Educational Material for Providers
Horizon NJ Health wants to make it easier for you to understand our procedures and the resources available to you. These educational presentations will benefit participating physicians, practice administrators, office managers and office personnel. Click a topic below for detailed information about how to get the most out of our products and services.
- Behavioral Health Program
- ClaimsXTen FAQs
- ClaimsXTen Edit Codes and Messages
- SimpleClaim Training Resources
- UM Tool Denial Appeal Tutorial for 2020
- UM Tool Tutorial 2020
- How to Correctly Submit Claims with J or Q Codes
- J and Q Code Billing Provider Update
- Horizon NJ TotalCare (HMO D-SNP): Common Non-Formulary Drugs and Formulary Alternatives
- Horizon NJ TotalCare (HMO D-SNP) Model of Care Training
- Indications for OB Ultrasound Overview Presentation
- Contracting Initiative FAQ
- Changes to the Management of the Horizon Behavioral Health Program
- Fact Sheet for Lead Screening in Children
Tikka Attach
Horizon NJ Health?s
Behavioral Health Program
October 2018
1 Government Programs
Objectives
? Overview of Beacon Health
Options and Horizon NJ
Health?s Behavioral Health
Network
? Summary of MLTSS, DDD and
FIDE-SNP Plans
? Benefit Changes - New
Effective Date October 1, 2018
? Clinical Care Management and
Authorizations
? Contracting and Credentialing
? Claims
? Beacon?s On-Line Portal
? Contact Information
2 Government Programs
Overview of Beacon Health Options
and Horizon NJ Health
1/1/14
Beacon Health Options began
managing the behavioral health
benefits for members covered
by Horizon NJ Health and
enrolled in the Division of
Developmental Disabilities
(DDD).
7/1/14
Beacon Health Options began managing the behavioral health
benefits for members covered by Horizon NJ Health and enrolled
in Managed Long Term Services and Supports (MLTSS).
Beacon Health Options began
managing the behavioral health
benefits for members covered by
Horizon NJ Health and enrolled in
the Dual Eligible Special Needs Plan
(FIDE-SNP).
1/1/17
3 Government Programs
Overview of Beacon Health Options
and Horizon NJ Health
Among the services Beacon Health Options provides include:
? Manage the Horizon Behavioral Health Networks
? Perform Credentialing and Recredentialing
? Perform Clinical Care Management and Authorizations
? Handle Complaints and Appeals, Provider and Member
? Provide Enhanced Care and Case Management programs
? Provide Provider and Member Customer Services
? Quality Improvement
4 Government Programs
MLTSS, FIDE-SNP and DDD Plans
5 Government Programs
Medicaid Managed Long Term Services & Supports (MLTSS)
Managed Long Term Services & Supports (MLTSS) refers to the
delivery of long-term services and supports through New Jersey
Medicaid?s NJ FamilyCare program. MLTSS is designed to expand
home and community-based services, promote community inclusion
and ensure quality and efficiency.
Horizon NJ Health coordinates all services for MLTSS members. The
program provides comprehensive services and supports, whether at
home, in an assisted living facility, in community residential services,
or in a nursing home. Behavioral Health is managed by Beacon.
Currently Beacon manages the Mental Health and Opioid
Treatment Services for Horizon NJ Health.
6 Government Programs
Horizon NJ TotalCare (HMO SNP)
Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP)
The FIDE-SNP plan is known as Horizon NJ TotalCare (HMO SNP).
FIDE-SNP is a Medicare Advantage plan that integrates all covered Medicare and Medicaid
managed care benefits into one health plan, including primary care and preventive services,
behavioral health and long-term care. Members receive quality care designed to meet all of
their needs.
*Horizon NJ Health will continue to pay both the Medicare and Medicaid components of claims
for Horizon NJ TotalCare (HMO SNP) members, eliminating the need to file Medicare claims
separately; however, any other coverage available for a Horizon NJ TotalCare (HMO SNP)
member should be filed first with that insurance program.
The most important features of the plan are:
? A team of doctors, specialists, and Horizon Care Managers working together for the FIDE-
SNP member
? A Model of Care that calls for individual care plans for each member
? No copayments, premiums or deductibles for most covered services.
Currently, Beacon manages the outpatient and inpatient mental health services for
Horizon NJ Health.
.
7 Government Programs
Division of Developmental Disabilities
The Division of Developmental Disabilities (DDD) provides
public funding for services and supports that assist New Jersey
adults with intellectual and developmental disabilities age 21
and older to live as independently as possible.
Currently, Beacon manages the outpatient and inpatient
mental health services for Horizon NJ Health.
8 Government Programs
Benefit Changes
New Effective Date
October 1, 2018
9 Government Programs
Benefit Changes for 2018
Inpatient Admissions
Effective October 1, 2018, all admissions to a general acute care or free standing psychiatric hospital,
including admissions to a psychiatric unit, shall be the responsibility of Horizon NJ Health for ALL
Horizon NJ Health enrolled members.
These changes are not limited to MLTSS, FIDE-SNP and DDD members.
Managed care organizations are responsible for all acute psychiatric admissions to a general care,
stand-alone psychiatric or specialty care hospital. This includes admissions directly from a
certified screening center.
Acute care admissions are required for individuals presenting with unstable behavior requiring
immediate professional intervention to monitor and diagnose, adjust and stabilize medications
and develop a treatment plan beyond the acute episode of care.
Guidelines on Psychiatric Continued Stays and Admissions can be found on our website:
www.horizonnjhealth.com/for-providers/resources/clinical-and-preventive-guidelines-and-policies
www.beaconhealthoptions.com/providers/beacon/network/horizon-nj-health/
10 Government Programs
Benefit Changes for 2018
Substance Use Disorder Coverage
All Substance Use Disorder (SUD) services including, but not limited to,
? Inpatient Detoxification services ? ASAM 3.7D
? Outpatient SUD services ? ASAM 1.0
? Intensive Outpatient Services (IOP) ? ASAM 2.1
? SUD partial care ? ASAM 2.5
? SUD residential services ? ASAM 3.7
? Ambulatory Withdrawal Management (AWM) services ?
ASAM 2-WM
? Medication Assisted Treatment (MAT) ? ASAM 1.0
All of the services above will be the responsibility of the managed care
organization (MCO) for all beneficiaries enrolled in MLTSS, FIDE-SNP
and DDD.
11 Government Programs
Benefit Changes for 2018
Mental Health Coverage
Effective October 1, 2018, in order to align behavioral health benefit
coverage, all managed care plans will be providing the mental health
services currently covered under MLTSS to the beneficiaries
enrolled in MLTSS, FIDE-SNP and DDD.
These services include the following mental health services:
? Outpatient
? Partial Care
? Adult Mental Health Rehabilitation (Group Homes and
Apartments)
? Inpatient
? Partial Hospitalization
12 Government Programs
Benefit Changes for 2018
Mental Health Coverage
The following services are not included in the mental health
coverage benefits for 2018, and will remain Fee-for-Service:
? Targeted Case Management (TCM) including:
? Justice Involved Services (JIS)
? Children's System of Care (CSOC) Care Management Organizations
(CMOs)
? Integrated Case Management (ICMS)
? Projects for Assistance in Transition from Homelessness (PATH)
? Behavioral Health Homes (BHH)
? Programs in Assertive Community Treatment (PACT)
? Community Support Services (CSS)
13 Government Programs
Clinical Care Management
and Authorizations
14 Government Programs
Sample NJ FamilyCare Member ID Card
ID card will have the prefix YHZ in front of the ID number.
Confirm eligibility on a monthly basis as with any other member at
NaviNet.net or call Provider Services at 1-800-682-9091.
