HorizonBlue.com

A Newsletter for Participating Physicians and Other Health Care Professionals, Acute Care Facilities and Ancillary Staff October 2016

Careful Antibiotic Use When your patient is sick,antibiotics can be the first line ofdefense in getting better. Butoveruse or inappropriate use ofantibiotics can be harmful.

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Blue Review

Verifying Member Coverage

When you provide care to your patients, youdo not need a physical copy of their memberID card to verify coverage.

Free Health Assessments AvailableMembers enrolled in Individual andSmall Group Plans can receive a freeHealthy House Call or a CompleteHealth Review.

Clinical Practice Guidelines AvailableHorizon Blue Cross Blue Shield ofNew Jersey and Horizon BehavioralHealthSM clinical practice guidelines(CPGs) are available online.

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Precertification/Prior Authorization SubmissionProcess ChangeCertain authorization requests forservices should be submittedelectronically for approval.

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Table of Contents

Ancillary Facilities Acute Care Facilities

Physicians and Other HealthCare Professionals

Ancillary Professionals

Icons throughout the newsletter will alert you to articles relevant to your area.

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News Brief Verifying MemberCoverageWhen you provide care to your Horizon BCBSNJ patients, you do not need a physical copy or virtual image of theirmember ID card to verify coverage.

Participating physicians and other health care professionalscan help minimize claim denials for their patients’ eligibility by verifying their coverage online prior to their visit. As youknow, a physical ID card is not the only source available toconfirm member eligibility or cost sharing information. Youcan verify your patient’s coverage through NaviNet, even prior to his/her visit.

When necessary, we encourage you to access virtual IDcards so that no member is denied services. Virtual ID cardsare typically available a few days before physical cards arereceived through the mail.

If you prefer to obtain an image of the patient’s ID card, youcan view a virtual ID card or print a paper copy from NaviNet.To access a virtual ID card, log in to NaviNet.net and:

• Select Horizon BCBSNJ within the My Health Plansmenu.

• Mouse over Eligibility & Benefits and select Eligibility & Benefits Inquiry.

• Enter your Horizon BCBSNJ patient’s member ID number and then click Search. You may also search by member’s first name, last name and date of birth.

• Within the member ID card column, select View next to the member’s name.

You can also accept the virtual ID card from patients if theydisplay it on their mobile devices from our Member OnlineServices website.

If you have questions, you can access our FAQs by logging into NaviNet and selecting Horizon BCBSNJ from the MyHealth Plans menu. You may also contact Provider Services at 1-800-624-1110, Monday through Friday, between 8 a.m. and 5 p.m., Eastern Time (ET), or Institutional Services at 1-888-666-2535 during those same hours.

Access to Safe and Effective Care

3 Clinical Practice Guidelines Available4 Prior Authorizations for Testosterone and Other Medications5 Pharmacy Corner: Formulary Changes Announced

Ease of Navigating the Health Care System

7 Attend an Educational Webinar8 CAQH Helps Ensure Accuracy10 Precertification/Prior Authorization Submission Process

Change11 Hospital Appeals Process and Guidelines13 Use Clear Claim Connection for Web-based Code Editing14 eviCore healthcare’s New Login Page14 Update to the Horizon Care@Home Program

Healthier Members ... Healthier Communities

15 2016 Appointment Availability Survey Results17 Transitioning Teens from Child to Adult Care18 Free Health Assessments Available19 Lower Back Pain Management20 Careful Antibiotic Use

Service Excellence

21 FAQs Available Online22 Learn More About Our Office Manager Seminars23 At Your Service

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Clinical Practice Guidelines Available

Horizon BCBSNJ and Horizon Behavioral Health clinicalpractice guidelines (CPGs) are available to all participatingphysicians, other health care professionals and facilitystaff.

These guidelines were adopted from nationally knownorganizations such as the Advisory Committee onImmunization Practices, the American Academy ofPediatrics, the American Academy of Family Physicians, the Agency for Health Care Policy and Research and theAmerican Diabetes Association. They also includeHealthcare Effectiveness Data and Information Set(HEDIS®) technical specifications.

Access Horizon BCBSNJ CPGs

To access Horizon BCBSNJ CPGs, visitHorizonBlue.com/guidelines.

If you would like copies mailed to you, email your request toQualityManagement_Coordinator@HorizonBlue.com ormail your request to:

Horizon BCBSNJ Quality ManagementAttn: Request for CPG3 Penn Plaza East, PP-12XNewark, NJ 07105-2200

If you have questions about Horizon BCBSNJ CPGs, call ourQuality Management Department at 1-877-841-9629.

Behavioral Health CPGs

You may view, print and download Horizon BehavioralHealth CPGs by visitingwww.valueoptions.com/providers/Handbook/treatment_guidelines.htm.

Accordant Clinical Practice Guidelines for FEPMembers

Horizon BCBSNJ has adopted the Accordant® MultipleSclerosis and Rheumatoid Arthritis CPGs for FederalEmployee Program® (FEP®) members. Accordant offers caremanagement program services for patients who live withcomplex, chronic diseases. The Accordant programprovides enrolled members the support they need tomanage their conditions and improve their health.

For more information, visit accordant.com/FEP. Choose thephysician’s tab to access the CPGs.

