Horizon Behavioral Health℠

Below is important information and links to resources to help behavioral health professionals manage their day-to-day relationship with us.

To stay up to date on provider news and announcements, access Updates and Announcements.


Useful Links

Find out more about the Horizon Behavioral Program for Horizon Blue Cross Blue Shield of New Jersey.

New! Upcoming Training

The Horizon Behavioral Health Network Relations team is offering monthly educational webinars to participating physicians, health care professionals and their office staff. Each session will include a period for questions and answers, time permitting. Please check back regularly to see if new webinars or additional sessions have been scheduled.

New Practitioner Orientation
An overview of the information every office should know to help in your day-to-day interactions with Horizon NJ Health.

To request a facility orientation, send an email to BHNetworkRelations@HorizonBlue.com.

Date Time  
 Monday, December 14, 2020 3 p.m. - 4 p.m. Register
Thursday, December 17, 2020 10 a.m. - 11 a.m. Register
Tuesday, January 12, 2021 10 a.m. - 11 a.m. Register
Wednesday, January 13, 2021 3 p.m. - 4 p.m. Register
Tuesday, February 9, 2021 10 a.m. - 11 a.m. Register
Thursday, February 11, 2021 3 p.m. - 4 p.m. Register
Wednesday, March 10, 2021 10 a.m. - 11 a.m. Register
Tuesday, March 16, 2021 3 p.m. - 4 p.m. Register

NaviNet Training
An overview of NaviNet’s online platform and self-service options.

Date Time  
Thursday, December 10, 2020 3 p.m. - 4 p.m. Register
Thursday, January 21, 2021 10 a.m. - 11 a.m. Register
Wednesday, February 17, 2021 3 p.m. - 4 p.m. Register
Tuesday, March 23, 2021 10 a.m. - 11 a.m. Register

Utilization Management Tool Webinars
An overview of the process for submitting authorization requests through the utilization management tool on NaviNet.

Date Time  
Tuesday, January 26, 2021 10 a.m. - 11 a.m. Register
Thursday, February 25, 2021 3 p.m. - 4 p.m. Register
Tuesday, March 30, 2021 10 a.m. - 11 a.m. Register
Tikka Attach




March 2020 update




Applied Behavior Analysis Provider Report Guidelines


Assessment


The following is a guide to what is expected in the individual assessment for members with Autistic Spectrum
Disorder. (Refer to page 3 for the Concurrent (Progress) Report guidelines.)

I. Member?s identifying information
a. Name
b. Date of birth
c. Age
d. Member?s insurance ID number
e. Service address
f. Parent/caregiver name
g. Diagnosis, include date, name and title of the professional
h. Date(s) of original assessment
i. Name, title and credential of the assessor
j. Name of the supervising BCBA ? If there was a change in supervisor, indicate date

of change and name of prior supervisor
k. Current report date


II. Basic biopsychosocial information

a. Family composition
b. Family primary concerns
c. Medical and mental health history, including treatment and medication, if applicable
d. Current or prior services (i.e., ABA, speech, occupational, social skills group, etc.)
e. Overall school functioning


III. Member?s capabilities/strengths and family?s support system


IV. Member?s current problem areas/skills deficits relating to their ASD diagnosis. If there is no

skill deficit in an area, indicate normal/average or further assessment is required.
a. Cognitive/pre-academic skills
b. Language/communication skills
c. Reduction of interfering or mild inappropriate behaviors
d. Severe behavior (aggression, property destruction)
e. Safety skills
f. Social skills
g. Play and leisure skills
h. Independent living/self-help skills
i. Community integration
j. Coping and tolerance skills
k. Other











V. List dates and data source/assessment tools used

a. Indirect observations used
i. Family/caregiver(s) interview (in-person, phone)
ii. Records reviewed (i.e., IEP, psychological evaluations, reports from other ABA

providers, etc.)
iii. Functional Assessment Screening Tool
iv. Other ? please specify

b. Direct observations used
i. ABC charting
ii. Functional behavioral assessment (direct and indirect)
iii. Verbal Behavior Milestones Assessment & Placement Program, include grid
iv. Assessment of basic language and learning skills ? revised, include grid
v. Other ? Specify other methods to systematically evaluate abilities and

development of structured program.


Note: If further assessment is needed or will be used during the first authorization
period, specify tool/type and why.


VI. Functional Behavior Assessment (FBA) of target behaviors/presenting problems (identified

above)
a. Description of the problem (topography, onset/offset, cycle, intensity, severity)
b. History of the problem (long-term and recent)
c. Antecedent analysis (setting, people, time of day, events)
d. Consequence analysis
e. Impression and analysis of the function of the problem

Note: If an FBA was not conducted, provide an explanation and time frame as to when an
FBA will be administered.


VII. Description of parent/caregiver behavioral management training progress/knowledge transfer

plan progress
a. Condition and frequency of parent/caregiver trainings
b. Progress related to observable and measurable goals for the parent/caregiver
c. Describe barriers to parent/caregiver involvement, if applicable


VIII. Signature, title and credential of the author of the report as well as the supervising BCBA, if

different than the author.









