3.0 BENEFIT OVERVIEW

Transcription

1 3.1 Medicaid/ Benefit Matrix and Managed Care Protocols This Benefit Matrix provides a comprehensive overview of the benefits for preventive and medically necessary services provided to Medicaid and members enrolled with Horizon NJ Health. members enrolled with Horizon NJ Health through A and B do not incur a copayment. Members enrolled through C, D and ADVANTAGE are required to pay a copayment for certain services. Not withstanding, the following is the Benefit Matrix for the Medicaid Contract and sets forth the services which are reimbursable to the physician by Horizon NJ Health. Benefits are established by the State of NJ and are subject to change. Service Codes HNJH: Horizon NJ Health pays for this benefit FFS: Medicaid FFS pays for this benefit. Benefit Service Code Medicaid and A B C D Abortions and Related Services HNJH Coverage limited to spontaneous abortions/miscarriages (such as those under ICD-9 diagnosis codes 632, , ) FFS limited to elective/induced abortions Acupuncture HNJH Coverage limited to acupuncture provided by a licensed physician when performed as a form of anesthesia in connection with covered surgery Audiology Services (See EPSDT for hearing screenings) HNJH Coverage limited to children under the age of 16 years Blood and Blood Plasma HNJH Coverage limited to administration of blood, processing of blood, processing fees and fees related to autologous blood donations. Chiropractic Services HNJH Coverage limited to spinal manipulation Coverage limited to spinal manipulation. $5 copayment Dental HNJH Coverage limited to members under the age of 19. $5 copayment except for preventive dentistry visits Coverage limited to preventive dental services including x-rays and sealants, for children under the age of 12 Treatment for Temporomandibular joint disorder (TMJ) is not covered Dental - Orthodontics HNJH Limited coverage only for members under the age of 21 where medical necessity to correct a facial deformity can be demonstrated. Continuity of care will be provided for certain instances where orthodontics were in progress prior to July 1, Limited coverage only for members under the age of 21 where medical necessity to correct a facial deformity can be demonstrated. Continuity of care will be provided for certain instances where orthodontics were in progress prior to July 1, $5 copayment Limited coverage only for members under the age of 19 where medical necessity to correct a facial deformity can be demonstrated. Continuity of care will be provided for certain instances where orthodontics were in progress prior to July 1, $5 copayment Horizon NJ Health Physician and Health Care Professional Manual, January

2 Benefit Service Code Medicaid and A B C D Diabetic Supplies and Equipment HNJH Durable Medical Equipment / Assistive Technology Devices Emergency Medical Care/ Emergency Services HNJH Coverage is limited to the specific durable medical equipment listed at the end of this document. HNJH $10 copayment for emergency room services $35 copayment for emergency room services, except when referred by PCP for services that should have been provided in PCP s office or when member was admitted to the hospital EPSDT HNJH, including: medical examinations; dental, vision, hearing and lead screening services; only those treatment services identified through the examination that are covered by the Medicaid and NJ FamilyCare Plan A benefit package, including: medical examinations; dental, vision, hearing, and lead screening services; only those treatment services identified through the examination that are covered by the Medicaid and NJ FamilyCare Plan B benefit package, including: medical examinations; dental, vision, hearing, and lead screening services; only those treatment services identified through the examination that are covered by the Medicaid and NJ FamilyCare Plan C benefit package Coverage limited to well-child care, newborn hearing screenings, preventive dental, immunizations, and lead screening and treatment Family Planning HNJH when services provided by a participating HNJH physician. Coverage includes medical history and physical exams (including pelvic and breast), diagnostic & lab tests, drugs and biologicals, medical supplies and devices, counseling, continuing medical supervision, continuity of care and genetic counseling. Certain members may only access services by participating HNJH physicians FFS when services provided by a non-participating HNJH physician. Only certain members may receive the same services noted above by non-participating HNJH physician Group Homes and DYFS Residential Treatment Facilities FFS Coverage limited to services provided by HNJH participating providers. HNJH shall cooperate with the medical, nursing and administrative staff to ensure members have timely and appropriate access to participating providers and to coordinate care between participating providers and those providers employed by facility/group home Hearing Aid Services HNJH Coverage limited to children under the age of 16 years 3-2 Horizon NJ Health Physician and Health Care Professional Manual, January 2011