To log in, use the username and password that is includedin the letter you received from Accordant advising you thatyour patient has been enrolled in the Accordant program. Ifyou have questions, you may call Accordant at1-866-648-4222, Monday through Friday, from 8 a.m. to 9 p.m., ET. Messages left after hours will be returned thenext business day.

Note: The Horizon BCBSNJ CPGs do not constitute medical advice,authorization, certification, approval, Explanation of Benefits, offer ofcoverage, contract or guarantee of reimbursement. The CPGs areconfidential and proprietary. They are to be used only as authorized byHorizon BCBSNJ and its affiliates. The contents of these CPGs are not tobe copied, reproduced or circulated to other parties without the expresswritten consent of Horizon BCBSNJ. The content of these CPGs may beupdated or changed without notice. However, benefit determinations aremade in the context of CPGs existing at the time of the decision and arenot subject to later revision as the result of a change in guidelines.

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If you have questions about HorizonBehavioral Health CPGs or would like torequest a copy, emailhorizonbehavioralhealthproviderrelations

@valueoptions.com or call 1-800-397-1630Monday through Friday, 8 a.m. to 8 p.m., ET.

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When you need to submit prior authorization (PA) requestsfor testosterone or other medications, it’s important toinclude all the information that is necessary for review.Incomplete submissions or missing documents may delaythe processing of PAs.

Testosterone PAs

For initial authorization of testosterone, you and/or youroffice staff need to submit two laboratory blood testingresults collected on two separate days. These blood testingresults must indicate total and free testosterone levelsbelow the testing laboratory’s lower limit of the normalrange.

For continuation authorization of testosterone, you and/oryour office staff must submit one recent (within last six months) blood testing for total and free testosteronealong with recent labs for prostate-specific antigen (PSA).

Initial and continuation PA approvals will last for 12 months.

Refer to our policy, Androgens and Anabolic SteroidsMedical Necessity and Appropriateness Review andQuantity Limit Program, for specifics.

Submitting Electronic Requests

You can complete electronic prior authorization (ePA)requests for testosterone and other medications requiringPA through NaviNet. To submit a request:

• Log in to your NaviNet account.

• From the Workflows menu, choose DrugAuthorizations and complete the electronic form. Be sure to attach clinical information, such aslaboratory results, if required.

• Once you submit the ePA, it is received andevaluated by our contracted pharmacy benefitmanager, Prime Therapeutics. You will then receiveapproval or denial information electronically in yourNaviNet dashboard.

• The Drug Authorization feature uses CoverMyMedsto pick the correct form, submit the PA request andreceive the outcome.

ePA through NaviNet is the preferred PA method for HorizonBCBSNJ. This service is free for all Horizon BCBSNJphysicians and their office staff. If you have questions aboutusing the Drug Authorization feature, you can callCoverMyMeds at 1-866-452-5017, Monday through Friday,from 8 a.m. to 11 p.m. ET, and Saturday, from 8 a.m. to 3 p.m. ET.

Prior Authorizations for Testosterone and Other Medications

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Pharmacy Corner: Formulary Changes AnnouncedChanges to our commercial formulary were determined at the Pharmacy and Therapeutics (P&T) Committee meeting inMay 2016. The most up-to-date commercial formulary can be found on HorizonBlue.com/formulary, or for FEP members,visit www.fepblue.org/en/formulary.

Moved from Non-Preferred to Preferred Status

Brand Generic Prior Authorization (Y/N)

Genvoyacobicistat, elvitegravir, emtricitabine andtenofovir alafenamide

N

Tagrisso osimertinib Y

Alecensa alectinib Y

Cotellic cobimetinib Y

Ninlaro ixazomib Y

Lyrica pregabalin N

Ascensia(formerly Bayer)test strips andmeters

n/a N

Moved from Preferred toNon-Preferred Status

Brand Generic Prior Authorization (Y/N)

Dutoprol hydrochlorothiazide and metoprolol N

Lipofen fenofibrate N

Carbatrol carbamazepine N

Rilutek riluzole N

Synthroid levothyroxine N

Armour Thyroid thyroid desiccated N

Lanoxin digoxin N

Dilantin/DilantinInfatabs

phenytoin N

Coumadin warfarin N

Namenda XR(Alzheimerdisease)

memantine N

Relpax (migraine) eletriptan N

Roche Diagnostictest strips andmeters

n/a N

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Pharmacy Corner

Recent changes to our Medicare formulary are listed in the table below. The most up-to-date Medicare formulary can beaccessed at HorizonBlue.com/medicare/formulary.

Brand Generic Formulary Status Prior Authorization (Y/N)

Zepatier elbasvir and grazoprevir Added YUptravi selexipag Added NVraylar cariprazine Added NNarcan naloxone (nasal spray) Added NXuriden uridine triacetate Not Covered -Nucala mepolizumab Not Covered -Viberzi eluxadoline Not Covered -Veltassa patiromer Not Covered -Odefsey emtricitabine, tenofovir alafenamide, rilpivirine Not Covered -Dyanavel XR amphetamine ER Not Covered -QuilliChew ER methylphenidate hydrochloride ER Not Covered -Enstilar calcipotriene and betamethasone Not Covered -

To request a printed copy of the formularies, call Pharmacy Member Services at 1-800-370-5088.