Concurrent (Progress) Report

Below are specific guidelines to what is expected in the Concurrent (Progress) Report. All progress
reports are due, at minimum, two weeks prior to, and no more than 30 days, to the authorization
end date.

I. Member?s identifying information


II. History of program summary
a. Treatment start date
b. Current authorization end date
c. If applicable, gaps in treatment such as vacation, change in staff, etc.


III. Re-assessment description and tools used

IV. Progress per domain/behavior

a. Progress data
i. Baseline data

Status of current behavior (in progress, met, cancelled, modified), include skill(s)
introduction date. Note: If no or minimal progress was made, describe barriers.

ii. Graphic representation of the data collected during the current
authorization period, per goal, including baseline data and parent goals.

iii. Interpretation of graph / data
Note: Item ii above is mandatory. If a mastery criterion was defined as per
session or per week, then the data on the graph must be displayed as per
session or per week. Do not aggregate or average data such as per month or
per quarter unless goal was written in that way.

Example 1: Client will initiate and reciprocate various forms of the greetings ?hi?
and ?bye? with adults and peers, in 80% or more opportunities, across three
consecutive days, by June 2019.












Figure 1. Client?s performance per session with the target reciprocates ?Hi?.
















Pe
rc

en
t C

or
re

ct









Example 2: By January 2019, client will decrease her toileting accidents (urinating
and bowel movements) to 1 time per week, across three consecutive weeks, as
measured by therapist and parent data.


Status: Goal Not Achieved. More time is needed to achieve this goal. Client has
0 accidents during sessions with her therapist, although she occasionally has
accidents when outside of therapy sessions. New goal target date September 2019.
Client is currently on a 30-minute toileting schedule.




















V. Parent/caregiver behavioral training progress

VI. Report in the same fashion as described in section Progress per domain/behavior (IV.a)


VII. Description of program supervision delivery (if applicable)


VIII. Transition/Discharge Plan

a. Member?s and family?s ability to generalize the skills in multiple settings and mastery of
the majority of the program goals

b. Step-down in program hours
c. Member?s readiness to move from current level of service (in-home) to lower level of

service (i.e., outpatient individual, social skills group therapy, medication
management, mainstream education, adult assistant living, other community
resources)

d. Communication and coordination between the supervising clinician and other
professionals such as psychotherapist, speech therapist, occupational therapist,
social worker, etc.


IX. Program recommendations, justification for continued treatment


X. Signature, title and credential of the author of the report as well as the supervising BCBA, if

different than the author




This Document is Proprietary and Confidential
Do Not Print or Distribute Without Permission

Provider Information Forum
Applied Behavior Analysis (ABA)

April 2020
Behavioral Health Team



Proprietary & Confidential

Topics of Discussion

? ABA Overview and MCO Basics
? ABA Services and Codes
? ABA Unit Guidance and Allowable Specialties
? Authorizations
? NaviNet
? Network ? Credentialing and Demographic Information Updates
? 21st Century Cures Act
? Claims
? Additional Supports



Proprietary & Confidential

? The management of Applied Behavior Analysis (ABA) services has transitioned from the
Division of Medical Assistance and Health Services, Children?s System of Care (CSOC) to the
Managed Care Organizations as of 4/1/20.


? Effective 4/1/20, Horizon New Jersey Health (HNJH) covers all medically necessary ABA

services for eligible Horizon Medicaid members.


? Services are available to any child diagnosed with an Autism Spectrum Disorder (ASD) as
defined by ICD-10 diagnoses F84.0 ? F84.9






ABA ? Managed Care Organization Basics



Proprietary & Confidential


? Providers should contact Horizon to ensure eligibility and benefits by contacting Horizon

member services at 1-800-682-9091


? For eligible Horizon members already receiving ABA services through CSOC, Horizon will
honor authorizations up until the current authorization end date to ensure services continue
uninterrupted


? Prior authorization will be required to continue services after the authorization end date


? Providers should bill Horizon for ABA services for all dates of service 4/1/20 and beyond





ABA ? Managed Care Organization Basics (cont.)



Proprietary & Confidential

ABA Services and Codes
CPT Code CPT Code Definition

97151
Behavior identification assessment, administered by a physician or other qualified healthcare professional, each 15 minutes of the physician's or
other QHP's time face-to-face with patient, and/or guardian(s) administering assessments and discussing findings and recommendations, and non
face-to-face analyzing past data, scoring/interpreting the assessment, and preparing the report/treatment plan

97152 Behavior identification supporting assessment, administered by one technician under the direction of a physician or other qualified healthcare professional, face to face with the patient, each 15 minutes.