3 Benefit Home Health & Visiting Nursing Services Service Code HNJH Medicaid and A B C Coverage limited to non-abd members. Coverage includes drugs and DME D Coverage limited to skilled nursing for home-bound member that is provided or supervised by a RN and a home health aide, when the purpose of the treatment is skilled care. Coverage includes medical social services that are necessary for treatment of the member s medical condition FFS Coverage limited to ABD members. Coverage includes drugs and DME Hospice Services HNJH in the community as well as in institutional settings. Room and board are included only when services are delivered in an institutional (non-private residence) setting. Hospital Services - Inpatient HNJH Hospital Services - Outpatient HNJH with $5 copayment except for preventive services Infertility Diagnosis and Treatment (including sterilization reversals, and related office [medical and clinic] visits, drugs, laboratory services, radiological and diagnostic services and surgical procudres) Intermediate Care Facilities/Mental Retardation FFS Laboratory Services HNJH NOTE: Routine testing related to the administration of atypical antipsychotic drugs is covered for DDD clients only FFS $5 copayment when not part of office visit NOTE: Routine testing related to the administration of atypical antipsychotic drugs is covered for DDD clients only For non-ddd clients, limited to routine testing related to the administration of atypical antipsychotic drugs Maternity Services and related newborm care and hearing screening HNJH Medicaid Fair Hearing FFS Members have a right to a Medicaid Fair Hearing, but the request must be filed with DMAHS within 20 days of the date of the adverse action by HNJH Only certain members have the right to a Medicaid Fair Hearing. The request must be filed with DMAHS within 20 days of the date of the adverse action by HNJH Medical Day Care FFS Mental Health - Inpatient Hospital Services Including Psychiatric Hospitals HNJH only for DDD clients FFS for all other members Coverage as follows: For members under the age of 19, covered with no service limits For members 19 years and older limited to 35 days per year Horizon NJ Health Physician and Health Care Professional Manual, January

4 Benefit Mental Health Outpatient (excluding partial care services) Service Code Medicaid and A B C D HNJH only for DDD clients FFS for all other members except DDD clients Coverage as follows: $5 copayment for members under the ages 19 $25 copayment for members 19 years and older Mental Health Home Health HNJH only for DDD clients Not FFS for all other members except DDD clients Coverage as follows: For members under the age of 19, covered with no service limits For members 19 years and older - limited to 20 visits per year Medical Supplies HNJH Limited coverage. See also Durable Medical Equipment benefit Nurse Midwife (Maternity) HNJH $5 copayment for each visit (except for prenatal care visits) Nurse Midwife (Non-Maternity) HNJH $5 copayment Nurse Practitioner HNJH $5 copayment for each visit (except for preventive care services) Nursing Facility Services - custodial care, rehabilitation, post-acute care, skilled nursing care, and services in special nursing facilities such as ventilator facilities, pediatric long term care and treatment for AIDS. HNJH Coverage limited to 30 days of nursing facility care following discharge from an acute care hospital FFS After 30 days in a nursing facility, DMAHS will disenroll the member from HNJH and the member will receive services from the Medicaid FFS program Coverage limited to 30 days of rehabilitation services following discharge from an acute care hospital if this is the appropriate setting for rehab to occur $5 copayment for first prenatal visit only $5 copayment (except for preventive care services). $10 copayment for each home visit or office visit after normal office hours $5 copayment for each visit during normal office hours (except for preventive care services). $10 copayment for each home visit or office visit after normal office hours Optical Appliances HNJH Selected eyeglasses and contact lenses are covered as follows: Age 18 and under - Replacement eyeglasses or contact lens annually if prescription changes. Age 19 to 59 - Replacement eyeglasses or contact lens every two years if prescription changes Age 60 and older - Replacement eyeglasses or contact lens annually if prescription changes. Replacement eyeglasses or contact lenses may be dispensed more frequently if significant vision changes occur. 3-4 Horizon NJ Health Physician and Health Care Professional Manual, January 2011