New Drugs Reviewed and Remain in Non-Preferred Status

Brand Generic Prior Authorization (Y/N)

Uptravi selexipag Y

Tresiba insulin degludec N

Veltassa patiromer N

Varubi rolapitant N

Viberzi eluxadoline Y

Envarsus XR tacrolimus N

Durlaza aspirin N

Flowtuss hydrocodone bitartrate and guaifenesin N

Hycofenixhydrocodone bitartrate, pseudoephedrinehydrochloride and guaifenesin

N

Enstilarcalcipotriene and betamethasonedipropionate

Y

Tolak fluoruracil Y

Epiduo Forte adapalene and benzoyl peroxide Y

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Attend an Educational Webinar

Horizon BCBSNJ regularly offers scheduled webinarsessions designed to provide physicians, office managers,staff and billing offices with important information about ourproducts, policies, procedures and self-service tools.

Our Network Specialists host these online training webinarstwice each month:

• The first Thursday of each month at 9 a.m.

• The third Thursday of each month at 12 p.m.

How to participate

Registered users of NaviNet may log in to NaviNet.neta few minutes before the scheduled webinar session.

Select Horizon BCBSNJ from the My Health Plansmenu and:

• Mouse over References and Resources and clickProvider Reference Materials.

• Mouse over Resources and select Training.

• Click Webinars.

• Click Physician Orientation Webinar.

• Click Join Our Webinar Session.

After you click Join our Webinar Session, you can call thephone number provided to access the audio portion of thewebinar.

Additional information about these seminars is alsoavailable on HorizonBlue.com/physicianwebinars.

If you have questions, please contact your NetworkSpecialist.

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Inaccurate or incomplete information may cause problemsand/or delays in the processing of claims, referrals andreimbursement. That’s why it’s important that theinformation in our provider files is accurate, current andcomplete. The information in our provider files is used topopulate our Online Doctor & Hospital Finder, which meansthat inaccurate or outdated information may result in amisrepresentation of your practice to patients and referringphysicians.

Horizon BCBSNJ strongly encourages all participatingphysicians and other health care professionals to useCAQH ProViewTM for your provider file changes. Wecapture all CAQH updates on a weekly basis andincorporate this information into our provider files system.1

CAQH Helps Ensure Accuracy

CAQH Outreach Effort

Horizon BCBSNJ is working to help ensure thatthe information in our provider files is accurate.

Earlier this year, CAQH began conducting anoutreach effort to encourage physicians andother health care professionals with existingCAQH ProView profiles to:

• Review their current information.

• Make updates to information and affiliations,as appropriate.

• Re-attest that the information is current,accurate and complete.

As part of this same initiative, CAQH is alsoreaching out to physicians and other healthcare professionals who do not have CAQHProView profiles to encourage them to createand maintain profiles.

Thank you in advance for your cooperationwith CAQH as they carry out this importantinitiative.

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1 Please note that although Horizon BCBSNJ works with Medversant to verify practitioner credentials as part of our recredentialing efforts, Medversant does not forwardchanges to practice demographic information.

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CAQH Helps Ensure Accuracy (continued)

Using CAQHEnsure that your demographic information is current, accurate and complete. Log in to caqh.org and:

1. Review your current information in the Provider Directory Snapshot.

2. Make updates to your information and affiliations, as appropriate, paying specific attention to:

• The office locations at which you practice• If you’re currently accepting new patients• Degree(s) earned• Board certifications• Specialty• Email address• Gender• Group affiliations• Hospital affiliation(s)• Language(s) spoken• Phone number(s)• Fax number(s)• NPI information• Practice limitations

3. Re-attest that this information is current, accurate andcomplete and may be included in files and published indirectories for the health plans you designate.

If you’re not registered with CAQH:

• Visit ProView.caqh.org/pr to self-register with CAQH.Upon completion of the self-registration process, youwill receive a CAQH welcome email with your uniqueCAQH Provider ID number.

• Visit caqh.org, mouse over CAQH Proview and selectLog In.

• Complete an online application (select HorizonBCBSNJ so we can access your information) andthen attest that the information is accurate andcomplete.

If you have questions about your provider file information or about CAQH ProView, please contact your NetworkSpecialist.

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Precertification/Prior Authorization SubmissionProcess ChangeEffective November 8, 2016, certain precertification/priorauthorization requests that may have formerly beensubmitted via fax by physicians, other health careprofessionals or ancillary providers must be submittedusing our online utilization management request tool.1

Requests for precertification/prior authorization will not beaccepted through the following fax numbers on and afterNovember 8, 2016:

1-877-798-5903 Prior Authorization Requests for MedicalServices

1-800-492-2580 Prior Authorization Requests for HomeCare Services (including Home IVServices)

1-973-274-4410 Prior Authorization Requests for InfertilityServices

1-888-456-2415 Prior Authorization Requests for SpeechTherapy

1-888-891-8913 Precertification Requests for Unite HereHealth (Local 54)

1-888-608-1015 Medical Necessity Determinations forObstructive Sleep Apnea

1-888-255-6160 Requests for Transition/Continuity of Care

We recommend you begin submitting requests online nowto help ensure your staff is prepared for the November 8, 2016 deadline. All authorization requestsshould be initiated under the group practice name, not thereferring/rendering practitioner.

Get started today!

All authorization requests for services youcurrently go to Horizon BCBSNJ for approvalsshould be submitted electronically. Our onlineutilization management request tool allowsproviders to submit authorization,predetermination and specialty pharmacyrequests easily and securely through NaviNet.