0362T
Behavior identification supporting assessment, each 15 minutes of technician's time face-to-face with a patient requiring the following
components: *administered by the physician or other qualified healthcare professional who is on-site, * with the assistance of two or more
technicians,*for a patient who exhibits destructive behavior, *completed in an environment that is customized to a patient's behavior

97153 Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other QHP, face-to-face with one patient, each 15 minutes

97154 Group adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other QHP , face-to-face with 2 or more patients, each 15 minutes

97155 Adaptive behavior treatment, with protocol modification, administered by physician or other QHP, which includes simultaneous direction of technician, face-to-face with one patient, each 15 minutes

97156 Family adaptive behavior treatment guidance administered by physician or other QHP (with or without the patient present), face-to-face with guardians(s)/caregiver(s), each 15 minutes

97157 Multiple-family group adaptive behavior treatment guidance administered by physician or other qualified healthcare professional (without the patient present) face-to-face with multiple sets of guardians(s)/ caregiver(s)

97158 Group adaptive behavior treatment with protocol modifications, administered by a physician or other QHP , face to face with multiple patents', each 15 minutes

0373T
Adaptive behavior treatment with protocol modification, each 15 minutes of technician's time face-to-face with a patient requiring the following
components: *administered by the physician or other qualified healthcare professional who is on site, * with the assistance of two or more
technicians,*for a patient who exhibits destructive behavior, *completed in an environment that is customized to a patient's behavior

H0032 Mental Health service plan development by a non-physician, per 15 minutes



Proprietary & Confidential 6











Authorization Unit Guidance and Allowable
Specialties



Proprietary & Confidential 7


? Provider submits the ABA Authorization Request Form via Utilization Management Request Tool accessible in

NaviNet
NOTE: Providers can obtain a copy of the ABA Authorization Request Form from the horizonblue.com website:


? Click on Provider Tab
? Select Products and Programs, then Horizon Behavioral Health
? Click on Frequently used forms
? Applied Behavior Analysis (ABA) Authorization Request
? https://www.horizonnjhealth.com/securecms-documents/900/ABA_Authorization_Request_Form_40001.pdf



? Request for assessment includes a copy of the Autism Spectrum Diagnosis (ASD) script with recommendation for

ABA therapy as completed by a Qualified Health Professional (QHP)


? Acceptable QHPs for the treatment planning for adaptive behavior services shall include:
? Physicians
? Psychologists trained and certified in behavior analysis, and
? Board Certified Behavior Analysts


? Horizon checks eligibility and benefits, confirms diagnosis and completes the assessment authorization for 32 units

of 97151 for 30 days













Process for Obtaining Authorization



Proprietary & Confidential 8


? After completing the assessment, provider submits the ABA Request Form via the Utilization

Management Request Tool, accessible via NaviNet

? Horizon, again, checks eligibility and benefits pursuant to internal processes


? A Horizon Behavioral Health Utilization Management (UM) Clinician reviews request form

against MCG Medical Necessity Criteria
o If clinical information meets medically necessary criteria, Horizon BH Clinician creates

authorization
o If clinical information does not meet medical necessity criteria, the Horizon BH

Clinician calls provider to discuss
o If necessary, Horizon BH Clinician sends the case to the Horizon Medical Director

Review for a Medical Necessity Review


? For cases that do meet criteria ? once approved ? Horizon BH clinician creates authorization
for 6 months












Process for Obtaining Authorization (cont.)



Proprietary & Confidential 9


? Horizon NJ Health offers multiple online services via NaviNet that can greatly benefit providers
? This is a free, secure website that offers a single sign-on where providers can access

transactions and services for multiple health plans
? NaviNet helps providers reduce administrative costs and time
? When providers have a claim inquiry, they can go to NaviNet
? By joining NaviNet, providers will get access to:

? Administrative Reports

? Utilization Management Tools

? Claims Appeals Checks and Status inquiries

? Search Eligibility and Benefit information











NaviNet



Proprietary & Confidential 10




Providers can access the Utilization Pre-authorization Management Tool through
NaviNet. Simply select Horizon NJ Health from the Plan Central page; mouse over
Referrals and Authorization on the left-hand navigation; then select Utilization
Management requests. Please refer to the Utilization Management Request Tool
Tutorial by visiting www.horizonblue.com:

? Under the Provider?s tab, select Products & Programs
? Click on Horizon Behavioral Health
? Under Training, click on Utilization Management Request Tool Tutorial


? NaviNet Support: 1-888-482-8057











NaviNet (cont.)




Proprietary & Confidential 11

Credentialing



? BCBAs and BCBA-Ds are required to successfully complete the credentialing process prior to being

accepted as a network provider. Recredentialing is required every 3 years.

? Bachelor?s level behavior analysts and support staff/technicians are not required to complete

credentialing with Horizon. Services they provide are required to be under the supervision of the
QHP. Horizon is not requiring Behavior Technicians to be Registered Behavioral Technicians, but it is
preferred.


? Please visit https://www.horizonnjhealth.com/for-providers/provider-recruitment

for more information and Horizon NJ Health Applications.
- Agreements are accessible via NaviNet?s Horizon BCBSNJ

plan central page. If you don?t have access to this page, email
EnterprisePDM@horizonblue.com to request an Agreement.


? A complete application can take between 45 and 90 days from date of receipt to process.