5 Benefit Service Code Medicaid and A Optometrist Services HNJH One routine eye exam per year Organ Transplants - Individual placed on transplant list while a HNJH member HNJH B C One routine eye exam per year $5 co-payment D Coverage includes all donor and recipient transplant costs for members who have transplants conducted within two months after disenrollment from Horizon NJ Health Organ Transplants - Individual placed on transplant list while in the FFS Program prior to initial enrollment with HNJH. HNJH FFS Coverage limited to transplant related physician costs for donor and recipient Coverage limited to donor and recipient inpatient hospital costs Orthotics HNJH Outpatient Diagnostic Testing HNJH Partial Care Program HNJH FFS Partial Hospital Program HNJH FFS Personal Care Assistant Services FFS Podiatrist Services HNJH $5 copayment Prescription Drugs Retail Pharmacy HNJH FFS for all members except ABD members and other dual eligible individuals No coverage for erectile dysfunction drugs or atypical antipsychotic drugs for all members except ABD members and other dual eligible individuals $1 copayment for generic drugs; $5 for brand name drugs No coverage for erectile dysfunction drugs or atypical antipsychotic drugs Certain cough/cold, topicals, and anti-obesity drugs are not covered for certain age groups for all ABD eligibles and other dual eligible individuals Coverage for all members for brand and generic Suboxone and Subutex, atypical antipsychotic drugs and methadone (including administration) Certain cough/cold, topicals, anti-obesity and erectile dysfunction drugs are not covered for certain age groups $5 copayment. Routine hygienic care of feet, including the treatment of corns, calluses, trimming of nails, and other hygienic care in the absence of a pathological condition is not covered for all members except ABD members and other dual eligible individuals Coverage excludes over the counter drugs $5 copayment for brand name and generic drugs. If greater than a 34-day supply, $10 copayment applies. No coverage for erectile dysfunction drugs or atypical antipsychotic drugs Certain cough/cold, topicals, and anti-obesity drugs are not covered for certain age groups for all ABD members and other dual eligible individuals Coverage for all members for brand and generic atypical antipsychotic drugs and methadone (including administration) $5 copayment Certain cough/cold, topicals, anti-obesity and erectile dysfunction drugs are not covered for certain age groups Horizon NJ Health Physician and Health Care Professional Manual, January

6 Benefit Prescription Drugs Medicare Part B physician administered (typically billed with J-codes or Q-codes.) Primary Care, Specialty Care, and Women s Health Services Service Code HNJH Medicaid and A B C HNJH $5 copayment for each visit. No copayment for well-child visits, lead screening/ treatment, age-appropriate immunizations, prenatal care or PAP smears. D $5 copayment for each visit during office hours. $10 copayment for each home visit or office visit after normal office hours. No copayment for well-child visits, lead screening/ treatment, age-appropriate immunization or preventive dental services for children under 12. $5 copayment for first prenatal visit, no subsequent copayments Private Duty Nursing HNJH for EPSDT age children only Prosthetics HNJH Coverage limited to the initial provision of a prosthetic device that temporarily or permanently replaces all or part of an external body part lost or impaired as a result of disease, injury, or congenital defect. Repair and replacement services are covered only when needed due to congenital growth Radiology Services -Diagnostic & Therapeutic Rehabilitation Services - Outpatient PT, OT and Speech Self initiated care from a non-participating provider without referral/ authorization HNJH $5 copayment when not part of an office visit FFS Coverage limited to 60 consecutive days per therapy per year HNJH The member shall be held responsible for the cost of care Coverage limited to 60 consecutive days per therapy per year $5 copayment Speech therapy for developmental delay is not covered Services provided outside of the United States and territories HNJH FFS Sex Abuse Examinations FFS Social Necessity Days FFS Coverage limited to no more than 12 inpatient hospital days Specialty Foods for member s with metabolic conditions and genetic disorders HNJH FFS 3-6 Horizon NJ Health Physician and Health Care Professional Manual, January 2011