To submit authorization requests online, simplylog in to NaviNet.net, access Horizon BCBSNJfrom the My Health Plans menu, then:• Mouse over Referrals and Authorizations• Select Utilization Management Requests

Not already using our online tool?

Registered NaviNet users have access to viewthe training manual online. Log in to NaviNet,and from the My Health Plans menu:• Select Horizon BCBSNJ• Mouse over References and Resources andclick Provider Reference Materials

• Mouse over Policies & Procedures and clickUtilization Management

• Click CareAffiliate

Not registered for NaviNet?

Access to NaviNet is free. To register, visitNaviNet.net and click Sign Up.

Providers that are not able to submit requestsfor precertification/prior authorization throughour online utilization management request toolon NaviNet may call our Prior Authorizationteam at 1-800-664-2583, Monday through Friday,between 8 a.m. and 5 p.m., ET.

1Network hospitals that fax authorization requests to one of the abovenoted numbers that have not transitioned to our online utilizationmanagement request tool will be provided with an alternative processfor submitting precertification/prior authorization requests forNovember 8, 2016 and after.

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Utilization Management Appeals

Horizon BCBSNJ offers network hospitals a formal processto appeal an adverse utilization management determination(e.g., denial of procedures or services; denial of inpatientadmissions; denial of day(s) within an admission; orassignment of alternate level of care).

The appeal must be received within 180 calendar days ofthe date of the written adverse determination and mustcontain the information outlined below. Horizon BCBSNJretains the right to accept only those appeals submitted bya hospital or contracted third party acting on behalf of thehospital if the procedures outlined on this page arefollowed. Once an appeal request is received, HorizonBCBSNJ conducts a full and fair investigation of the issueand provides a timely written response.

If appealing on behalf of a member, please ensure the letterof appeal clearly states “appealing on behalf of member”and proper member consent is attached to the appealrequest.

Information Required for UM Appeals

The appeal must be submitted in writing. It must be writtenand signed by a health care professional (doctor or RN) andinclude the following information:

• Member’s full name and date of birth

• Horizon BCBSNJ member ID number (including all prefixes)

• Hospital name and division/location

• Admission and discharge date(s)

• Specific date(s) being appealed

• Nature and reason for the appeal for each denied day

• Remedy sought for each day being appealed

• Copy of complete medical record (must be legibleand organized)

UM Appeal Submission

If your hospital is located in northern New Jersey (Bergen,Essex, Hudson, Hunterdon, Middlesex, Monmouth, Morris,Ocean, Passaic, Somerset, Sussex, Union or Warrencounties) write to:

Horizon BCBSNJ Appeals DepartmentUtilization Management AppealsMail Station PP-12EPO Box 420Newark, NJ 07101-0420

If your hospital is located in southern New Jersey (Atlantic,Burlington, Camden, Cape May, Cumberland, Gloucester,Mercer or Salem counties), or the states of Pennsylvania orDelaware, write to:

Horizon BCBSNJ Appeals DepartmentUtilization Management AppealsMail Station MT-03WPO Box 110Newark, NJ 07101-0110

Submission of Appeals by a Third Party

Hospitals must follow the procedures below for HorizonBCBSNJ to consider an appeal submitted on their behalf bya third party.

The network hospital must forward a completed copy of ourThird Party Vendor Information Form to their HorizonBCBSNJ Network Hospital Relations representative. Thisform, available from your Network Hospital Relationsrepresentative, provides information about the third partyincluding:

• Full name of the contracted third party

Hospital Appeals Process and Guidelines

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Hospital Appeals Process and Guidelines (continued)

• Effective date of the contracted relationship

• Vendor relationship with the contracted third party

• Assurance that the contracted third party is incompliance with all applicable state and federallaws on confidentiality, including, but not limited to, HIPAA

The third party must follow Horizon BCBSNJ’s utilizationmanagement policies, including, but not limited to thefollowing:

• Guidelines on appeal submissions must contain theinformation outlined in this article.

• Third parties must identify themselves correctly onall phone inquiries and correspondence.

All responses to appeals by a third party representing thehospital will be communicated to that third party.

Appeals Related to Medical Necessity/Appropriateness Determinations

Level 1 Appeals

This appeal is reviewed by a Horizon BCBSNJ MedicalDirector who did not participate in the originaldetermination. The appeal is completed within 30 calendardays of receipt of the appeal and the determination iscommunicated in writing to the facility. The communicationwill contain information and directions for requesting a level 2 appeal, as applicable.

Level 2 Appeals

This appeal must be received within 60 calendar days of thedate of the level 1 determination letter. It must include thereason a second review is requested and must be for thesame dates and services indicated on the level 1 appeal.The request should not include a second copy of themedical record.

The Provider Appeal Subcommittee reviews alldocumentation submitted for the level 2 appeal, as well asthe original case file.

The Provider Appeal Subcommittee is comprised of HorizonBCBSNJ Medical Directors and other health careprofessionals. The Provider Appeal Subcommittee memberswho participated in the original determination or level 1appeal do not vote on the level 2 appeal.

The Provider Appeal Subcommittee may seek guidancefrom consultant practitioners who are trained or whopractice in the same or similar specialty that typicallymanage the case at issue or such other licensed healthcare professionals. The consulting physician or other healthcare professional(s) participate in a nonvoting capacity inthe Provider Appeal Subcommittee’s review of the case.