Proprietary & Confidential 12

Credentialing

Helpful Hints

? CAQH Tips

? Current attestation
? Horizon authorized to access the application
? Assure that new practitioners joining your group have the group?s location information included in the

practice locations
? Ensure consistency in formatting of office locations

? Leave the effective dates blank in the agreements

? Include all pages of the agreements

? All documents must be sent via mail

? Include all documents on the checklist

? Ensure all documents are up to date







Proprietary & Confidential 13

Updating Your Demographic Information

? Use CAQH ProviewTM

? Or email Demographic Update requests to EnterprisePDM@horizonblue.com
? Submit requests & supporting documentation at least 30 days before the effective date of

the change.
? Always include the submitter?s name, email & telephone # with all email requests.
? EnterprisePDM@horizonblue.com is not managed by a representative who reads &

responds immediately to your emails. Emails received are converted to Service Requests
which are then addressed offline by our Provider team.

? Submit ONLY demographic Updates to this email address.
DO NOT email initial credentialing submissions, claims, questions, etc.

? To help ensure that you are getting these responses (and that they are not flagged as
spam), please add EnterprisePDM@HorizonBlue.com to your list of safe or approved
senders/contacts. This will keep emails from us out of your junk/spam folder.








Proprietary & Confidential 14

21st Century Cures Act

? Effective January 1, 2018, the 21st Century Cures Act 114 P.L. 255 requires that all Medicaid managed care
network providers must enroll with the State Medicaid program or risk being removed from the provider network.
This is both a federal and state requirement.


? Each individual BCBA is required to register for a Medicaid number. Providers do not need to wait for their
Medicaid number to be assigned to submit the credentialing applications to Horizon for network participation.
Please notify us of your Medicaid number once received so we can update our systems accordingly.


? Registering as an NJ FamilyCare provider does not require you to service NJ FamilyCare Fee-for-Service

beneficiaries.

? To register, Go to the NJ Medicaid Management Information System?s (NJMMIS) website at njmmis.com and select

Provider Enrollment Application on the left blue bar OR use the following direct link
njmmis.com/onlineEnrollment.aspx. Under the Your Information section, click the down arrow in the Provider
Type field and select 21st Century Cures Act.



? Please note: If you select your specialty from the drop down menu, the fee-for-service 20 page application will
generate. However, by selecting the 21st Century Cures Act option, the 4-page application needed to satisfy the
law?s requirement will appear.


? You can submit your application and credentials by:
? Fax: 1-609-584-1192
? Mail: P.O. Box 4804, Trenton, NJ 08650









15


Horizon?s participating providers are assigned to a Network Specialist based on their county.
Your Network Specialist is available via phone or email and is your primary point of contact
for the following areas:


? General Education
? Requests for a Site/Education Visit
? NaviNet Training
? Network Status Inquiries


Please continue to contact Customer Service for all claims related concerns.







Network Management



Behavioral Health Provider Relations:
Horizon NJ Health

16

Dottie Laisi
LaTanya
McLean Barkley Michelle McCusker Olivia Inniss

Atlantic Hunterdon Burlington Bergen

Cape May Mercer Camden Essex

Cumberland Morris Middlesex Hudson

Gloucester Somerset Salem Passaic

Monmouth Sussex

Ocean Union

Warren

856-638-3215 856-638-3228 856-638-3223 973-466-4609

Dorothy_Laisi@horizonblue.
com

LaTanya_Barkley@horizonblue.
com

Michelle_McCusker@horizonblue.
com Olivia_Inniss@horizonblue.com



17

? Horizon NJ Health encourages all health care professionals to submit claims electronically


? Claims should be submitted with the BCBAs name and NPI as the rendering provider


? HNJH members to not have copays and/or coinsurance

? We utilize the TriZetto Provider Solutions (TTPS) Direct Data Entry (DDE) SimpleClaim system

? For more information on registering, please go to https://www.trizettoprovider.com/horizon/simpleclaim. If you have any further

questions about registering with TTPS for DDE claims submission, please contact TriZetto at 1-800-556-2231 or email
ttpssupport@cognizant.com. Payer Number: 22326


? While Horizon NJ Health strongly encourages submitting claims via EDI, if a paper claim is necessary, please submit red and white

paper claims only for all services to Horizon NJ Health at the following address:


Horizon NJ Health
Claims Processing Department
PO BOX 24078
Newark, NJ 07101-0406


? Electronic Funds Transfer forms for providers who wish to use EFT to receive payments can be found by visiting

https://www.horizonnjhealth.com/for-providers/resources/forms/electronic-funds-transfer-eft-forms


? EDI Technical Support Team is available during regular business hours, 8 a.m. through 5 p.m., Monday through Friday at 1-800-556-

2231





Claims















Proprietary & Confidential 18


? Horizon?s Case Management can also help facilitate linkages to care and coordinate care with

other providers and caretakers in the member?s environment


? Provider referrals can also be found via Horizon?s Doctor & Hospital Finder ? our on-line
Provider Directory (https://www.horizonnjhealth.com/findadoctor)


? Provider Referrals can also be given by calling Horizon Customer Service at 1-800-682-9091

? For any additional questions, please contact Vincent_Visioli@horizonblue.com















Applied Behavioral Analysis ? Additional Supports






Thank you for your time today






Network - BHNetworkRelations@horizonblue.com
Clinical ? Vincent_Visioli@horizonblue.com



Q & A

19

Presenter
Presentation Notes
remove





20

Sample MLTSS Member ID Card

Confirm eligibility at NaviNet.net or call MLTSS Provider Services at
1-855-777-0123.





