1. Operations Update February 22, 2019
HORIZON NJ HEALTH
Operations Update
February 22, 2019

2. Agenda Horizon NJ TotalCare (FIDE SNP) Expansion Benefit Changes
Model of Care Webinars
Utilization Management (UM) Request Tool Update and Appeals
Claim Appeals
Navinet Self-Service Tools

3. Horizon NJ TotalCare (FIDE-SNP)
In January 2017, Horizon Blue Cross Blue Shield of New Jersey reentered the Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP) marketplace under the management of Horizon NJ Health.
The plan is known as Horizon NJ TotalCare (HMO SNP), a Medicare Advantage plan that integrates all covered Medicare and Medicaid managed care benefits into one health plan.

4. FIDE-SNP Features:
A Model of Care (MOC)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
No referrals required
Zero dollar cost sharing: no copayments, premiums or deductibles

5. Providers who are participating in this program have an addendum to their contract or have a unique contract covering FIDE-SNP.
When payment is made for a Horizon NJ TotalCare (HMO SNP) member, providers will receive a unique Electronic or Paper Remittance Advice showing how payment was made and indicating whether payment was for a Medicare or Medicaid service. Examples of these remittances are located in Section 14.6 of the HNJH Provider Administrative Manual.

6. 2019 FIDE-SNP Expansion
Effective January 1, 2019, Horizon NJ TotalCare (HMO SNP) will be available statewide. Newly added counties are Bergen, Burlington, Camden, Cape May, Middlesex and Ocean.
No referrals required for any services rendered by providers
No Balance Billing for FIDE-SNP Members
Model Of Care Training required on a annual basis- Please complete Attestation Form

7. Horizon NJ TotalCare (FIDE-SNP)
2019 FIDE-SNP Benefits:
Medicare Part A and B services
Medicare Part D plus Medicaid covered drugs
Medicaid Services
Extra DSNP benefits for 2019 include:

8. 2019 FIDE-SNP Benefits
$245 per quarter for over-the-counter (OTC) personal health items with paper or online catalog
OTC Benefit card $250 per quarter to make in store purchases of personal health items
This allows members to choose different in-store brands than what is offered in the catalog
American Specialty Health FitnessCoach

9. Horizon NJ TotalCare MOC (Model of Care)
CMS requires that all Special Needs Plans (SNP) have a Model of Care (MOC)
The MOC goals include:
Care coordination and care management for all DSNP members enrolled in the plan
An individualized plan of care based on member assessment and member feedback
An interdisciplinary care team (ICT) that reviews the member’s plan of care and provides input in a collaborative way
Improve members’ experience with care

10. Horizon NJ TotalCare MOC (Model of Care)
Improve members’ health outcomes
Improve quality
Keep members in the community
Reduce unnecessary costs

11. 2019 FIDE-SNP Model of Care Webinars
Provider services offers information webinars twice a month for the Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP) Model of Care (MOC).
Webinars occur every other Wednesday at 10am and 2pm throughout 2019.
Next session date is February 27, 2019.

12. Horizon NJ TotalCare (FIDE-SNP)
Enter your name and address (or registration ID ).
Go to horizon.webex.com.
Enter the session password: Vfp3DQma.
Click "Join Now.”
Follow the instructions that appear on your screen.
Date: February 27, 2019 Time: 10 a.m. Session number: Session password: 2qJJz5qy
Date: February 27, 2019 Time: 2 p.m
Session number: Session password: GnUnTEs5

13. Utilization Management Request Tool Update (formerly called CareAffiliate)
Horizon NJ Health has updated the online Utilization Management Request Tool for an improved user experience. The new design will continue to allow you to easily and securely perform all the same self-service functions through NaviNet®, plus you will be able to use the tool to..
submit appeals for denied authorizations
Referral (pre-determination) requests
Use the online Utilization Management Request Tool to:
Submit authorization requests
Submit referral (pre-determination) requests
Verify the status of previously submitted authorization or referral requests
Online training tools are located at:

14. Online training resources:
Utilization Management Request Tool Update (formerly called CareAffiliate)
Online training resources:

15. Utilization Management Appeals
A UM appeal is the result of a medical necessity denial. All UM appeals must be initiated within 60 days of the date of the notification of action. In your appeal, include the UM Appeals Form. The UM Appeals Form is included in your denial notice and auto populated with the member information.
• Health Claims Authorization, Processing and Payment (HCAPP) Forms should not be included in an UM appeal.
• UM Appeals should be mailed to the following PO Box, depending on type of plan:
Medicaid UM Appeals
PO Box 10194
Newark, NJ 07101
Medicare UM Appeals
PO Box 10195
Horizon NJ TotalCare (HMO SNP)
UM Appeals
PO Box 10196
-or- CareAffiliate (online)

16. UM Appeal Function
From here user can see all results for individual member.

17. CareAffiliate - UM Appeal
Click on the specific authorization that has been denied to view the General Information screen.
Click on the Create Appeal button.
Once the appeal is submitted a new number will be generated.

18. Claim Appeals
A claim appeal is dissatisfaction with a claim payment, including prompt payment or no payment made by Horizon NJ Health. All claim appeals must be initiated on the applicable appeal application form created by the Department of Banking and Insurance.
An appeal application form must be submitted within 90 calendar days following the claim determination or the date on the explanation of benefits.
Claim appeals may be faxed to or mailed to: Horizon NJ Health
PO Box Newark, NJ *
The status of your appeal(s) can be accessed viaNaviNet.net in the administrative reports menu. For assistance with accessing claim appeal status, contact NaviNet Support at
DO NOT submit utilization management (UM) appeals, FIDE-SNP appeals or Health Insurance Portability and Accountability Act (HIPAA) requests to this address.

19. Claim Appeal Form

20. Self – Service Tools www.horizonnjhealth.com under the tab PROVIDERS
Access to our Provider Manual Frequently used forms and guides Credentialing Application Status Checks-
UM Tool (CareAffiliate via Navinet) request prior authorizations, check status of authorizations, pre-determination requests

21. Clinical Reports
Admit Report
Care Gap Query Report
Discharge Report
Member Alert Standalone Care Gap Request
Missing and Overdue Care Gaps Adult Only
Missing and Overdue Care Gaps All Members
Missing and Overdue Care Gaps Pediatric Only
Administrative Reports
Authorization Status Summary
Claims Appeal Status Report
Claims Status Summary Report
Panel Roster Report
Provider Quality Measures Report
Referrals without a Visit Report
Financial Reports
Cap Roster Report
Not all offices have the same report options
NaviNet Security Officer may need to enable permissions to users within the office for specific transactions
Copyright© NaviNet. All rights reserved. NaviNet® is a registered trademark of NaviNet, Inc.

22. Claims Status Summary Report
See all Claims by your Payer ID
View all claims for a 2 year period
View in a PDF or Excel Spreadsheet
Search by Member
Follow the Steps Below:
Once on the HNJH Plan Central Page, select Report Inquiry > Administrative Reports
Select the Claim Status Summary Report, then:
Payer ID
Status
Date Range
Report Format (Excel/PDF)
This Report displays the Claim Number, Member ID and Name, Service Start and End Dates, Claim Received, Billed Amount, Claim Status, Paid Amount and Date, EOB Code and Description, Denied Claim Amount and Member’s Plan.