The Provider Appeal Subcommittee issues a determinationwithin 30 calendar days of receipt of the level 2 appeal. Thedetermination is communicated to the facility in writing.

If you have questions, please contact your HospitalNetwork Specialist.

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Use Clear Claim Connection for Web-based Code EditingTo help you navigate the health care system, HorizonBCBSNJ offers the McKesson Clear Claim Connection™, a web-based code editing disclosure solution.

Clear Claim Connection is designed to help ensure our claim reimbursement policies, related rules, clinical editclarifications and clinical sourcing information are easilyaccessible and transparent to participating practices andthe staffs of participating facilities and other health careproviders. Clear Claim Connection displays HorizonBCBSNJ’s code auditing rules for various codecombinations and the corresponding clinical rationale.

To access Clear Claim Connection, log in to NaviNet.net,select Horizon BCBSNJ from the My Health Plansmenu and:

• Mouse over Claim Management

• Click Clear Claim Connection

Within Clear Claim Connection, enter the required data toview the appropriate Horizon BCBSNJ code auditing rulesfor the codes in question.

Auditing rules are updated regularly for consistency withclaim payment policy, new procedure codes, current healthcare trends and/or medical and technological advances.Clear Claim Connection results are based on the rules inforce on the date a query is made.

Auditing rules are applied to the claim based on the date aservice is rendered. Actual claims may receive a differentediting outcome based on the clinical relationship logic thatis in effect at the time the claim is received and processed,and may be affected by other system edits outside of ourauditing rules (e.g., member eligibility or other claimprocessing and/or pricing logic). If a denial is issued forcoding, the clinical rationale for the denial will be provided.

If you have questions about Clear Claim Connection, pleasecall 1-800-624-1110 to speak with a member of our PhysicianServices team or 1-888-666-2535 to speak with a member ofour Institutional Services team.

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eviCore healthcare has established a new, unified loginpage on eviCore.com to simplify navigation between theirlegacy portals.

Use your existing legacy user ID and password to log oneviCore.com. You will then be able to access information on both the carrier’s web (carecorenational.com) andPortal 2.0 (medsolutions.com).

Navigation between these sites is as simple as clicking abutton conveniently located in the top menu – you no longerhave to logout and re-enter a new set of login information.

Carecorenational.com and medsolutions.com will continueto function for a period of time; however, in the future theywill redirect visitors to the new eviCore.com log in page.

eviCore healthcare’s New Login Page

Please note that you won’t be able to access MedSolutions 1.0Portal (medsolutionsonline.com) from the new eviCore.com loginpage. However, you can register through eviCore.com to accessPortal 2.0 and take advantage of all the great features availablethere.

The Horizon Care@Home Program, currently administeredby CareCentrix, will begin to transition the management ofcertain home health services (including in-home nursingservices and physical, occupational and speech therapy)back to Horizon BCBSNJ.

This change is effective November 1, 2016. Through theHorizon Care@Home Program, CareCentrix will continue tocoordinate and manage:

• Durable medical equipment (DME), which alsoincludes diabetic supplies, medical foods and homemedical supplies

• Orthotics and prosthetics (O&P)

• Home infusion therapy (HIT) services

• Hemophilia factor drugs

All Horizon BCBSNJ health plans are included in thisprogram. During the transition, Horizon BCBSNJ andCareCentrix will focus on ensuring our members continue tohave access to all home health care services that aremedically necessary. Members should continue to accessall home health care services through the HorizonCare@Home Program, as their benefits will not change orbe impacted.

If you have questions, please call the Horizon Care@HomeProgram at 1-855-243-3321.

Update to the Horizon Care@Home Program

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Horizon BCBSNJ maintains appointment availabilitystandards for certain participating Primary Care Physicians(PCPs), obstetricians and gynecologists (Ob/Gyns) andother specialists (those directly under contract with HorizonBCBSNJ) to ensure our members receive care when theyneed it.

Each year, we survey a random sample of theseparticipating physicians and specialists to measure howwell they meet the following standards:

• Appointment for routine preventive exam: The PCPshall offer the member a scheduled appointment assoon as possible, but not to exceed four months ofthe request.

• Appointment for routine care: The PCP or Ob/Gynshall offer the member a scheduled appointment assoon as possible, but not to exceed two weeks of therequest. A specialist shall offer the member ascheduled appointment as soon as possible, but notto exceed three weeks from the request.

• Appointment for urgent care: The PCP shall offer themember a scheduled appointment within 24 hours ofthe request.

• Appointment for emergent care: The PCP shallrespond to the member’s call immediately and advisethe best course of action. This may include sendingthe member to an emergency facility. HorizonBCBSNJ encourages members who believe thattheir medical condition is a medical emergency to godirectly to the nearest Emergency Room, call 911 orcall their local emergency response number.

• Respond to after-hours call for urgent/emergentcare: The PCP shall have a mechanism to respond tomembers’ calls for urgent or emergent care thatensures calls in these circumstances are returnedwithin 30 minutes.

• Length of wait past appointment time: HorizonBCBSNJ Medicare Advantage members shall waitno more than 15 minutes from a scheduledappointment time to see a practitioner. Other HorizonBCBSNJ members shall wait no more than 30 minutes from a scheduled appointment time tosee a practitioner. If the waiting time is expected toexceed the above-noted time periods, the office shalloffer the member the choice of rescheduling his/herappointment or continuing to wait.