Members will not receive new member ID cards.
15 Government Programs
Sample MLTSS Member ID Card
ID card will have the prefix YHZ in front of the ID number.
Confirm eligibility on a monthly basis as with any other member
at NaviNet.net or call MLTSS Provider Services at 1-855-777-0123.
Members will not receive new member ID cards.
16 Government Programs
Sample FIDE-SNP Member ID Card
ID card will have the prefix YHZ in front of the ID number.
Confirm eligibility on a monthly basis as with any other member at
NaviNet.net or call Provider Services at 1-800-682-9091.
Members will not receive new member ID cards.
17 Government Programs
Authorizations
Members will not need a referral from their PCP to see a behavioral health
provider.
We encourage all providers to call us in advance of providing services to
confirm the member?s eligibility, the in-network status of the facility, and to
verify benefits.
For authorization requests and other related clinical questions, please call:
Authorizations and Care Management
1-800-682-9091 (24 hours a day/7 days a week) ? NJ FamilyCare
1-800-682-9091 (24 hours a day/7 days a week) ? DDD
1-855-777-0123 (24 hours a day/7 days a week) ? MLTSS
1-855-955-5590 (24 hours a day/7 days a week) ? FIDE-SNP
18 Government Programs
Authorizations - continued
All Horizon NJ Health behavioral health authorizations requests are communicated via telephonic review only
at this time. All calls will be recorded for quality assurance. Both the provider and the member will receive
written confirmation of an authorization.
Authorization is obtained by calling the number on the back of the member?s identification card. If the
member does not have an ID card, call 1- 800 - 682- 9091.
? For all but out-patient requests, you are asked to call Beacon within 24 hours of the admission with
the reason for the admission, diagnosis, medication, treatment plan, discharge plan and any other
pertinent information we need so medical necessity review can be completed.
Medical Services: All calls are received by Horizon NJ Health. Medical needs will be addressed at the initial
point of contact. Calls will then be directed to Beacon as needed for Behavioral Health service needs
19 Government Programs
Authorizations - continued
HNJH Emergent Behavioral Health Services: Inpatient Mental Health and Inpatient Detoxification
Services:
Authorization is available 24/7
HNHJ Non-Emergent Behavioral Health Services:
Authorization is available Monday-Friday, 8 am to 5 pm
Substance Use Services for individuals who are not Non-MLTSS, DDD and FIDE-SNP Members:
IME: 1-844-276-2777 (24 hours a day/7 days a week)
For any inpatient admission that occurred prior to 10/1/18 and was discharged after 10/1/18, the
State is responsible for paying the claim under FFS.
20 Government Programs
Authorizations - continued
Out Patient Services:
In-network providers - Authorization is not required for outpatient services as detailed
on slide 21, including Medication Assisted Treatment.
Out-of-network providers - All services require authorization and a single case
agreement. Criteria for single case agreement will be discussed during the review for
authorization.
21 Government Programs
Authorization Required ? Effective 10/1/18
Requires Authorization No Authorization Required
Inpatient Psychiatric Treatment In-network Outpatient psychotherapy
Partial Hospitalization In-network outpatient psychiatric/ Medication
Management
Partial Care Medication Assisted Treatment ? not including actual
medication
Adult Mental Health Rehabilitation (AMHR) Group
Homes and Apartments
In-network Outpatient treatment for substance use
disorders
Psychological Testing In-network outpatient psychiatric/ Medication
Management for substance use disorders
ECT
Trans Magnetic Stimulation
Short Term Residential Treatment (ASAM 3.7)
Ambulatory Withdrawal Management (ASAM 2-WM)
Medically Monitored Detox (SUD ASAM 3.7D)
IOP SUD (ASAM 2.1)
Partial SUD (ASAM 2.5)
All out of network providers will require an authorization
for any level of care including outpatient levels of care.
For a complete listing of services and associated codes, please visit our website:
www.beaconhealthoptions.com/providers/beacon/network/horizon-nj-health/
22 Government Programs
Clinical Appeals Process
Members and providers that are in-network are eligible for the initial Peer Advisor review
as well as a Level 1 appeal. This is applicable whether the request for an appeal is made
while the member remains in treatment or post-service. These appeals are delegated to
Beacon Health Options.
All out-of-network provider appeals are delegated to HNJH.
To appeal a Level 1 denial rendered by Beacon, the member/facility is entitled to an
external IURO appeal via DOBI and Fair Hearing by DMAHS.
23 Government Programs
Continuity of Care Process
For the first 30-days post-go-live, we will not require authorization for any services
rendered by an out-of-network provider.
During the initial 30-day period, our Clinical team is available to work with members to
help transition them to an in-network provider.
Requests to continue with an out-of-network provider after the initial 30 days will be
evaluated on a case-by-case basis to determine the most appropriate course of action.
After the initial 30-day period, all services rendered by an out-of-network provider will
require authorization and a single case agreement.
24 Government Programs
Clinical Care Management and Follow-up Care
? HEDIS Quality Measure - Follow-up After Hospitalization
? Requires member to be seen within 7 days of discharge, by
a qualifying behavioral health provider, from the inpatient
setting
? Collaboration between the inpatient facilities and Horizon NJ
Health?s Clinical Care Management team on the discharge
planning
? Clinical Care Management team can assist with
appointment and discharge barriers.
25 Government Programs
Contracting and
Credentialing
26 Government Programs
If you are already participating - A letter with an amendment to add these new
services to your existing contract was sent to you via email, fax or mail in April.
If you are currently non-par and would like to join the Horizon NJ Health
network, please call Beacon?s Provider Services Line at 1-800-397-1630 from 8
a.m. to 8 p.m., Monday through Friday. You will be advised on how to complete
provider agreement for each line of business.
The credentialing process can take up to 90 days after we have received a
complete application and signed agreements. However, if you were previously
treating a member prior to October 1, 2018 under the state program and you
have returned your signed agreement, you will be able to treat members for six
months while your credentialing application is in process.
Effective October 1, 2018, Horizon NJ Health is aligning its standard fee schedule
with the NJ Medicaid fee schedule for non-TotalCare members. Reimbursement
for TotalCare members will not be impacted by the October 1 changes.
Contracting for New Services
27 Government Programs
Claims
28 Government Programs
Claims
Horizon NJ Health retains ownership of claims processing and claims and payment
inquiries from providers and members.
? Horizon NJ Health encourages all hospitals, physicians, and health care
professionals to submit claims electronically. We utilize the TriZetto Provider
Solutions (TTPS) as the EDI vendor.
? For more information on registering, please go to
www.trizettoprovider.com/horizon/simpleclaim. If you have any further
questions about registering with TTPS for EDI claim submission, please call TriZetto
at 1-800-556-2231 or email ttpssupport@cognizant.com.
? Submit all electronic claims to the Horizon NJ Health EDI Payer Number 22326.
? You may also choose to contract with another EDI clearinghouse or vendor who
already has access to TriZetto EDI services.
? The other electronic way to submit claims is Direct Data Entry (DDE) through the
TTPS SimpleClaim system. For more information about SimpleClaim please use the
TTPS contacts above for additional information.
29 Government Programs
Claims
? All services rendered must be submitted on the CMS 1500 (HCFA 1500) version
02/12 or UB-04 claims form, or via electronic submission in a HIPAA-compliant
837 or NCPDP format.
? NPI numbers are required for all claims submissions.
? An authorization number must be included in box #23 on a CMS 1500 (HCFA 1500)
claim form or box #63 on a UB-04 form for all services which require an
authorization.
? Although a primary insurer may have unique coding specific to their business,
providers must bill with valid ICD-10-CM, CPT-4 and HCPCS codes. Unique or
invalid codes specific to other insurers will cause claim processing delays or
denials.