21

Sample FIDE-SNP Member ID Card

Confirm eligibility at NaviNet.net or call Provider Services at
1-855-955-5590.





22

Sample NJ FamilyCare Member ID Card

Confirm eligibility at NaviNet.net or call Provider Services at
1-800-682-9091.





23

Products are provided by Horizon Insurance Company and/or Horizon NJ Health. Communications are issued by
Horizon Blue Cross Blue Shield of New Jersey in its capacity as administrator of programs and provider relations for
all its companies. All are independent licensees of the Blue Cross and Blue Shield Association. ECN00524 (0720)



Provider Information Forum
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Behavioral Health Provider Relations:?Horizon NJ Health
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Q & A
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Proprietary & Confidential

Horizon Behavioral Health
Applied Behavior Analysis (ABA)
Government Programs

November 2020



Proprietary & Confidential

Topics of Discussion

? Horizon NJ Health

? ABA Overview and Authorizations

? Claims

? Credentialing

? Demographic Information Updates and Directory Verification

? Resources, NaviNet?

? Contacts

? Appendix
2



Proprietary & Confidential

Horizon NJ Health Overview
Horizon NJ Health manages government program ABA benefits for the following members:

? Division of Developmental Disabilities (DDD)
? Members with physical, mental or developmental disabilities

? Managed Long Term Services & Supports (MLTSS)
? Expands home and community services to keep members out of nursing homes and in the

community, mostly elderly

? FIDE-SNP programs
? Eligible for both Medicaid and Medicare, mostly elderly

? Core Medicaid

3



Proprietary & Confidential 4

ABA Overview
?The management of Applied Behavior Analysis (ABA) services has transitioned from the Division
of Medical Assistance and Health Services, Children?s System of Care (CSOC) to the Managed
Care Organizations as of 4/1/20.

?Effective 4/1/20, Horizon New Jersey Health (HNJH) covers all medically necessary ABA services
for eligible Horizon Medicaid members.

?Services are available to any child diagnosed with an Autism Spectrum Disorder (ASD) as defined
by ICD-10 diagnoses F84.0 ? F84.9, under the age of 21.

?Providers should contact Horizon to ensure eligibility and benefits by contacting Horizon member
services at 1-800-682-9091.



Proprietary & Confidential 5

ABA Services and Codes
CPT Code CPT Code Definition

97151
Behavior identification assessment, administered by a physician or other qualified healthcare professional, each 15 minutes of the physician's or
other QHP's time face-to-face with patient, and/or guardian(s) administering assessments and discussing findings and recommendations, and non
face-to-face analyzing past data, scoring/interpreting the assessment, and preparing the report/treatment plan

97152 Behavior identification supporting assessment, administered by one technician under the direction of a physician or other qualified healthcare professional, face to face with the patient, each 15 minutes.

0362T
Behavior identification supporting assessment, each 15 minutes of technician's time face-to-face with a patient requiring the following components:
*administered by the physician or other qualified healthcare professional who is on-site, * with the assistance of two or more technicians,*for a
patient who exhibits destructive behavior, *completed in an environment that is customized to a patient's behavior

97153 Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other QHP, face-to-face with one patient, each 15 minutes

97154 Group adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other QHP , face-to-face with 2 or more patients, each 15 minutes

97155 Adaptive behavior treatment, with protocol modification, administered by physician or other QHP, which includes simultaneous direction of technician, face-to-face with one patient, each 15 minutes

97156 Family adaptive behavior treatment guidance administered by physician or other QHP (with or without the patient present), face-to-face with guardians(s)/caregiver(s), each 15 minutes

97157 Multiple-family group adaptive behavior treatment guidance administered by physician or other qualified healthcare professional (without the patient present) face-to-face with multiple sets of guardians(s)/ caregiver(s)

97158 Group adaptive behavior treatment with protocol modifications, administered by a physician or other QHP , face to face with multiple patents', each 15 minutes

0373T
Adaptive behavior treatment with protocol modification, each 15 minutes of technician's time face-to-face with a patient requiring the following
components: *administered by the physician or other qualified healthcare professional who is on site, * with the assistance of two or more
technicians,*for a patient who exhibits destructive behavior, *completed in an environment that is customized to a patient's behavior

H0032 Mental Health service plan development by a non-physician, per 15 minutes



Proprietary & Confidential 6

Authorization Unit Guidance

Code Unit MUE Limits
97151 15 minutes 32 units
97152 15 minutes 8 units
97153 15 minutes 32 units
97154 15 minutes 12 units
97155 15 minutes 24 units
97156 15 minutes 16 units
97157 15 minutes 16 units
97158 15 minutes 16 units
0362T 15 minutes 8 units
0373T 15 minutes 32 units
H0032 15 minutes 4 units



Proprietary & Confidential 7

? Provider submits the ABA Authorization Request Form via Utilization Management Request Tool
accessible in NaviNet. NOTE: Providers can obtain a copy of the ABA Authorization Request Form
from the horizonnjhealth.com website:

? Click on Provider Tab
? Select Resources, then Forms
? Click on Behavioral Health
? ABA Authorization Request Form
? https://www.horizonnjhealth.com/securecms-

documents/900/ABA_Authorization_Request_Form_40001.pdf

? Request for assessment includes a copy of the Autism Spectrum Diagnosis (ASD) script with
recommendation for ABA therapy as completed by a Qualified Health Professional (QHP)

? Acceptable QHPs for the treatment planning for adaptive behavior services shall include:
? Physicians
? Psychologists trained and certified in behavior analysis, and
? Board Certified Behavior Analysts

? Horizon checks eligibility and benefits, confirms diagnosis and completes the assessment
authorization for 32 units of 97151 for 30 days

Process for Obtaining Authorization



Proprietary & Confidential 8

? After completing the assessment, provider submits the ABA Request Form via the
Utilization Management Request Tool, accessible via NaviNet

? Horizon, again, checks eligibility and benefits pursuant to internal processes

? A Horizon Behavioral Health Utilization Management (UM) Clinician reviews request
form against MCG Medical Necessity Criteria

o If clinical information meets medically necessary criteria, Horizon BH
Clinician creates authorization

o If clinical information does not meet medical necessity criteria, the Horizon
BH Clinician calls provider to discuss

o If necessary, Horizon BH Clinician sends the case to the Horizon Medical
Director for a Medical Necessity Review

? For cases that do meet criteria ? once approved ? Horizon BH clinician creates
authorization for 6 months

? Horizon reviews requests for authorization within 14 days of their receipt

Process for Obtaining Authorization (cont?d)
(cont.)



Proprietary & Confidential 9

Claims



Proprietary & Confidential 10

? Horizon NJ Health encourages all providers to submit claims electronically

? HNJH members do not have copays and/or coinsurance

? HNJH utilizes the TriZetto Provider Solutions (TTPS) Direct Data Entry (DDE) SimpleClaim system

? All HNJH claims must be submitted to TriZetto

? For more information on registering with TriZetto, please go to
https://www.trizettoprovider.com/horizon/simpleclaim

? To contact TriZetto?s Technical Support Team, call 1-800-556-2231 or email them at
ttpssupport@cognizant.com. They are available during 8 a.m. through 5 p.m., Monday to Friday

? Horizon NJ Health?s payer number: 22326

Horizon NJ Health Claims





Proprietary & Confidential 11

? Electronic Funds Transfer ? to receive payments via EFT, complete the forms at the
following link: https://www.horizonnjhealth.com/for-providers/resources/forms/electronic-
funds-transfer-eft-forms. Horizon NJ Health?s EFT is processed through Change
Healthcare

? If a paper claim is necessary, please submit red and white paper claims only for all services
to Horizon NJ Health at the following address:

Horizon NJ Health
Claims Processing Department
PO BOX 24078
Newark, NJ 07101-0406

Claims (cont?d)




Proprietary & Confidential

Claims (cont?d)

12

? Professional providers? claims must include both the rendering and billing providers? NPI*

? NPI Types
? Type 1 NPI - Individual ? solo practitioner
? Type 2 NPI ? Organization ? group with multiple providers billing under the same tax identification number

(TIN)

? If you are a solo practitioner:
? Rendering Provider - enter your Type 1 NPI in the un-shaded area of box 24j
? Billing Provider ? enter your Type 1 NPI in box 33a (unless you have a Type 2 NPI , then enter the Type 2

NPI)

? If you are group provider:
? Rendering Provider ? enter your Type 1 NPI in the un-shaded area of box 24j
? Billing Provider ? enter the group?s Type 2 NPI in box 33a

Note: The name of the rendering BCBA must match the name of the authorized BCBA. If you need to update
the authorization, please contact UM.

*If you do not have an NPI, please apply for one through the National Plan and Provider Enumeration System (NPPES) at
https://nppes.cms.hhs.gov/NPPES/Welcome or call 1-800-465-3203




Proprietary & Confidential

Claims (cont?d)

13

? Claims must be submitted within 180 calendar days of the date of service

? Horizon NJ Health will pay clean claims as follows*:
? within 30 days - for electronic claims
? within 40 days - for paper claims

? See the Provider Manual - Section 9 - Billing Guide for helpful information on HNJH claims submission
https://www.horizonnjhealth.com/securecms-documents/605/Provider_Manual.pdf

? Information on corrected claims can be found in section 9.1.5

? For questions regarding your claims, call 800-682-9091

? If you need additional assistance with your ABA claims after calling the 800#, contact:
Nadine Assouman
Provider Resolution Analyst
Nadine_Assouman@horizonblue.com
973-466-4492

? Claims appeals should be submitted to:
Horizon NJ Health
Claim Appeals
P.O.Box 63000
Newark, NJ 07101-8064

? *MLTSS claims are paid within 15 days for electronic claims and within 30 days for paper claims





Proprietary & Confidential 14

21st Century Cures Act
The 21st Century Cures Act 114 P.L. 255 requires that all Medicaid managed care network providers
must enroll with the State Medicaid program or risk being removed from the provider network. This is
both a federal and state requirement.