2016 Appointment Availability Survey Results

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Our Appointment Availability Access Standards areavailable in our:

• Participating Physician and Other Health CareProfessional Office Manual

• Member handbooks

• Member website

Our Network Relations department educates physicianoffices about our standards to help ensure that ourstandards are met.

Results from our most recent survey

Standard

Percentage of surveyed participating practitioners who met our standards

PCPs Ob/Gyn Specialists

Appointment for routine preventive care 99.7% 100% N/A

Appointment for routine care 96% 91% 93%

Appointment for urgent care 93% 83% 79%

Appointment for emergent care 95% 96% 92%

Respond to after-hours call for urgent/emergent care 91% 94% 80%

Length of wait past appointment time 94% 92% 94%

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2016 Appointment Availability SurveyResults (continued)

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Transitioning Teens from Child to Adult Care

According to the American Academy of Pediatrics, thetransition to adult-oriented health care should beginbetween the ages of 18 and 21 years old. If you are apediatrician providing services to members over age 18 years, Horizon BCBSNJ requests that you assist themand their parents in transitioning care to an adult PrimaryCare Physician. This may include helping them choose anew physician and transferring medical records. You alsomay need to assist with the transfer of specialty care toadult subspecialists.

For more information or additional resources about thisprocess, visit the Got Transition/Center for Health CareTransition Improvement website at gottransition.org. Thecenter works to improve adolescents’ transition frompediatric to adult health care through the use of new andinnovative strategies for health professionals and families.

Resources: Healthychildren.org; American Academy of Pediatrics

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A Healthy House Call or Complete Health

Review takes about an hour and includes:

• A complete review of the member’s currenthealth, medical history, current treatmentsand medicines

• A brief physical exam, which includes takingthe member’s blood pressure

• A conversation with the member about anyhealth care concerns he or she may haveand answers to any questions

• Recommendations about the member’s care

The Healthy House Call and the CompleteHealth Review are strictly voluntary, offered atno cost to the member and will not impact themember’s benefits or premium. No medicines,treatments or tests are ordered during the visit.

Results are shared with the member, his or herprimary doctor and Horizon BCBSNJ to helpensure our member – your patient – receivesthe best care possible and stays on top of anyhealth conditions.

Free Health Assessments Available

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Members enrolled in Individual and Small Group plans canreceive a free health assessment in one of two convenientways to ensure they’re receiving the best care possible:

• A Healthy House Call® from a doctor or nursepractitioner in the convenience of their home or atanother private location they prefer, or

• A Complete Health Review by a nurse practitioner ata MinuteClinic® inside CVS Pharmacy®.

Once members complete either health assessment, theywill receive a $20 CVS Pharmacy gift card. Note: Gift cardsare not offered if members receive a physical or healthassessment from their doctor.

Horizon BCBSNJ is working with EMSI Health® and CVS Pharmacy to bring this service to our members.

Chart Retrievals & Affordable Care Act

Horizon BCBSNJ is working with EMSI Health to collectmedical documents for qualified health plans under theAffordable Care Act. The documents help Horizon BCBSNJaccurately reflect the health status of our members. Thepurpose of this review is to identify all documented ICD-10-CM codes associated with your patients who areHorizon BCBSNJ members in Individual and Small Grouphealth plans.

In the coming months, you may be contacted by arepresentative of EMSI Health. They will share with youfurther details and will work through the appropriateprocess to retrieve charts from your office.

The Affordable Care Act stabilizes risk selection forIndividual and Small Group plans on and off the HealthInsurance Marketplace. It helps health insurers offervarious plans to meet the needs of a diverse population andis administered either by individual states or by the U.S.Department of Health and Human Services.

To learn more, visit: HorizonBlue.com/riskadjustment.

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Lower Back Pain Management

When a patient comes to you with lower back pain, how doyou treat the individual? After meeting with the patient, doyou immediately schedule an X-ray, CT scan or MRI? Do you offer alternative treatment methods such as over-the-counter medicine, heat, rest and other options?

While imaging tests are necessary for patients with lowerback pain that may be due to cancer, infection, nervedamage or worsening pain, it is not recommended for allpatients, according to guidelines from the AmericanCollege of Physicians.

The American College of Physicians and the American PainSociety recommend alternatives to imaging for patientswith nonspecific lower back pain, including:

• A focused history and physical examination

• Initial pain management medications

• Physical therapy

Additionally, the American College of Physicians and theAmerican Pain Society recommend that first-line treatmentshould emphasize patient education, activity, use of heat,and anti-inflammatory and analgesic over-the-countermedications.

Consumer Reports Health states that unnecessary imaginghas risks, such as exposure to radiation. It also costs thepatient more out of pocket for the tests, and can lead tounnecessary follow-up tests, procedures and even surgery.Lower back pain generally improves within the first two weeks of onset for the majority of individuals.

At Horizon BCBSNJ, we can help your patients manageconditions such as lower back pain through our CaseManagement Program. Our Care Managers will provideeducation, available community resources and collaboratewith physicians and other health care professionals to helpyour patients get the best care possible.

For more information, visit HorizonBlue.com/case-management.

If you have questions about the Case ManagementProgram, call 1-888-621-5894 and select prompt 2, Mondaythrough Friday, between 8 a.m. to 5 p.m., ET.

If you have questions regarding the FEP Service BenefitPlan Benefit Case Management program, call 1-866-697-9696 and select prompt 6, Monday through Friday,between 8 a.m. to 5 p.m., ET.