? Corrected claims must be billed with a frequency 7 or the third bill type code as 7
and the PCCN number must be included on the claim.
? All claims must include taxonomy codes. More information on taxonomy codes
can be found at https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/MedicareProviderSupEnroll/Taxonomy.html.
30 Government Programs
Claims
Billing Outpatient Clinic Services as a Ancillary Facility
If you are contracted and credentialed to provide Outpatient Clinic services as an
ancillary facility, please include only the facility NPI number.
Ancillary facilities who bill for Outpatient Clinic services on a HCFA 1500 should
bill either the billing entity?s NPI in field J (Rendering Provider ID) or leave the field
blank.
This applies to both outpatient mental health and substance use disorder clinic
services.
If you have additional questions regarding your contracting status, please call 1-
800-397-1630 or your assigned Contract Manager.
31 Government Programs
Claims
? Horizon NJ Health will pay claims based only on eligible charges.
Unless the provider contract states otherwise, claims will be paid on
the lesser of billed charges or the contracted rate (Horizon NJ Health
fee schedule).
? Horizon NJ Health is the ?payor of last resort? on all claims submitted
for members of its health plan. Hospitals, physicians and health care
professionals must verify whether the member has Medicare
coverage or any other third party resources and, if so, provide
documentation that the claim was first processed by this other
insurer as appropriate. If the amount that Medicaid (HNJH
contracted rates) would pay is less than Medicare and/or the third
party payor, then the claim will pay at $0.
32 Government Programs
Claims
? Horizon NJ Health must receive all claims within 180 calendar days
from the initial date when services were rendered. If claims are not
received within 180 calendar days from the initial date of service,
claims will be denied for untimely filing. Coordination of benefits
claims must be received within 60 days from the date on the primary
Explanation of Benefit (EOB).
? EFT and Electronic Remittance Advice (ERA-835) is available via
Navinet.
33 Government Programs
In-Patient Administrative Days - Claims Submission
? Claims will be reimbursed according to the authorization.
? In order to properly capture the encounter for the
administrative rate (Rev 199) paid in acute care hospitals,
please bill type 11x for acute care hospitalizations for
these types of encounters.
34 Government Programs
HNJH Secondary Payment
? Except Medicare for Horizon NJ TotalCare (HMO SNP) members, all coordination
of benefit (COB) claims must be submitted with a copy of the EOB from the
primary insurer. Medicaid is the ?payor of last resort.?
? Paid primary claims can be submitted via EDI. Denied primary claims must be
submitted as paper claims.
? Secondary claims must be submitted to Horizon NJ Health within 60 days of the
date of the EOB or within 180 days of the date of service, whichever is later.
? Providers must bill with valid ICD-10-CM, CPT-4 and HCPCS codes. Unique or
invalid codes specific to other insurers will cause claim processing delays or
denials.
? For more detailed information, please refer to the current Horizon NJ Health
Provider Administrative Manual.
35 Government Programs
Paper Claims
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 medical
services to Horizon NJ Health at the following address:
Horizon NJ Health
Claims Processing Department
PO Box 24078
Newark, NJ 07101-0406
Horizon NJ Health does not accept handwritten or black and white claims.
Effective 1/1/18, Horizon NJ Health will only accept paper claims on an exception
basis. If you are unable to submit claims electronically, please contact Provider
Services at 1-800-682-9091.
36 Government Programs
Administrative Claim Appeals
All claim appeals must be submitted within 90 calendar days from the date of the
finalized claim (date of the Horizon NJ Health explanation of benefits) and initiated
on the applicable appeal application from created by the Department of Banking and
Insurance.
Claim Appeal Department
PO Box 63000
Newark, New Jersey 07101
or
Fax to: 1-973-522-4678
For more information on claim appeals and to access the appeal application form,
please visit www.horizonnjhealth.com/securecms-documents/131/Instructions-
for-Application-to-Appeal-a-Claims-Determination.pdf
37 Government Programs
Required Fields for CMS 1500 and
UB-04 Claim Forms
Information on submitting a complete CMS 1500 form can be found in
the Provider Manual on the Horizon NJ Health website under Section
9.2.1.
Information on submitting a complete UB-04 form can be found in the
Provider Manual on the Horizon NJ Health website under Section 9.2.2
www.horizonNJhealth.com/securecms-
documents/605/provider_manual.pdf
38 Government Programs
How to Check Claim Status
Online
? NaviNet.net
? Access Horizon NJ Health within the Plan Central drop-down menu
? Click Claim Management, then Claim Status Inquiry
For more information about billing and filing claims, please see
Section 9 of the Horizon NJ Health Provider Manual, available on
www.horizonNJhealth.com.
39 Government Programs
Beacon Health Options?
OnLine Portal
Provider Connect
40 Government Programs
Updating Provider Information
It is provider?s responsibility to submit updates to practice location(s), billing
information, telephone/fax numbers, hours of availability and any other
demographic changes.
Updating of provider information is available through Beacon Health Options? on-
line portal called ProviderConnect.
To learn more, call Beacon Health Options? Provider Services Line at
1-800-397-1630 (8 a.m. ? 8 p.m., EST, Monday through Friday)
or visit
Free demonstration:
www.beaconhealthoptions.com/Providers/Beacon/ProviderConnect
Click on Access the Provider Connect Demo
41 Government Programs
Contact Information
42 Government Programs
Provider Contacts
Beacon Provider Relations, Credentialing and Contracting Questions:
Provider Services Line:
1-800-397-1630 (8 a.m. - 8 p.m. ? Monday to Friday)
Email:
horizonbehavioralhealthproviderrelations@beaconhealthoptions.com
Authorizations and Care Management
1-800-682-9091 (24 hours a day/7 days a week) ? NJ FamilyCare
1-800-682-9091 (24 hours a day/7 days a week) ? DDD
1-855-777-0123 (24 hours a day/7 days a week) ? MLTSS
1-855-955-5590 (24 hours a day/7 days a week) ? FIDE-SNP
43 Government Programs
Provider Contacts
Horizon NJ Health Physician & Health Care Hotline
1-800-682-9091 (8 a.m. - 5 p.m., ET - Monday through Friday)
Navinet
www.Navinet.net or call Provider Services at 1-800-682-9091
TriZetto EDI Services and Simple Claim inquires
1-800-556-2231
Horizon NJ Health?s Website
www.horizonNJhealth.com
Horizon NJ Health?s Provider Manual
www.horizonnjhealth.com/securecms-documents/605/Provider_Manual.pdf
Horizon NJ Health?s Provider Specific Website
https://www.beaconhealthoptions.com/providers/beacon/network/horizon-nj-health/
Scroll to the section called ?NJ State Medicaid Behavioral Health Changes ? October 1, 2018? for helpful reference
information.
44 Government Programs
Provider Contacts
Claims Submission/ Address
Reference the address on the member?s identification card, as the address may vary
based on payment location.
Member Benefits, Eligibility, and Authorizations
If you have a question about authorization or benefits, call the (800) number on the
back of the member?s identification card.
Member Customer Service
To reach Member Services, call the phone number on the back of the member?s
identification card.
If the member does not have an ID card, call 1-800-682-9091.
45 Government Programs
Questions?
Questions and answers: Contracting Initiative
Products are provided by 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. Both 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. ? 2019 Horizon
Blue Cross Blue Shield of New Jersey, Three Penn Plaza East, Newark, New Jersey 07105. EC003660 (0619)
Below are answers to questions you may have about signing Horizon NJ Health?s provider
agreement.
Q1. Why do I need to sign this contract?