7 Benefit Substance Abuse (Inpatient and Outpatient) Service Code Medicaid and A B C D HNJH only for DDD clients. FFS for all other members except DDD clients Benefit limited to detoxification. For members under the age of 19, covered with no service limits For members 19 years and older - limited to 20 visits per year Transportation to medically necessary services - higher mode HNJH Coverage includes all higher mode transportation for all HNJH covered or non covered service, including ambulance, mobile intensive care units (MICUs) and invalid coach (including lift equipped vehicles) Invalid coach transportation is not covered for any member who chooses to see a provider outside of their county of residence Transportation to Medical Day programs is not covered Coverage limited to ambulance for medical emergency only Transportation to Medical Day programs is not covered Transportation to medically necessary services - lower mode HNJH only if HNJH refers a member to a provider greater than 30 miles from their residence and the member requests transportation. Transportation to Medical Day programs is not covered Waiver and demonstration program services (except DDD-waiver) FFS FFS 3.2 ADVANTAGE Benefit Matrix and Managed Care Protocols Benefit Abortions and Related Services Acupuncture Audiology (See EPSDT for hearing screenings) Blood and Blood Plasma Chiropractic Services Dental Dental - Orthodontics Diabetic Supplies and Equipment Durable Medical Equipment/Assistive Technology Devices Emergency Medical Care/Emergency Services EPSDT (Early and Periodic Screening, Diagnosis and Treatment) Family Planning Group Homes and DYFS Residential Treatment Facilities (Services provided to members) Hearing Aid Services ADVANTAGE Coverage limited to spontaneous abortions/miscarriages (such as those under ICD-9 diagnosis codes 632, , ) Coverage limited to children under the age of 16 years Coverage limited to administration of blood, processing of blood, processing fees and fees related to autologous blood donations Coverage is limited to preventive dental services (including X-rays and sealants) for children under the age of 12. Treatment for Temporomandibular joint disorder (TMJ) is not covered., $35 copayment for each visit Coverage limited to well-child care, newborn hearing screenings, immunizations, and lead screening and treatment Coverage includes medical history and physical exams (including pelvic and breast), diagnostic and lab tests, drugs and biologicals, medical supplies and devices, counseling, continuing medical supervision, continuity of care and genetic counseling. All services must be delivered by HNJH participating providers Coverage limited to children under the age of 16 years Horizon NJ Health Physician and Health Care Professional Manual, January

8 Benefit Home Health & Visiting Nursing Services Hospice Services Hospital Services (Inpatient) ADVANTAGE Coverage is limited to skilled nursing for home-bound member that is provided or supervised by a RN and a home health aide when the purpose of the treatment is skilled care. Coverage includes medical social services that are necessary for treatment of the member s medical condition in the community as well as in institutional settings. Room and board are included only when services are delivered in an institutional (non-private residence) setting.. Horizon NJ Health is not responsible, when the primary admitting diagnosis is mental health or substance abuse related Hospital Services (Outpatient) Infertility Diagnosis and Treatment (including sterilization reversals, and related office (medical and clinic) visits, drugs, laboratory services, radiological and diagnostic services and surgical procedures) Intermediate Care Facilities/ Mental Retardation Laboratory Services Maternity Services Medicaid Fair Hearing Medical Day Care Mental Health - Inpatient Hospital Services Including Psychiatric Hospitals Mental Health Outpatient (excluding partial care services) Mental Health Home Health Medical Supplies Nurse Midwife (Maternity) Nurse Midwife (Non-Maternity) Nurse Practitioner Nursing Facility Services - custodial care, rehabilitation, post-acute care, skilled nursing care, and services in special nursing facilities such as ventilator facilities, pediatric long term care and treatment for AIDS. Optical Appliances Optometrist Services Organ Transplants - Individual placed on transplant list while a HNJH member Organ Transplants - Individual placed on transplant list while in the FFS Program prior to initial enrollment with HNJH. Orthotics Outpatient Diagnostic Testing Partial Care Program Partial Hospital Program Personal Care Assistant Services Podiatrist Services Prescription Drugs from a Retail Pharmacy, $5 copayment for each visit, $5 copayment for each visit that is not part of an office visit. NOTE: Routine testing related to the administration of atypical antipsychotic drugs is not covered. Coverage limited to diabetic supplies, $5 copayment for each visit, $5 copayment for each visit, $5 copayment for each visit Selected eyeglasses and contact lenses are covered as follows: Replacement eyeglasses or contact lenses annually if prescription changes. Replacement eyeglasses or contact lenses may be dispensed more frequently if significant vision changes occur. for one routine eye exam per year, $5 copayment, HNJH is responsible for entire cost of non-experimental/non-investigational organ transplants Coverage limited to transplant related physician costs for donor and recipient, $5 copayment for each visit, Routine hygienic care of feet, including the treatment of corns, calluses, trimming of nails and other hygienic care in the absence of a pathological condition, is not covered Coverage excludes over the counter drugs $1 copayment for generic drugs $5 copayment for brand name drugs $10 copayment for >34-day supply No coverage for erectile dysfunction drugs or atypical antipsychotic drugs Certain cough/cold, topicals, and anti-obesity drugs are not covered for certain age groups 3-8 Horizon NJ Health Physician and Health Care Professional Manual, January 2011