Sources:acr.org

familydoctor.org/dam/familydoctor/documents/ChooseWiselyBackPainAAFP-ER.pdf

qualitymeasures.ahrq.gov/content.aspx?id=49748

https://ecqi.healthit.gov/system/files/ecqm/2014/EP/measures/CMS166v4.html

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When your patient is sick, antibiotics can be the first line ofdefense in getting better. But overuse or inappropriate useof antibiotics can be harmful to your patient. HorizonBCBSNJ encourages prescribing physicians and otherhealth care professionals to educate their patients aboutappropriate antibiotic use. We recommend using thefollowing tips from the Centers for Disease Control andPrevention when patients ask for antibiotics to treat viralinfections:

• Listen to and validate your patients’ concerns.

• Educate patients that antibiotics are not always theappropriate course of action. Antibiotics can beharmful to their health by promoting resistantorganisms in their bodies and in the community,increasing the risk of an antibiotic-resistant infectionand causing side effects such as nausea, vomitingand diarrhea.

• Remind your patients that if they do take antibiotics,it’s important to carefully follow the instructions onuse to avoid becoming more sick in the long term.

• Talk to your patients about over-the-countermedications to ease pain and reduce fever whenantibiotics are not appropriate.

• Emphasize the importance of rest, adequatenutrition, hydration and good hygiene.

• Let them know that overuse of antibiotics can becostly. When a medicine-resistant infection needsmore drugs and medical care, such as a hospitalstay, it can cost your patients more money out ofpocket.

Remind your patients of the importance of staying up-to-date on their vaccinations, such as the flu, pneumoniaand Tdap (tetanus, diphtheria and pertussis) vaccines. Thiswill help reduce the use of antibiotics as well.

Sources: Consumer Reports Health; WebMD.com; cdc.gov/getsmart/community/materials-references/print-materials/index.html

Careful Antibiotic Use

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Our Frequently Asked Questions (FAQs) section is now onNaviNet. When you have questions about your HorizonBCBSNJ patients’ eligibility, benefits or claims, simply:

• Sign in to NaviNet.net

• Click Help

• Click Horizon BCBSNJ

There, you will get step-by-step instructions on how youcan easily access information. Our online FAQs areorganized so you can quickly find information about thesetopics and more:

• Claims & Payments – View the status of a claim orpayment, including how to enroll in Electronic FundsTransfer (EFT).

• Eligibility & Benefits – Look up which services arecovered benefits for a specific Horizon BCBSNJpatient.

• Provider Resources – Check which plans youparticipate in and update your demographicinformation.

• Referrals & Authorizations – Access HorizonBCBSNJ’s Medical Policies or prior authorizationprocess.

• Office & Provider Management – Access reports,including capitation and panel reports.

Horizon BCBSNJ remains committed to providing you withaccess to the information you need. We will continue to addmore answers to frequently asked questions.

FAQs Available Online

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Horizon BCBSNJ conducts Office Manager Seminarsthroughout the state. At these events, your office managerand staff will learn about Horizon BCBSNJ programs andproducts and improve their ability to do business with us ona day-to-day basis.

How to participate

To learn more about attending an upcoming Office ManagerSeminar, registered NaviNet users may log in toNaviNet.net, select Horizon BCBSNJ from the My HealthPlans menu and:

• Mouse over References and Resources and selectProvider Reference Materials

• Mouse over Resources and select Training

• Select Office Manager Seminars

Our online Office Manager Seminars page will include a listof upcoming events, when available, and instructions onhow to register for a scheduled event.

Additional information is available onHorizonBlue.com/omseminar.

If you have questions about Office Manager Seminars,please call 1-973-466-5573 or emailphysician_seminars@HorizonBlue.com.

Learn More About Our Office Manager Seminars

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At Your Service

CLAIM SUBMISSION

All claims should be submitted electronically. UsePayer ID 22099 if you use a vendor or clearinghouse.Primary claims, including claims using a legacy provider ID(TIN + suffix), behavioral health claims and claims requiring amedical record, can be submitted from the Horizon BCBSNJpage after logging in to NaviNet.net.

SHBP/SEHBP

Claim Appeals/Inquiries: PO Box 820, Newark, NJ 07101-0820Provider Services: 1-800-624-1110Institutional Services: 1-888-666-2535Utilization Management: 1-800-664-2583Advanced Radiology -eviCore healthcare: 1-866-496-6200

Behavioral Health Precertification: 1-800-991-5579

PROFESSIONAL CLAIMS

HCAPPA Appeals: Use Appeal a Claims Determinationform and mail to PO Box 10129, Newark, NJ 07101-3129General Appeals: Use 579 form and mail to PO Box 54,Newark, NJ 07101-0054Inquiries: Use 579 form and mail to PO Box 199,Newark, NJ 07101-0199

IVR and PHONE INQUIRES

Provider Services: 1-800-624-1110Institutional Services: 1-888-666-2535

ELIGIBILITY AND BENEFITS

Log in to NaviNet.net and access the Horizon BCBSNJ page.Mouse over Eligibility & Benefits and select Eligibility &Benefits Inquiry.

HORIZON BEHAVIORAL HEALTHSM 1-800-626-2212

Unless otherwise noted on the member ID card, mail claimforms to PO Box 10191, Newark, NJ 07101-3189.Please refer to the ValueOptions Resource Manual atValueOptions.com/Horizon for more information.