A1. All of Horizon NJ Health?s participating providers must have a dually executed contract to
protect the interest and establish the expectations of mutual agreement between parties.
Q2. What do I need to do?
A2. Sign the attached agreement and return the contract to Horizon NJ Health by June 28, 2019.
Q3. How will this impact my payments/rates?
A3. This is a seamless process that will not impact your current payments/rates. However, if the
contract is not signed and returned by June 28, 2019, it will lead to termination from the
Horizon NJ Health network.
Q4. When will the agreement become effective?
A4. The agreement will be effective the first of the month after it is received and dually executed.
Q5. Who can I contact if I have questions?
A5. Please forward any additional questions to Provider_Relations@horizonNJhealth.com with
the subject Contracting Initiative.
For Ancillary ? Lori Bembry 1-609-537-2427 or Lori_Bembry@horizonNJhealth.com
For Physician ? Tara Black-Jones 1-609-537-2636 or Tara_Black-Jones@horizonNJhealth.com
Q6. What will happen if I do not return this contract?
A6. Failure to return your contract will result in your termination as a Horizon NJ Health provider.
Q7. Can I return it by email or fax?
A7. You can email your contract to Provider_Relations@horizonNJhealth.com with the subject
Contracting Initiative or fax your contract to 1-609-583-3004, attention Tara Black-Jones - PC&S
Contracting.
Q8. What products are covered under this contract?
A8. Horizon NJ Health products are covered, including Horizon NJ Total Care (HMO SNP) and
Medicaid.
Proprietary & Confidential
Changes to the Management of the Horizon
Behavioral Health Program
December 2019
Proprietary & Confidential 2
Overview
? Beginning on or about January 1, 2020, Horizon BCBSNJ will transition
the administration and clinical management of behavioral health services from
Beacon Health Options (formerly ValueOptions) to our internal operations for all
Horizon BCBSNJ plans that offer behavioral health benefits through the
Horizon Behavioral Health? program.
? The complete transition to Horizon BCBSNJ?s internal management will occur in
a phased approach based on line of business.
? The following are the target effective dates:
? January 1, 2020: Horizon Medicare Advantage and Horizon NJ Health Plans,
including Division of Developmental Disabilities (DDD), NJ FamilyCare and
Managed Long Term Services & Supports (MLTSS), and Horizon NJ TotalCare
(HMO D-SNP)
? April 1, 2020: Horizon BCBSNJ fully insured plans/products, self-insured
(Administrative Services Only [ASO]) employer group plans including the State
Health Benefits Program (SHBP) and the School Employees? Health Benefits
Program (SEHBP) and the Federal Employee Program? (FEP?)
Proprietary & Confidential 3
? Current Horizon Behavioral Health provider contracts will not be impacted
by the change in the management of behavioral health benefits.
? Horizon BCBSNJ remains committed to working with health care
professionals throughout the state to improve the patient experience and
lower the total cost of care
? Horizon BCBSNJ will also be looking for ways to build on the current level
of support services and programs offered through the existing
Horizon Behavioral Health Program.
Important Changes: Key Points
Proprietary & Confidential
What Will Insourcing Achieve?
Horizon BCBSNJ?s insourced behavioral health management model will:
Promote clinical integration between physical and mental health
Improve health care affordability through greater operational efficiencies
and cost trend mitigation
Increase member and provider satisfaction through a seamless experience
and expansion of access and availability of services
Promote behavioral health expertise and increased knowledge base across
all functional areas
4
Proprietary & Confidential 5
Important Changes: Key Dates
Policy/Process Change
Horizon
NJHealth &
Medicare
Advantage
Horizon
BCBSNJ fully
insured
plans/products
Recredentaling
Horizon BCBSNJ manages the recredentialing for all providers who are due to be recredentialed on and
after January 1, 2020.
7/1/19 7/1/19
Credentialing & Demographic Updates
Horizon BCBSNJ manages the initialing credentialing of non-participating Behavioral Health professionals and
ancillary providers who are seeking to join one of our network(s) and provider file changes.
10/1/19 10/1/19
Medical Necessity Criteria
Clinical care guidelines from MCG Health, LLC (MCG) will be used to make behavioral health care utilization
management determinations. The American Society of Addiction Medicine (ASAM) criteria Substance Use Disorder
determinations.
12/30/19 3/30/20
Prior Authorization
Requests and status via NaviNet, our Online Utilization Management Tool will only online option ? Beacon?s
ProviderConnect system no longer an online source.
1/1/20 4/1/20
Transition of all Network Management Functions
Horizon BCBSNJ manages all Network relationship management., i.e. education
1/1/20 1/1/20
Verifying Member Eligibility & Benefits
Online via NaviNet or phone ? Beacon?s ProviderConnect system no longer active
1/1/20 4/1/20
Doctor Hospital Finder
Enhanced behavioral health search capabilities . (Digital enhancements will continue through Q1 2020).
11/1/19 11/1/19
Horizon NJ Health and Horizon NJ
TotalCare (HMO D-SNP) Plans
6
Horizon NJ Health Behavioral Health
Overview
7
Horizon NJ Health is responsible for managing the behavioral health benefits for
members of our Developmental Disabilities (DDD), Managed Long Term Services
& Supports (MLTSS) and FIDE-SNP programs.
Horizon NJ Health is also responsible for managing the acute inpatient mental
health benefits for all of our Medicaid members, while the State manages the
non-acute behavioral health benefits through the NJ Medicaid Fee-for-Service
program.
Horizon NJ Health PCPs refer non-DDD, non-MLTSS and non-FIDE-SNP
members to a NJ Medicaid Fee-for-Service behavioral health professional.
Horizon NJ Health provides behavioral health benefits to Horizon NJ Health
members through the Horizon Behavioral Health Network.
Horizon NJ Health?s Care Management Department can coordinate the behavioral
health services for DDD, MLTSS and FIDE-SNP members with the PCP,
Horizon Behavioral Health and its professional network.
Proprietary & Confidential 8
Horizon NJ Health has adopted the following appointment scheduling standards
to ensure timely access to quality medical care. Compliance with these
standards will be audited by periodic on-site reviews and chart sampling
For Mental Health/Substance Use Disorder Appointments (Clients of the Division
of Developmental Disabilities, MLTSS and FIDE-SNP only):
? Emergency services- Immediate care
? Urgent care appointments within twenty-four (24) hours.
? Routine care appointments within ten (10) days of request.
? Waiting time in office: less than 45 minutes
Behavioral Health Appointment Scheduling
Standards
Proprietary & Confidential 9
Members will not need a referral from their PCP to see a behavioral health provider.
? Provider who use NaviNet can access the Utilization Management Request Tool to
submit authorization requests easily and securely. This tool allows providers to
communicate directly with Horizon NJ Health by checking the statuses of all requests in
real time. It also sends providers notification when requests are completed. The main
features in the tool include authorizations requests viewing status of authorization
requests. It can also be used for authorizations for home care, DME purchase /rental,
surgical procedures and inpatients admission.
? Providers can access 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
? You may also reach out to our Utilization Management Department at 1-800-682-9094
for precertification request at least five business days before rendering services for
routine services
Procedural Standards: Prior Authorization
Proprietary & Confidential 10
Procedural Standards: Behavioral Health Prior
Authorization
List
Requires Authorization No Authorization Required
Inpatient Psychiatric Treatment In-network Outpatient psychotherapy
Residential Mental Health In-network outpatient psychiatric/ Medication Management
Partial Hospitalization Medication Assisted Treatment ? not including actual medication
Partial Care In-network Outpatient treatment for substance use disorders
Intensive Outpatient (IOP) In-network outpatient psychiatric/ Medication Management for
substance use disorders
Adult Mental Health Rehabilitation (AMHR) Group
Homes and Apartments
Psychological Testing
Repetitive Transcranial Magnetic Stimulation (RTMS)
ECT
Medically Managed Detox (ASAM 4.0)
Medically Monitored Detox (SUD ASAM 3.7D)
Inpatient SUD Rehab (ASAM 3.7)
Residential SUD (ASAM 3.5))
Partial SUD (ASAM 2.5)
IOP SUD (ASAM 2.1)
All out of network providers will require an authorization
for any level of care including outpatient levels of care.