9 Benefit ADVANTAGE Prescription Drugs Medicare Part B physician administered (typically billed with J-codes or Q-codes.) Primary Care, Specialty Care and Women's Health Services Private Duty Nursing Prosthetics Radiology Services Diagnostic & Therapeutic Rehabilitation Services - Outpatient PT, OT and Speech Self-initiated care from a non-participating provider without referral/authorization Services provided outside of the United States and territories Sex Abuse Examinations Social Necessity Days Specialty Foods for member s with metabolic conditions and genetic disorders Substance Abuse Transportation to medically necessary services - higher mode Transportation to medically necessary services - lower mode Waiver and demonstration program services (except DDD-waiver) with a $5 co-payment for each visit Coverage limited to the initial provision of prosthetic device that temporarily or permanently replaces all or part of an external body part lost or impaired as a result of disease, injury, or congenital defect. Repair and replacement services are covered when due to congenital growth, $5 copayment for each visit that is not part of an office visit The member shall be held responsible for the cost of care Coverage limited to ambulance for medical emergency only. Transportation to Medical Day programs is not covered only if HNJH refers a patient to an out of county or out of State provider when the services could have been rendered in-county/in-state 3.3 Exclusions The following services are not covered by Horizon NJ Health or the NJ Medicaid Fee-For-Service program Services identified as being not medically necessary, provided, approved or arranged by a Horizon NJ Health participating physician or other provider (within his/her scope of practice) except emergency services Services or items furnished that the provider does not normally charge Cosmetic surgery except when medically necessary and approved Experimental organ transplants Claims arising directly from services provided by or in institutions owned or operated by the federal government such as Veterans Administration hospitals Respite Care Rest cures, personal comfort and convenience items, services and supplies not directly related to the care of the patient, including, but not limited to, guest meals and accommodations, telephone charges, travel expenses, take home supplies and similar costs. Costs incurred by an accompanying parent(s) for an out-of-state medical intervention are covered under EPSDT by Horizon NJ Health Services billed for which the corresponding health care records do not adequately and legibly reflect the requirements of the procedure described or procedure code utilized by the billing provider Services furnished by an immediate relative or member of the Medicaid beneficiary s household Services involving the use of equipment in facilities, the purchase, rental or construction of which has not been approved by applicable laws of the State of New Jersey and regulations issued pursuant thereto Services or items furnished for any condition or accidental injury arising out of and in the course of employment for which any benefits are available under the provisions of any workers compensation law, temporary disability benefits law, occupational disease Horizon NJ Health Physician and Health Care Professional Manual, January