PRIOR AUTHORIZATIONS (PA) ANDUTILIZATION MANAGEMENT

Most PAs should be requested online using the CareAffiliatetool. After logging into NaviNet.net, select Horizon BCBSNJwithin the My Health Plans menu, mouse over Referrals andAuthorization, then select Utilization Management Requests.

PT/OT ServicesFrom NaviNet.net, access the Horizon BCBSNJ page, mouseover Referrals and Authorizations and select Physical andOccupational Therapy Authorization.

Outpatient Advanced Imaging and Pain ManagementeviCore healthcare: 1-866-496-6200

Drug AuthorizationsFrom NaviNet.net, access the Horizon BCBSNJ page and select Drug Authorizations.

Alternate Request MethodsPrior Authorization Unit: 1-800-664-2583

FEP®

Claim Inquiries:PO Box 656, Newark, NJ 07101-0656Reconsiderations/Appeals: 1-800-624-5078PO Box 10181, Newark, NJ 07101Precertification: 1-800-664-2583Care Management andHealth and Wellness: 1-866-697-9696

BLUECARD®

Claim Appeals/Inquiries:PO Box 1301, Neptune, NJ 07754-1301 1-888-435-4383

FACILITY CLAIMS

Appeals/Inquiries: Use 579 form and mail toPO Box 1770, Newark, NJ 07101-1770

Find forms at HorizonBlue.com/providers/forms.

HORIZON CARE@HOME PROGRAM

Horizon BCBSNJ conducts the review of requests for: HomeHealth Services (including in-home nursing services, physicaltherapy, occupational therapy and speech therapy). Prior authorization requests for these services must be submittedusing Horizon BCBSNJ’s online utilization management requesttool via NaviNet.

CareCentrix conducts the review of requests for HorizonCare@Home services for: Durable Medical Equipment (including Medical Foods [Enteral], and Diabetic and OtherMedical Supplies); Orthotics and Prosthetics and Home Infusion Therapy Services, including hemophilia. Call 1-855-243-3321 to initiate the review of these services.

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Editor: Katie SullivanManaging Editor: Melissa RiosecoDesign and Layout: Michael PiersantiDirector: Daisy Chan

Horizon BCBSNJ Katie Sullivan, PP-02APO Box 420Newark, NJ 07101-0420

Blue Review is written and produced by Enterprise Communications at Horizon Blue Cross Blue Shield of New Jersey. We welcome your comments and suggestions onthis publication. Write to:

Horizon Blue Cross Blue Shield of New Jersey is an independent licensee of the Blue Cross and Blue Shield Association. The Blue Cross® and Blue Shield® names and symbols, and BlueCard® and Federal Employee Program® (FEP®), are registered marks of the Blue Cross and Blue Shield Association. The Horizon® name andsymbols are registered marks of Horizon Blue Cross Blue Shield of New Jersey.

At Horizon Blue Cross Blue Shield of New Jersey, we are proud of our commitment to diversity and inclusion among our employees, members, physicians and businesspartners. Diversity is part of who we are as a Company. We embrace and value differences of culture, education, experience and perspective in our workplace. For more information, please visit HorizonBlue.com/diversity.

This document contains references to brand name prescription medicines that are trademarks or registered marks of pharmaceutical manufacturers that are not affiliated with Horizon Blue Cross Blue Shield of New Jersey, the Blue Cross and Blue Shield Association or Prime Therapeutics.

Horizon Pharmacy and its network of participating pharmacies are administered by its contracted pharmacy benefits manager, Prime Therapeutics, LLC.

EMSI Health® is responsible for administering the Healthy House Call® program. MinuteClinic® is responsible for Complete Health Review. Doctors/nurse practitionerswho conduct in-home Healthy House Calls® are the personnel of EMSI Health® and nurse practitioners who conduct Complete Health Reviews at MinuteClinic areemployees of MinuteClinic. EMSI Health® and MinuteClinic are each independent from and not affiliated with Horizon Blue Cross Blue Shield of New Jersey.Accordant is a wholly owned subsidiary of CVS Caremark.The EMSI Health® and Healthy House Calls® names and symbols are registered trademarks of Examination Management Services, Inc.CAQH ProViewTM is a registered trademark of theCouncil for Affordable Quality Healthcare (CAQH).CaremarkConnect® is a registered trademark of CVS/caremark.Clear Claim Connection™ is a trademark of McKesson Corporation.CPT® is a registered trademark of the American Medical Association.NaviNet® is a registered trademark of NaviNet, Inc., an independent company providing provider portal service on behalf of Horizon Blue Cross Blue Shield of New Jersey. Facebook® is a registered mark of Facebook, Inc.TwitterTM is a registered trademark of Twitter, Inc.Instagram is a trademark of Instagram, LLC in the United States and elsewhere. YouTubeTM is a trademark of Google, Inc.LinkedIn, the LinkedIn logo, the In logo and InMail are registered trademarks or trademarks of LinkedIn Corporation and its affiliates in the United States and/or other countries.All other trademarks and trade names are the property of their respective owners.

© 2016 Horizon Blue Cross Blue Shield of New Jersey. Three Penn Plaza East, Newark, New Jersey 07105-2200.

Blue Review A Newsletter for Participating Physicians and Other Health Care Professionals,Acute Care Facilities and Ancillary Staff

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