Verify benefits prior to requesting Prior Authorization, not all products will have all levels of care. Core Medicaid only has IP Mental Health &
Detox level of care.
Proprietary & Confidential 11
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.
? Ancillary Providers should submit the following through your Ancillary Contracting Specialist:
? Provider File Change Requests
? Tax Identification Number (TIN) Changes
Proprietary & Confidential
Access our Doctor & Hospital Finder
on Horizonnjhealth.com by clicking
the Find a Doctor link
Confirming Demographic Information
12
Proprietary & Confidential
Search Options
Proprietary & Confidential
Use the search boxes to locate participating providers.
Search Options
13
Proprietary & Confidential 14
How to Update Your Information
Type of Request Documentation Required Comments
Relocation or Add New Location 1) Communication from provider
2) List of providers
3) W-9
4) ADA Survey
Specify whether you are closing an existing office and/or adding
an additional location
Add Provider to New Location/Group 1) Communication from provider
2) List of location(s)
3) W-9
4) ADA Survey for new location
Close or Open Panel 1) Communication from provider There is a 90-day waiting period, per policy. Provider must have
at least 50 members. We do not close panels for specialists.
Update Other Demographics (hours, phone, fax,
suite, languages, age limits, panel limit)
1) Communication from provider
TIN Change or Purchase of Another Entity 1) Communication from provider
2) W-9
3) List of providers
Note whether you are assuming liability of prior TIN
Billing and Remittance Change 1) Communication from provider
2) W-9
Be sure the billing address is not a P.O. box; must be a physical
location
Term from Location/Group 1) Communication from provider Advise where paneled members should be moved/transferred, if
applicable (for PCP's only)
This information can also be viewed at: horizonNJhealth.com/demographicupdates
Proprietary & Confidential 15
Credentialing
? As of October 1, 2019, Horizon BCBSNJ is managing the initial credentialing of
nonparticipating behavioral health professionals and ancillary providers who are seeking
to join one of our network(s).
? Beacon Health Options no longer performs these processes but will continue to manage
all changes and applications submitted prior to October 1, 2019
? Please visit https://www.horizonnjhealth.com/for-providers/provider-recruitment
for more information and Horizon NJ Health Applications.
- 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.
? 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
22
? Doctor Attribute Icons
Proprietary & Confidential
Self Service Tools
? www.horizonnjhealth.com under the menu option
? Providers
?Access to our Provider Manual
?Frequently used forms and guides
?Horizon Behavioral Health dedicated landing page
? Navinet
? Online Utilization Management Request Tool (via Navinet)
? Request prior authorizations
? Check status of authorizations
Horizonnjhealth.com: Reference Material Page
options
23 Proprietary & Confidential
Dedicated Behavioral Health Landing Page
24 Proprietary & Confidential
Horizonnjhealth.com/providerbh
25
NaviNet
Proprietary & Confidential
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:
? Claim Status
? Provider Directory
? Member Eligibility and Benefit
? Financial Reports
? Electronic Referral Submission and Inquiry
? Utilization Management Requests
? Clinical Reports
? Administrative Reports
To learn more about NaviNet, visit NaviNet.net.
? To access a NaviNet Information Demo, select Provider Reference Materials and
mouse over Resources.
? Select Training, then Education
? Select NaviNet Information Demo
All participating physicians and health care professionals are required to register for NaviNet
NaviNet Support
20
Required Information The following information is required to aid in further investigation:
? NaviNet Username
? TIN
? NPI
? Contact information
? Steps to replicate (screenshots of issue).
For error messages, please send a screenshot of error message with
date and time error occurred.
Required Information
21
22
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
? Fee schedule requests
? Copies of Contracts
Please continue to contact Customer Service for all claims related
concerns.
Network Management
Behavioral Health Provider Relations:
Horizon NJ Health
23
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
BEHAVIORAL HEALTH ANCILLARY TEAM SPECIALTY ASSIGNMENT
Andrew Alleman
Andrew_Alleman@horizonblue.com
973-466-6824
24
Important Phone Numbers
How Do I Stay Informed?
? To check the status of the transition or for frequently asked questions, please
refer to:
? HorizonNJhealth.com/providernews
25
Thank you for your time today
BHNetworkrelations@horizonblue.com
Q & A
26
Appendix
27
28
There are several ways to determine a member?s eligibility for benefits:
? Check on NaviNet, our online provider center at NaviNet.net.
? Call Horizon NJ Health Provider Services at 1-800-682-9091.
Representatives are available Monday-Friday, 8 a.m. to 5 p.m.
Please note: Presentation of a member ID card is not a guarantee of member
eligibility.
Always confirm enrollment before providing services.
Member Eligibility
29
Member Eligibility: Tips!
30
Sample NJ FamilyCare Member ID Card
Confirm eligibility at NaviNet.net or call Provider Services at
1-800-682-9091.
31
Sample MLTSS Member ID Card
Confirm eligibility at NaviNet.net or call MLTSS Provider Services at
1-855-777-0123.
32
Sample FIDE-SNP Member ID Card
Confirm eligibility at NaviNet.net or call MLTSS Provider Services at
1-800-682-9091.
33
Hospitals, physicians and health care professionals submitting claims electronically should
make sure the referral number is present on the claim.
If you are a hospital, physician or health care professional interested in submitting claims
electronically to Horizon NJ Health but do not have TriZetto EDI services, contact TriZetto
at 1-800-556-2231
You may also choose to contract with another EDI clearinghouse or vendor who already
has access to TriZetto EDI services
EDI Technical Support Team is available during regular business hours, 8 a.m. through 5
p.m., Monday through Friday. It can be reached at 1-800-556-2231
Electronic Claim Submission
34
We encourage all Horizon NJ Health providers who have not yet begun to receive their payments
using Electronic Funds Transfer (EFT) to sign up.
Advantages:
? With EFT, your reimbursement cycle will be accelerated, since providers can receive EFT
payments more quickly than check payments sent through the mail.
? Payments can be distributed more securely by virtually eliminating check payments lost in
the mail, and this can help increase cash flow. In most situations, funds are available on the
date the payment is credited to the provider's bank account
How to sign up:
? Dial 1-866-506-2830, option 1 for more information
? Email or visit the Horizon NJ Heath online to sign up:
? Email: eftenrollment@changehealthcare.com
? Link for form: http://www.horizonnjhealth.com/for-
providers/resources/forms/emdeon-electronic-funds-transfer-forms
EFT Enrollment ? Electronic Fund Transfer
35
Claim inquiries must first be directed to Provider Services at 1-800-682-9091
Provider Correspondence Unit:
For more complex problems such as inquiries on 10 or more claims, providers must
complete a spreadsheet with the following data elements:
? Member Name
? Member ID Number
? Claim Number
? Date of Service
? CPT Codes
? Specific nature of inquiry
? Total billed charges
Send these inquiries to: Provider Correspondence, PO Box 24077, Newark, NJ 07101-
0406. We can only accept inquiries for claims in dispute when all of the above elements
are included. Other inquiries will be returned.