? Each individual practitioner is required to register for a Medicaid number
? To register, go to the NJ Medicaid Management Information System?s (NJMMIS) website at njmmis.com and select

Provider Enrollment Application on the left blue bar OR use the following direct link
njmmis.com/onlineEnrollment.aspx. Under the Your Information section, click the down arrow in the Provider Type field
and select 21st Century Cures Act

? Please note: If you select your specialty from the drop down menu, the fee-for-service 20 page application will generate.
However, by selecting the 21st Century Cures Act option, the 4-page application needed to satisfy the law?s requirement
will appear

? You can submit your application and credentials by:
? Fax: 1-609-584-1192
? Mail: P.O. Box 4804, Trenton, NJ 08650
? Email: bbrown91@dxc.com



Proprietary & Confidential 15

Credentialing and Recredentialing



Proprietary & Confidential 16

? BCBAs and BCBA-Ds are required to successfully complete the credentialing process prior to being accepted as a
network provider

? Bachelor?s level behavior analysts and support staff/technicians are not required to complete credentialing with Horizon.
Services they provide are required to be under the supervision of the QHP. Horizon is not requiring Behavior Technicians
to be Registered Behavioral Technicians, but it is preferred.

? Please visit https://www.horizonnjhealth.com/for-providers/provider-recruitment to learn more about credentialing
requirements

? Physician Agreements are accessible via NaviNet?s Horizon BCBSNJ plan central page. If you don?t have access to this
page, email EnterprisePDM@horizonblue.com to request a Physician Agreement

? For Horizon NJ Health, if you are with a group of two or more practitioners billing under the same tax
identification number, you will need to complete a group agreement instead of an individual agreement.

? Email your Network Specialist to request a group agreement
? Please submit a copy of your group agreement along with the credentialing application documents for any

additional practitioners you are adding to your group

Credentialing





Proprietary & Confidential 17

? A complete application can take between 45 to 90 days from date of receipt at Horizon BCBSNJ for all
applicable documentation that is submitted correctly

? Please allow 10 working days before calling 1-800-624-1110 to confirm receipt of the application (do not
send emails to the EnterprisePDM mailbox for this information)

? You will receive an email if your application has been approved or denied

? Once approved, you will receive a letter within 30 days that includes your participation effective date
and copies of the fully executed Provider Agreement(s). We will email letter to the email address
provided on the application

Credentialing (cont?d)



Proprietary & Confidential 18

Recredentialing
? Providers are recredentialed every three years
? Ensure your CAQH application has a current reattestation
? Andros works on Horizon BCBSNJ?s behalf to assist in carrying out our recredentialing

responsibilities
? The recred process begins 6 months prior to the month in which a practitioner?s

recredentialing is due
? Practitioners will be terminated if not recredentialed before the end of the 3 year

credentialing cycle

Note: Demographic updates are not made from information obtained as part of the
recredentialing process. You must submit all updates separately.



Proprietary & Confidential 19

Demographic Information Updates
&

Directory Verification



Proprietary & Confidential

Demographic Information Updates

Email demographic update requests to EnterprisePDM@horizonblue.com
? Submit requests & supporting documentation at least 30 days before the effective date of the change
? Always include the submitter?s name, email & telephone # with all email requests
? This mailbox is not able to accept secure emails
? EnterprisePDM@horizonblue.com is not managed by a representative who reads & responds

immediately to your emails. Emails received are converted to Service Requests which are then addressed
offline by our Provider team

? To help ensure that you are getting these responses (and that they are not flagged as spam), please add
EnterprisePDM@HorizonBlue.com to your list of safe or approved senders/contacts

? The email response with SR# ending with PDM is your proof of receipt .

20






Proprietary & Confidential

Demographic Information Updates (cont?d)

Access our Doctor & Hospital Finder on HorizonBlue.com by
clicking the Find a Doctor link to see if the updates were

made
https://doctorfinder.horizonblue.com

21




Proprietary & Confidential

Demographic Information Updates (cont?d)
Doctor & Hospital Finder

Horizon NJ
Health: BH is
not a separate
tab; select
Behavioral Health
Provider in the
?What type of
care are you
looking for? field.

22



Proprietary & Confidential

Directory Verification

The Centers for Medicare & Medicaid Services (CMS) requires health plans to validate all
participating providers? directory information on a quarterly basis. To comply with this
requirement, Horizon will:

? Call each of your practice locations quarterly

? Three outreach attempts will be made to verify your information

? If we are unable to validate the data, the location(s) will be suppressed from our online Doctor
& Hospital Finder until we receive verification from you

23



Proprietary & Confidential

Websites
Horizonblue.com/providers

To access the BH
landing pages:

Commercial:
? Click on Providers
? Click on Products &

Programs
? Click on Horizon

Behavioral Health

Horizon NJ Health:
? Click on Providers
? Click on Programs
? Click on Horizon

Behavioral Health

24

Dedicated
behavioral
health landing
page



Proprietary & Confidential 25

Resources



Proprietary & Confidential

Resources

Web Page Commercial Horizon NJ Health
Main Provider Page https://www.horizonblue.com/providers https://www.horizonnjhealth.com/for-providers

Horizon Behavioral Health Page
https://www.horizonblue.com/providers/products-
programs/horizon-behavioral-health

https://www.horizonnjhealth.com/for-
providers/programs/horizon-behavioral-healthsm

