall
practice environment?
Before posting a review, Horizon BCBSNJ
validates that the member writing the review has
seen the physician being evaluated.
If you have questions about our quality
programs or the consumer transparency tools,
please call your Horizon BCBSNJ Network
Specialist, Ancillary Account Executive or
Hospital Relations Representative.
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PREFIX OR AREA
YHB, YHC, YHI, YHJ, YHK, YHL, YHS, YHU, YHV,
YHY, YKN, JGA, JGD, JGG
For Facilities:
ATT, FMA, FMR, JGA, JGB, JGD, JGE, JGG, JGH,
NCH, NJP, NJX, YHB, YHC, YHI, YHJ, YHK, YHG,
YHD, YHF, YHM, YHN, YHP, YHQ, YHR, YHS, YHT,
YHU, YHV, YHX, YHY, YKN, YKP or other
Horizon BCBSNJ prefixes not shown here.
SERVICE #
1-800-624-1110**
1-888-666-2535**
CLAIMS ADDRESS
CLAIM APPEALS
INQUIRY ADDRESS*
PO Box 1609
Newark, NJ 07101-1609
PO Box 10129
Newark, NJ 07101-3129
PO Box 199
Newark, NJ 07101-0199
PO Box 25
Newark, NJ 07101-0025
PO Box 1770
Newark, NJ 07101-1770
PO Box 1770
Newark, NJ 07101-1770
R, 8-digits with the PPO or Basic logo
Federal Employee Program
1-800-624-5078
PO Box 656
Newark, NJ 07101-0656
PO Box 656
Newark, NJ 07101-0656
PO Box 656
Newark, NJ 07101-0656
FMA, FMR, NCH, YHF, YHN, HIF, HSG, HWA,
HWW and other National Accounts***
1-800-624-4758
PO Box 247
Newark, NJ 07101-0247
PO Box 247
Newark, NJ 07101-0247
PO Box 199
Newark, NJ 07101-0199
AHX, AWW, BBB, DNB, IRA, NVP, NVY, PFZ,
WYE and other National Accounts***
1-800-624-1110**
PO Box 1219
Newark, NJ 07101-1219
Addresses vary. Please review
your patient’s ID card.
PO Box 199
Newark, NJ 07101-0199
MKV, MKY, MWK, MWJ
1-877-663-7258
PO Box 18
Newark, NJ 07101-0018
PO Box 317
Newark, NJ 07101-0317
PO Box 199
Newark, NJ 07101-0199
HSE, NFW, YHD, YHG, YHM, YHP, YHT
and other Point of Service members
1-800-624-1110**
PO Box 820
Newark, NJ 07101-0820
PO Box 10129
Newark, NJ 07101-3129
PO Box 199
Newark, NJ 07101-0199
JGE, JGB, JGH, YHQ, YHX, YKP
and other Horizon Direct Access members
1-800-624-1110**
PO Box 1609
Newark, NJ 07101-1609
PO Box 10129
Newark, NJ 07101-3129
PO Box 199
Newark, NJ 07101-0199
NJ State Health Benefits Program (SHBP)
1-800-624-1110**
PO Box 1609
Newark, NJ 07101-1609
PO Box 10129
Newark, NJ 07101-3129
PO Box 199
Newark, NJ 07101-0199
NJX, NJP NJ State Health Benefits Program
(SHBP)
1-800-624-1110**
PO Box 820
Newark, NJ 07101-0820
PO Box 10129
Newark, NJ 07101-3129
YHR, YHW
Medigap
1-800-624-1110**
PO Box 1184
Newark, NJ 07101-1184
PO Box 10129
Newark, NJ 07101-3129
PO Box 199
Newark, NJ 07101-0199
For Professionals:
PO Box 639
Newark, NJ 07101-0639
For Professionals:
PO Box 639
Newark, NJ 07101-0639
For Professionals:
PO Box 639
Newark, NJ 07101-0639
For Facilities:
PO Box 25
Newark, NJ 07101-0025
For Facilities:
PO Box 1770
Newark, NJ 07101-1770
For Facilities:
PO Box 1770
Newark, NJ 07101-1770
DEH, DMM, DTP, NGM
General Motors/Delphi Auto
1-800-456-9336
BlueCard (out-of-state) claims
BlueCard Service Team
1-888-435-4383
BlueCard Claims
PO Box 1301
Neptune, NJ 07754-1301
Magellan Behavioral Health®
1-800-626-2212
Addresses vary according to product.