Handling Claim Disputes
36
Claim Appeals
? When a physician, facility or health care professional is dissatisfied with a claim payment, including
determinations, prompt payment or no payment made by Horizon NJ Health, he/she may file a claim
appeal, as described herein.
? All claim appeals must be initiated on the applicable appeal application form created by the Department
of Banking and Insurance.
? The appeal must be received by Horizon NJ Health within 90 calendar days following receipt by the
physician, facility or health care professional of the payer?s claim determination.
? To file a claim appeal, a physician or health care professional must send the appeal application form,
which is available at horizonNJhealth.com/for-providers, and any supporting documentation to Horizon NJ
Health using one of the following methods: submission is considered to be correct
? Fax: 973-522-4678 /: Mail: Horizon NJ Health, Claim Appeal, P.O. Box 63000, Newark, NJ 07101-8064
? IMPORTANT ? Please do not send medical records with administrative claim appeals. Supporting
documentation, e.g., proof of timely filing, may be submitted. Please follow all appropriate procedures as
defined in this manual before submitting an appeal.
? Status of Appeal is available via Navinet (Report Functions)
*Please note: Corrected claims should be sent to Horizon NJ Health, Claims Processing Department, PO Box
24078, Newark, NJ 07101-0406. These claims should not be submitted through the appeals process, unless
the original submission is considered to be correct
Handling Claim Disputes/Appeals
Slide Number 1
Slide Number 2
Slide Number 3
What Will Insourcing Achieve?
Slide Number 5
Horizon NJ Health and Horizon NJ TotalCare (HMO D-SNP) Plans
Horizon NJ Health Behavioral Health Overview
Slide Number 8
Slide Number 9
Slide Number 10
Slide Number 11
Slide Number 12
Slide Number 13
Slide Number 14
Slide Number 15
Slide Number 16
Slide Number 17
Slide Number 18
Slide Number 19
NaviNet Support
Slide Number 21
Slide Number 22
Behavioral Health Provider Relations:?Horizon NJ Health
Slide Number 24
How Do I Stay Informed?
Q & A
Appendix
Slide Number 28
Slide Number 29
Slide Number 30
Slide Number 31
Slide Number 32
Slide Number 33
Slide Number 34
Slide Number 35
Slide Number 36
This Document is Proprietary and Confidential
Do Not Print or Distribute Without Permission
Horizon NJ TotalCare (HMO D-SNP) Model of Care
Training 2021
Effective January 2021
1Proprietary and Confidential Government Programs
Objectives
? At the end of this training, the participant will be able to:
? Define the components of a Dual Special Needs Plan (DSNP)
? Understand what a Fully Integrated Dual Special Needs Plan
means
? Identify the changes to benefits for TotalCare in 2021
? Define the goals of the Horizon NJ TotalCare Model of Care (MOC)
? Identify the elements in the MOC program
? Understand the different roles of the DSNP Team members
? Understand the purpose of the Interdisciplinary Care Team
? Identify the methods by which the MOC is evaluated for
effectiveness
This Document is Proprietary and Confidential
Do Not Print or Distribute Without Permission
Horizon NJ TotalCare (HMO D-SNP)
3Proprietary and Confidential Government Programs
DSNP stands for Dual Special Needs Plan. A DSNP is a special kind of
Medicare Advantage plan that integrates all covered Medicare and Medicaid
managed care benefits into one health plan.
DSNP features:
? A Model Of Care that calls for individual care plans for members
? General Goals that are member centric
? SMART Goals (Specific, Measurable, Attainable, Relevant, Timely)
? A team of doctors, specialists and Care Managers working together for
the DSNP member
? The same member rights available to Medicare and Medicaid recipients
? Zero dollar cost sharing: no copayments, premiums or deductibles
What is DSNP?
4Proprietary and Confidential Government Programs
? FIDE SNP stands for Fully Integrated Dual Eligible Special Needs Plan.
? A FIDE SNP is a special kind of Medicare Advantage plan that integrates
all covered Medicare and Medicaid managed care benefits into one
health plan
FIDE SNPs will:
? Provide dually-eligible beneficiaries access to Medicare and Medicaid
benefits under a single managed care organization
? Have a CMS approved contract with a State Medicaid Agency that
includes coverage of specified primary, acute, and long-term care
benefits and services, consistent with State policy
What is FIDE SNP?
5Proprietary and Confidential Government Programs
2021 DSNP benefits include:
? Extra benefits for 2021:
? Over The Counter (OTC) Benefits:
? OTC Benefit Catalog - $250 per quarter for over the counter
(OTC) personal health items that can be ordered via paper / mail
or online catalog. Up to $1,000 annually.
? OTC Benefit Card - $375 per quarter for over the counter (OTC)
personal health items that can be purchased in store at
participating retailers like; Walgreens, Dollar General, Rite Aid,
Walmart, CVS. Or online at NationsOTC.com for home delivery.
This benefit can total up to $1,500 annually
? New for 2021 - Healthy Food purchases using the OTC Benefit
Card. Eligibility criteria required.
Product and Benefit Information
6Proprietary and Confidential Government Programs
2021 DSNP benefits include:
? Over The Counter (OTC) Benefits: Continued
? New for 2021 - Healthy Food purchases using the OTC Benefit
Card. For those members that qualify their OTC Benefit Card
will be enhanced to include food and produce as eligible items.
In order to qualify they must meet the following criteria:
? have been diagnosed with one or more certain chronic
conditions,
? have a higher risk to be in the hospital and
? participate in the Horizon NJ Health Care Management
Program.
? See listing of qualifying chronic conditions on next slide
Product and Benefit Information
7Proprietary and Confidential Government Programs
2021 DSNP benefits include:
? Over The Counter (OTC) Benefits: Continued
? New for 2021 - Healthy Food purchases using the OTC Benefit Card. Chronic
conditions
Product and Benefit Information
1. Chronic alcohol and other drug dependence;
2. Autoimmune disorders limited to: Polyarteritis nodosa, Polymyalgia rheumatica, Polymyositis,
Rheumatoid arthritis, and Systemic lupus erythematosus;
3. Cancer, excluding pre-cancer conditions or in-situ status;
4. Cardiovascular disorders limited to: Cardiac arrhythmias, Coronary artery disease, Peripheral vascular
disease, and Chronic venous thromboembolic disorder;
5. Chronic heart failure;
6. Dementia;
7. Diabetes mellitus;
8. End-stage liver disease;
9. End-stage renal disease (ESRD) requiring dialysis;
10. Severe hematologic disorders limited to: Aplastic anemia, Hemophilia, Immune thrombocytopenic
purpura, Myelodysplatic syndrome, Sickle-cell disease (excluding sickle-cell trait), and Chronic
venous thromboembolic disorder;
11. HIV/AIDS;
12. Chronic lung disorders limited to: Asthma, Chronic bronchitis, Emphysema, Pulmonary fibrosis, and
Pulmonary hypertension;
13. Chronic and disabling mental health conditions limited to: Bipolar disorders, Major depressive
disorders, Paranoid disorder, Schizophrenia, and Schizoaffective disorder;
14. Neurologic disorders limited to: Amyotrophic lateral sclerosis (ALS), Epilepsy, Extensive paralysis
(i.e., hemiplegia, quadriplegia, paraplegia, monoplegia), Huntington?s disease, Multiple sclerosis,
Parkinson?s disease, Polyneuropathy, Spinal stenosis, and Stroke-related neurologic deficit; and
