Managed Care Enrollment
Expansion
George Ingram
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Horizon NJ Health
Phase I
•
ABD and DYFS with Medicaid only•
40,000 People•
Plan self selection ending July 18 with auto enrollment effective August 1, 2011•
Enrollment is through the State’s vendor•
HNJH currently serving more than 40,000 ABDmembers (non-dual eligible) and more than 8,000 DYFS members
Phase II
•
Enrollees who have both Medicare and Medicaid (dual-eligible)•
100,000 people•
Mandated into a MCO in the fall (date to be determined)•
HJNH currently serving more than 12,000 dual-eligible members4
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Horizon NJ Health
Amending Existing Contract
Process
• Amendments are being mailed to the providers that are currently contracted for other services
• You will need to sign and return two copies of the amendment to Horizon NJ Health
• Mail to:
Attention: Name of Your Contracting Representative Horizon NJ Health
210 Silvia Street
Non-Contracted Providers
Credentialing Process
• Contracts, credentialing applications and MOAs will be mailed upon request
• You will need to complete and sign the MOA and W-9, supply us with your NPI and return it to us to receive payment
• Mail to: George Ingram Horizon NJ Health 210 Silvia Street West Trenton, NJ 08628 • Fax to: 609-583-3004 • Email: [email protected]
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Horizon NJ Health
Electronic Claims Submission
•
Emdeon is the only service currently accepted by Horizon NJ Health. To contact the Electronic Data Interchange (EDI) Technical Support Hotline call or email:•
(877)-234-4273•
E-mail: [email protected]•
Submit all electronic claims to the Horizon NJ Health EDI Payor Number 22326.•
NPI numbers must be included on all claims submissions.Paper Claims Submission
Mailed to:
Horizon NJ Health
Claims Processing Department P.O. Box 7117
London, KY 40742
•
To ensure accurate payment:–Hospital affiliated facility use a UB-04 Claim Form
–Non-hospital affiliated facility use a CMS HCFA-1500
–Home Health provider use a CMS HCFA-1500
–NPI numbers must be included on all claims submissions.
Managed Care Enrollment
Expansion
Dee Rago RN, BSN, MA
Director of Health Services
Medical Management Contact
Facility Based
Physical, Occupational & Speech Therapies
•
Fax Prior Authorizations to:–(609) 583-3042
•
Authorization Questions–(800) 682-9094, extension 89500
•
Dee Rago, Director of Health Services–(609) 718-9220
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Horizon NJ Health
Medical Authorization Process
Facility Based
Physical, Occupational & Speech Therapies
•
Authorization For Therapy Services–Submit:
- Horizon NJ Health Therapy Authorization Request Form
- PT/OT/ST evaluation with signature
• Horizon NJ Health initial therapy authorization
will be up to 12 visits
• Reauthorization is required for additional
Medical Authorization Process
Facility Based
Physical, Occupational & Speech Therapies
•
Continuation of Therapy Services–Submit:
• Horizon NJ Health Therapy Authorization
Request Form
• Horizon NJ Health PT/OT/ST evaluation with
signature
• Progress notes including Plan of Care,
Treatment goals and reason for continuation of services
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Horizon NJ Health
Medical Authorization Process
Facility Based
Physical, Occupational & Speech Therapies
•
Communications of Therapy Authorization Determinations–Horizon NJ Health PT/OT/ST authorization approval or denial includes letter sent to requesting provider, servicing provider, PCP and member
–PT/OT/ST authorization denials are determined by Horizon NJ Health medical director review
–Member and provider appeal rights included in denial letter
Medical Management Contacts
HOME HEALTH SERVICES (Includes PT, OT, ST)
•
Fax Prior Authorizations to:–(609) 583-3013
•
Authorization Questions–(800) 682-9094, extension 81025
•
Dee Rago, Director of Health Services14
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Horizon NJ Health
Medical Authorization Process
HOME HEALTH SERVICES (Includes PT, OT, ST)
• Authorization Process for Home Care Skilled Nursing
Services – Submit:
• Horizon NJ Health Home Health Authorization Request Form
• Authorization Process for Physical, Occupational and Speech
Home Therapy
– Initial therapy evaluation - no authorization required
– Authorization required following initial evaluation
– Submit:
• Horizon NJ Health Home Health Authorization Request Form
• Physical, occupational and speech home therapy evaluation report • Horizon NJ Health will authorize up to 6 visits
Medical Authorization Process
HOME HEALTH SERVICES (Includes PT, OT, ST)
• Communication of Home Services Authorization Determination
– Horizon NJ Health Home Care Services authorization approval or denial includes letter sent to requesting provider, servicing provider, PCP and member
– Home Care Services authorization denials are determined by HNJH Medical Director
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Horizon NJ Health
Key Contact Information
• Contracting and Provider Relations– George Ingram (609) 718-9100
email: [email protected]
– Fax MOA and W9 to: 609-583-3004
• Fax Facilities Based Prior Authorizations to:
– (609) 583-3042
• Facilities Based Authorization Questions
– (800) 682-9094, extension 89500
• Fax Home Health Based Prior Authorizations to:
– (609) 583-3013
• Home Health Based Authorization Questions
– (800) 682-9094, extension 81025
• Electronic Claims Submissions (EDI)
– Hotline: (877)-234-4273
email: [email protected]
Website Information
•
www.horizonNJhealth.com –Provider Directory • Updated daily –Policies –Provider Manual –Authorization Forms•
NaviNet–Member eligibility look-up
–Claims Status inquiry