Demographic Updates
https://www.horizonblue.com/providers/policies-
procedures/demographic-updates

https://www.horizonnjhealth.com/for-
providers/programs/horizon-behavioral-
healthsm/demographic-updates

Credentialing
https://www.horizonblue.com/providers/why-join/join-our-
networks

https://www.horizonnjhealth.com/for-providers/provider-
recruitment

Policies & Procedures
https://www.horizonblue.com/providers/policies-
procedures

https://www.horizonnjhealth.com/for-
providers/resources/policies

Forms
https://www.horizonblue.com/providers/forms/forms-
specialty-type/horizon-behavioral-health

https://www.horizonnjhealth.com/for-
providers/resources/forms/behavioral-health

Provider Manuals
https://www.horizonblue.com/providers/resources/manua
ls-user-guides

https://www.horizonnjhealth.com/securecms-
documents/605/Provider_Manual.pdf

News https://www.horizonblue.com/providers/news https://www.horizonnjhealth.com/for-providers/news

NaviNet https://navinet.navimedix.com/sign-in?ReturnUrl=/ https://navinet.navimedix.com/sign-in?ReturnUrl=/

26





















Proprietary & Confidential

NaviNet

NaviNet is a single sign on, multi-payer tool, that allows self-service options to both in
network and out of network offices.

NaviNet Features:
? Utilization Management Request Tool
? Claim Status
? Provider Directory
? Member Eligibility and Benefit
? Financial Reports
? Electronic Referral Submission and Inquiry
? Clinical Reports
? Administrative Reports

All participating physicians and health care professionals are required to register for NaviNet

27



Proprietary & Confidential

NaviNet (cont?d)

To learn more about NaviNet, visit NaviNet.net.

For upcoming NaviNet webinars, please visit
https://www.horizonblue.com/providers/products-programs/horizon-behavioral-health

To access a NaviNet Information Demo:

? Select Provider Reference Materials and mouse over Resources

? Select Training, then Education

? Select NaviNet Information Demo

28




Proprietary & Confidential 29

Providers can access the Utilization Pre-authorization Management Tool through
NaviNet. Simply select Horizon NJ Health from the Plan Central page; mouse
over Referrals and Authorization on the left-hand navigation; then select
Utilization Management requests. Please refer to the Utilization Management
Request Tool Tutorial by visiting www.horizonnjhealth.com:

? Under the Provider?s tab, select Resources
? Click on UM Tool Tutorial 2020

? NaviNet Support: 1-888-482-8057

NaviNet (cont?d)




Proprietary & Confidential 30

Contacts



Proprietary & Confidential 31

Horizon?s participating providers are assigned to a Network Specialist based on their county. Your Network
Specialist is available via phone or email and is your primary point of contact for the following areas:

? General Education
? Requests for a Site/Education Visit
? NaviNet Training
? Network Status Inquiries

Network Specialists:
Horizon NJ Health:
https://www.horizonnjhealth.com/securecms-documents/625/Provider_Quick_Contact_Guide_2019_0.pdf

Please continue to contact Customer Service for all claims related concerns

Contacts




Proprietary & Confidential

Behavioral Health Provider Relations:
Horizon NJ Health

32

Dottie Laisi
LaTanya
McLean Barkley Michelle McCusker Olivia Inniss

Atlantic Hunterdon Burlington Bergen

Cape May Mercer Camden Essex

Cumberland Morris Middlesex Hudson

Gloucester Somerset Salem Passaic

Monmouth Sussex

Ocean Union

Warren

856-638-3215 856-638-3228 856-638-3223 973-466-4609

Dorothy_Laisi@horizonblue.
com

LaTanya_Barkley@horizonblue.
com

Michelle_McCusker@horizonblue
.com Olivia_Inniss@horizonblue.com



Proprietary & Confidential 33

Additional Contacts



34

???

BHNetworkRelations@HorizonBlue.com

Questions



35

Appendix



36

Sample NJ FamilyCare Member ID Card

Confirm eligibility at NaviNet.net or call Provider Services at 1-800-682-9091

Proprietary & Confidential



37

Sample MLTSS Member ID Card

Confirm eligibility at NaviNet.net or call MLTSS Provider Services at 1-855-777-0123

Proprietary & Confidential



38

Sample FIDE-SNP Member ID Card

Confirm eligibility at NaviNet.net or call Provider Services at 1-855-955-
5590.

Proprietary & Confidential



Proprietary & Confidential

Products are provided by Horizon Blue Cross Blue Shield of New Jersey, Horizon Insurance Company, and/or Horizon NJ Health. Communications are issued by Horizon Blue Cross
Blue Shield of New Jersey in its capacity as administrator of programs and provider relations for all its companies. All are independent licensees of the Blue Cross and Blue Shield
Association. The Blue Cross? and Blue Shield? names and symbols are registered marks of the Blue Cross and Blue Shield Association. The Horizon? name and symbols are
registered marks of Horizon Blue Cross Blue Shield of New Jersey. ? 2020 Horizon Blue Cross Blue Shield of New Jersey. Three Penn Plaza East, Newark, New Jersey 07105.

Thank you

39