15. Stroke.
8Proprietary and Confidential Government Programs
2021 DSNP benefits include:
? Home delivered meals after an acute inpatient
hospital stay for those members who qualify
? 14 meals for 1 week or 28 meals for 2 weeks
? Eligibility requirements must be met
? Limit 1 episode of meal delivery per year
Product and Benefit Information
9Proprietary and Confidential Government Programs
2021 DSNP benefits include:
? Medicare Part A and B services
? Medicare Part D plus Medicaid covered drugs
? Medicaid Services
? Behavioral Health and Substance Use Treatments
? Telemedicine for:
? Physical Health
? Behavioral Health
Product and Benefit Information
10Proprietary and Confidential Government Programs
2021 DSNP benefits include:
? 24/7 Nurse Line
? Silver & Fit Healthy Aging and Exercise Program
? Worldwide emergency/urgent care ($60,000 cap)
? Routine podiatry care up to 8 visits
? No referrals required
? Routine dental and vision benefits
Product and Benefit Information
11Proprietary and Confidential Government Programs
11
New or Changed Benefit/Cost
Share
2020 Benefit 2021 Benefit
OTC Benefit Card $300 per quarter $375 per quarter
OTC Benefit Card
Dollars used only to purchase
personal health items
Dollars can be also used to purchase
healthy foods from current retailors (for
eligible members)
OTC Benefit Card
OTC card used to purchase
personal care items onsite at
approved retailers
OTC card can also be used to order items
by phone or online through mail order
partner NationsOTC
Meal Benefit N/A Available following an acute inpatient stay
Fitness Benefit FitnessCoach Silver&Fit? (change in Program)
Telemedicine Medical Services only
Behavioral Health Services in addition to
Medical
Opioid Treatment Services Prior authorization required Prior authorization not required
Overall 2021 Changes to Horizon NJ TotalCare (HMO D-SNP) Benefits and Cost Share
Product and Benefit Information
DSNP benefits: 2020 vs. 2021
12Proprietary and Confidential Government Programs
12
2021 Medicaid Wrap and OTC Benefit Comparison
Features/Process Medicaid Wrap* OTC Catalog OTC Benefit Card
Total Annual
Benefit Unlimited $1,000 $1,500
$$ Limit Per
Quarter Not Applicable $250 $375
Unused amount
rolls to next
quarter?
Not Applicable No No
Prescription
Required? Yes No No
How are OTC
medications and
supplies obtained? Take prescriptionto a
participating Provider
(i.e. CVS Pharmacy)
? Member orders
online or by phone
? Order shipped to their
home in 7-10 days
? Member uses Benefit
card to purchase
OTC items directly
from designated
retailers or Nations
OTC
* Medicaid Wrap - Unlimited supplemental Wrap benefit covering many medications and supplies, including over the counter vitamins that are
not covered by Part D Medicare, that members can obtain with a prescription (in addition to drugs already covered under their prescription benefit)
13Proprietary and Confidential Government Programs
Horizon NJ TotalCare (HMO D-SNP) Service Area 2021
Service Area
1. Atlantic
2. Cumberland
3. Essex
4. Gloucester
5. Hudson
6. Hunterdon
7. Mercer
8. Monmouth
9. Morris
10. Passaic
11. Salem
12. Somerset
13. Sussex
14. Union
15. Warren
16. Bergen
17. Middlesex
18. Ocean
19. Burlington
20. Camden
21. Cape May
CMS
Contract # Individual/Group Product Type PBP Service Area
H-8298 Individual SNP 001 21Counties
14Proprietary and Confidential Government Programs
Horizon NJ TotalCare (HMO D-SNP)
Definition of deemed
? A dual-eligible enrollee of a DSNP
may become ineligible for the plan
due to the loss of his/her Medicaid
eligibility for a period of time that
may be one or more months in
duration
? Horizon NJ TotalCare (HMO SNP)
deeming period is 2 calendar
months/60 days
Deemed
/demed/
1. Period of time
in which a member
may lose Medicaid
benefits
-
15Proprietary and Confidential Government Programs
Special Enrollment Period Changes
Continued in 2021
Dual Eligible members can
enroll/dis-enroll quarterly,
instead of monthly
? Members can enroll or dis-enroll
from an MA plan once per calendar
quarter during the first 9 months of
the year.
Dual SEP
Time Periods
January ? March
April ? June
July - September
? Example; if an election is made in March and
effective in April, the 1st quarter use of the SEP
would be considered ?used?, not the 2nd
quarter. Once the SEP is used in a given
quarter the member will need to wait to the
next quarter or qualify for another type of SEP.
This Document is Proprietary and Confidential
Do Not Print or Distribute Without Permission
What is a Model of Care?
17Proprietary and Confidential Government Programs
Horizon NJ TotalCare (HMO D-SNP)
Model Of Care (MOC) overview
? CMS requires that all Special Needs Plans (SNP) have an MOC
? The projected membership is to grow to 17,000 members by the end of 2021
? The MOC goals include:
? Care coordination and care management for all DSNP members enrolled in the
plan
? An individualized care plan (ICP) based on member assessment and member
feedback
? An interdisciplinary care team (IDT) that reviews the member?s plan of care and
provides input in a collaborative way
18Proprietary and Confidential Government Programs
Goals of Horizon NJ TotalCare (HMO D-SNP)
? Efficiently coordinate the care members receive
? Improve members? experience with care
? Improve members? health outcomes
? Improve quality
? Keep members in the community
? Reduce unnecessary costs
Horizon NJ TotalCare (HMO D-SNP)
Enhancing
member experience
Improving
health outcomes
Lowering costs
This Document is Proprietary and Confidential
Do Not Print or Distribute Without Permission
Elements of the Model of Care
20Proprietary and Confidential Government Programs
Horizon NJ TotalCare (HMO D-SNP)
Medical
Director
Behavioral
Health Care
Manager
Horizon NJ TotalCare (HMO D-SNP)
Care Management Team
SNP
Director
Care
Manager
SNP
Manager
Clinical Care
Coordinator
SNP
Supervisor
SNP
Operations
This Document is Proprietary and Confidential
Do Not Print or Distribute Without Permission
Roles and Responsibilities
22Proprietary and Confidential Government Programs
Role of the Care Coordinator
? Call member to complete the Confirmation/Welcome Call
? Review the Horizon NJ TotalCare (HMO D-SNP) benefits with the
member
? Perform annual reassessment and management for Level 1 SNP
Members
? Provide education and ongoing support to the member as needed
Horizon NJ TotalCare (HMO D-SNP)
23Proprietary and Confidential Government Programs
Role of the Care Manager
? Address barriers to care
? Advocate for the member
? Arrange for homecare, therapies and evaluation
? Conduct face-to-face visits as indicated
? Contact member and PCP and/or specialist on a regular basis as needed
? Coordinate behavioral health
? Coordinate with community resources/agencies
? Guide, direct and educate member
? Assess and reassess health status, including conditions, medications and
functional status
Horizon NJ TotalCare (HMO D-SNP)
24Proprietary and Confidential Government Programs
Role of the Behavioral Health (BH) Care Manager
? Address and close care gaps relevant to BH
? Arrange and coordinate care for the member as needed
? Contribute to the development of the BH plan of care
? Participate in the IDT Meetings
? Provide education and ongoing support to the member as needed
? Facilitate coordination and linkage of formal and informal community
supports related to behavioral health to enhance member outcomes and
wellness
? Work closely with the Care Manager to coordinate care for the member
Horizon NJ TotalCare (HMO D-SNP)
25Proprietary and Confidential Government Programs
Horizon NJ TotalCare (HMO D-SNP)
Role of the PCP:
? Attend/participate in the ICT meetings
? Receive calls from the member?s Care Manager
? Review and comment on the plan of care
? Collaborate with the member?s Care Manager to address needs
26Proprietary and Confidential Government Programs