Please review the behavioral health information on your patient’s ID card.
Chronic Care Program
1-888-333-9617
3 Penn Plaza East, PP-13X
Newark, NJ 07105-2200
Pre-existing Medical Documentation
PO Box 1740
Newark, NJ 07101-1740
Claim Policy Clinical Appeals
PO Box 220
Newark, NJ 07101-9020
Claim Policy Code Edit Inquiries
PO Box 681
Newark, NJ 07101-0681
Claim Policy Clinical Predetermination for
PPO and Indemnity Products
PO Box 220
Newark, NJ 07101-9020
Inpatient Case Management, Complex Case
Management and Prior Authorization
1-888-621-5894
Service excellence
Please use the chart below to identify specific Horizon Blue Cross Blue Shield of New Jersey contact and mailing information.
41
Press 1 for Inpatient Case Management; Press 2 for Complex Case Management;
Press 3 for Prior Authorization.
Please do not send medical documentation with your claim if it has not been requested.
*
Corrected claim submissions that are mailed, must be accompanied by a completed Inquiry Request and Adjustment Form (579).
** These numbers can also be used to access our Interactive Voice Response (IVR) system to create referrals and for service information.
*** Check your patient’s ID card to confirm the contact and mailing information for prefixes that are not listed here.
This prefix information is confidential and should only be used to identify health insurance claims/service contact information for Horizon BCBSNJ and/or other Blue Cross and/or
Blue Shield Plan patients and not for other purposes and will not divulge any such information to any other party. Reproduction of this information, in whole or in part, is prohibited
without the permission of Horizon BCBSNJ.
Blue Review
A newsletter for participating physicians and
other health care professionals, acute care facilities and ancillary staff
Blue Review is written and produced by Enterprise Communications at Horizon Blue Cross Blue Shield of New Jersey. We welcome your comments and suggestions on this publication.
E-mail [email protected] or write to:
Horizon BCBSNJ
Renee Engelhardt, PP-15Z
PO Box 420
Newark, NJ 07101-0420
Editor:
Managing Editor:
Design and Layout:
Director:
Printing:
Renee Engelhardt
Jennifer Roche
Alice Ugarte
Daisy Chan
Corporate Services
Services and products may be provided by Horizon Blue Cross Blue Shield of New Jersey, Horizon Healthcare of New Jersey, Inc. or Horizon Healthcare Innovations, LLC, each of which is an independent licensee
of the Blue Cross and Blue Shield Association. Horizon Healthcare of New Jersey, Inc. and Horizon Healthcare Innovations, LLC are subsidiaries of Horizon Blue Cross Blue Shield of New Jersey.
The Horizon name and symbols are service marks of Horizon Blue Cross Blue Shield of New Jersey. Making Healthcare Work is a registered mark of Horizon Blue Cross Blue Shield of New Jersey.
Facebook® is a registered mark of Facebook, Inc.
HEDIS® is a registered mark of the National Committee for Quality Assurance.
Laboratory Corporation of America® is a registered mark of Laboratory Corporation of America Holdings.
Magellan Behavioral Health® is a registered mark of Magellan Health Services, Inc.
NaviNet® is a registered mark of NaviNet, Inc.
TwitterTM is a registered trademark of Twitter, Inc.
YouTubeTM is a registered trademark of Google, Inc.
© 2012 Horizon Blue Cross Blue Shield of New Jersey, Three Penn Plaza East, Newark, New Jersey 07105-2200.
CMC0003895 (W0912)