Role of the behavioral health provider:
? Attend/participate in the IDT meetings
? Collaborate and coordinate care with the member?s PCP (physical health)
? Review and comment on the Interdisciplinary Plan of Care
? Receive calls from the member?s Care Manager
? Behavioral health
? Physical health
Horizon NJ TotalCare (HMO D-SNP)
This Document is Proprietary and Confidential
Do Not Print or Distribute Without Permission
Key Member Touches
28Proprietary and Confidential Government Programs
? Confirmation/Welcome call completed by the CCC
? Once enrollment is confirmed and prior to the effective date
? Confirm the member?s plan of choice is Horizon NJ
TotalCare (HMO D-SNP)
? Review of benefits
? Review PCP selection
? Health Risk Assessment
? Within 90 days of enrollment effective date
? Review of Medications
? Complete the Health Risk Assessment
Horizon NJ TotalCare (HMO D-SNP)
29Proprietary and Confidential Government Programs
2021 HRAT Incentive
? In 2021 TotalCare Members will be eligible for an
incentive ($10 CVS Gift Card) as part of the Health
Risk Assessment process
? Initial within 90 days of enrollment
? Annually / 365 days from last assessment
HRAT Incentive Information
This Document is Proprietary and Confidential
Do Not Print or Distribute Without Permission
Levels and Time Frames
31Proprietary and Confidential Government Programs
? Level 1: Low Risk, or Unable to Reach / Member chose
to opt out
? Level 2: Moderate Risk
? Level 3: High Risk
Horizon NJ TotalCare (HMO D-SNP)
This Document is Proprietary and Confidential
Do Not Print or Distribute Without Permission
Care Plan Elements for DSNP Members
33Proprietary and Confidential Government Programs
Individual Care Plan (ICP)
? Created for each member using the HRAT and other data
? Coordinated with the member/caregiver
? Goals
? General Goals
? SMART Goals
? Interventions/actions
? Culturally appropriate
? Easy to understand
? No medical terminology/ abbreviations
? Updated when a member?s
status changes
? Share with PCP and member
Horizon NJ TotalCare (HMO D-SNP)
34Proprietary and Confidential Government Programs
Purpose of the Interdisciplinary Care Team (IDT)
? Meets five times per week to review DSNP member Care Plans
? Level 1 reviewed at least annually by consent agenda
? Level 2 reviewed at least every 180 days
? Level 3 reviewed at least every 90 days
? Comprised of internal and external attendees that impact the member?s
plan of care
? Behavioral Health Readmission Rounds once per month for members
with multiple BH hospitalizations
Horizon NJ TotalCare (HMO D-SNP)
35Proprietary and Confidential Government Programs
Interdisciplinary Care Team (IDT)
? Attendees include (but are not limited to):
? Member or designee
? Medical Director
? PCP
? SNP Care Manager
? Behavioral Health Care Manager
? Pharmacist
? MLTSS
? Quality
? PT/OT
? Dental
Horizon NJ TotalCare (HMO D-SNP)
This Document is Proprietary and Confidential
Do Not Print or Distribute Without Permission
DSNP Operations, Correspondence and Rights and
Responsibilities
37Proprietary and Confidential Government Programs
Horizon NJ TotalCare (HMO D-SNP)
Member Information Mailings
? New Members (Initially)
? Welcome Guide
? OTC Catalog
? OTC Benefit Card and Information
? Member may also access other documents via online or by calling Member Services
? Existing Members (Annually)
? Updated Welcome Guide
? Updated OTC Catalog
? Updated OTC Benefit Card Information
? Member may also access other documents via online or by calling Member Services
38Proprietary and Confidential Government Programs
Horizon NJ TotalCare (HMO D-SNP)
Ongoing Member Mailings
? Quarterly Newsletters
? Health Information (examples)
? How to Read a Medication Label
? Nutrition/ Healthy Habits
? Disease Specific
? Dental Care
? Eye Care
? Care Plan
? TotalCare Care Management Brochure
This Document is Proprietary and Confidential
Do Not Print or Distribute Without Permission
Evaluation of Effectiveness of the Model Of Care
40Proprietary and Confidential Government Programs
Purpose
? To ensure the DSNP Model of Care Monitoring and Evaluation is
an ongoing process that is reported through a committee and
monitored by the leadership team for DSNP so that any deficits
or opportunities can be addressed and remediated
? To ensure the ability to intervene or take action on program
components if undesired trends are identified
? To monitor the MOC program effectiveness on a regular basis
through multiple channels
Horizon NJ TotalCare (HMO D-SNP)
41Proprietary and Confidential Government Programs
Scope and oversight
? The DSNP Committee and the QIC will review findings of ongoing
monitoring and evaluation of the MOC and will review any open corrective
action plans to address identified deficiencies
? Annually (on a calendar year schedule), a formal program evaluation will
be completed and submitted for committee review and approval as
follows:
? DSNP Committee
? Quality Improvement Committee (DSNP Report)
? Board of Directors (QIC Report)
Horizon NJ TotalCare (HMO D-SNP)
42Proprietary and Confidential Government Programs
Elements of monitoring the MOC
? Elements of the MOC will be monitored via multiple approaches
including formal and informal ongoing monitoring and evaluation
? D-SNP Committee and QIC ? quarterly
? Care Management Dashboard (Tableau) ? ongoing
? D-SNP Key Performance Indicator Report ? monthly
? Readmissions Report ? monthly
Horizon NJ TotalCare (HMO D-SNP)
43Proprietary and Confidential Government Programs
Examples of elements for monitoring the MOC
? The elements of the MOC to be monitored via the Care Management Dashboard
include:
? Care Manager case loads
? Risk stratification levels
? Health Risk Assessment completion rate
? CNA completion rate
? Care plans developed
? Interdisciplinary Care Team meetings
? Unable to reach rate
? Behavioral health referrals
Horizon NJ TotalCare (HMO D-SNP)
44Proprietary and Confidential Government Programs
Examples of elements for monitoring the MOC
? The elements of the MOC to be evaluated quarterly via the D-SNP Committee and
QIC include:
? Care Management
? Pharmacy
? Operations
? Behavioral health
? Call center
? Appeals and grievances
? Complaints/critical incidents
? HEDIS and Star Rating
? Provider network
Horizon NJ TotalCare (HMO D-SNP)
45Proprietary and Confidential Government Programs
Horizon NJ TotalCare (HMO D-SNP)
Quality Improvement Program (QIP)
? Required by both CMS and DMAHS
? Supports the national and CMS quality strategy goals
? Promotes effective management of chronic conditions
? In 2021, the Horizon NJ TotalCare (HMO SNP) QIP continues to focus on
Management of Asthma
? NEW in 2021 will be a QIP focused on PCP Access & Diabetes Care
? CMS & State
required
? Better manages
chronic conditions
46Proprietary and Confidential Government Programs
Horizon NJ TotalCare (HMO D-SNP)
In closing
? Horizon NJ TotalCare (HMO D-SNP) will begin year five of its D-SNP Program on
January 1, 2021
? Some of the highlighted benefit changes include: Silver & Fit Health Aging and
Exercise Program, Telemedicine, increase in OTC Benefit card from $300 to $375
per quarter, ability to purchase healthy groceries (criteria applied) and the addition of
home delivered meals once per year after a hospital stay (criteria applied & 1
occurrence / year)
? Each member will receive individualized care management and a plan of care that is
developed in a collaborative manner
? The Interdisciplinary team meets several times each week to review member plans
of care and provide collaborative feedback and input
? The members? providers are an integral part of the care team
? The MOC effectiveness is monitored in several ways both formally and informally to
ensure adherence to the program timelines and identify opportunities for
improvement