10 law, or similar legislation, whether or not the Medicaid beneficiary claims or receives benefits thereunder, and whether or not any recovery is obtained from a third-party for resulting damages Services or items furnished for any sickness or injury occurring while the covered person is on active duty in the military Services or items reimbursed based upon submission of a cost study when there are no acceptable records or other evidence to substantiate either the costs allegedly incurred or beneficiary income available to offset those costs. In the absence of financial records, a provider may substantiate costs or available income by means of other evidence acceptable to the Division Services provided in an inpatient psychiatric institution, that is not an acute care hospital, to individuals under 65 years of age and over 21 years of age Services provided outside the United States and territories Services provided primarily for the diagnosis and treatment of infertility, including sterilization reversals, and related office (medical or clinic), drugs, laboratory services, radiological and diagnostic services and surgical procedures Services provided to all persons without charge. Services and items provided without charge through programs of other public or voluntary agencies (for example, New Jersey State Department of Health and Senior Services, New Jersey Heart Association, First Aid Rescue Squads, and so forth) shall be utilized to the fullest extent possible That part of any benefit which is covered or payable under any health, accident, or other insurance policy (including any benefits payable under the New Jersey no-fault automobile insurance laws), any other private or governmental health benefit system, or through any similar third-party liability, which also includes the provision of the Unsatisfied Claim and Judgment Fund Exclusions for D Members The following services are not covered for D participants either by Horizon NJ Health or DMAHS Biofeedback Cosmetic Services Court-ordered services Custodial Care Experimental and Investigational Services Hearing Aid Services for members over the age of 16 Infertility Services Intermediate Care Facilities/Mental Retardation Medical Day Care Services Personal Care Assistant Services Radial keratotomy Recreational therapy Rehabilitative Services for Substance Abuse Religious non-medical institutions care and services Residential treatment center psychiatric programs Respite Care Nursing facility services Sleep therapy Special Remedial and Educational Services Temporomandibular joint disorder treatment, including treatment performed by prosthesis placed directly in the teeth Thermograms and thermography Weight reduction programs or dietary supplements, except surgical operations, procedures or treatment of obesity when approved by Horizon NJ Health Exclusions for ADVANTAGE Members The following services are not covered for ADVANTAGE participants either by Horizon NJ Health or DMAHS Biofeedback Cosmetic services Cosmetic surgery except when medically necessary and approved Court-ordered services Custodial care Radial keratotomy Recreational therapy Religious non-medical institutions care and services Respite care Services or items furnished for any sickness or injury occurring while the covered person 3-10 Horizon NJ Health Physician and Health Care Professional Manual, January 2011

11 is on active duty in the military Services or items reimbursed based upon submission of a cost study, when there are no acceptable records or other evidence to substantiate either the costs allegedly incurred or beneficiary income available to offset those costs. In the absence of financial records, a provider may substantiate costs or available income by means of other evidence acceptable to the Division Services provided outside the United States and territories Services provided primarily for the diagnosis and treatment of infertility, including sterilization reversals, and related office (medical or clinic), drugs, laboratory services, radiological and diagnostic services and surgical procedures Sleep therapy Special Remedial and Educational Services Temporomandibular joint disorder treatment, including treatment performed by prosthesis placed directly in the teeth Thermograms and thermography Weight reduction programs or dietary supplements, except surgical operations, procedures or treatment of obesity when approved by the contractor 3.4 Family Planning Horizon NJ Health members are entitled to receive family planning services through Horizon HMO. Services that prevent or delay pregnancy are covered, including: Medical history and physical examination (including pelvic and breast) Diagnostic and laboratory tests Drugs and biologicals Medical supplies and devices Counseling Continuing medical supervision Continuing care and genetic counseling Elective/Induced abortions and related services are not covered under this contract, but will continue to be paid on a Fee-For-Service basis by Medicaid. Infertility diagnosis and treatment services, including sterilization reversals and related office (medical or clinical) drugs, laboratory, radiological and diagnostic and surgical procedures are not covered. Elective/Induced abortions and related services as well as infertility diagnosis and treatment services are not covered for ADVANTAGE members. Horizon HMO is available to assist members in locating family planning services. Members can access services through Horizon NJ Health s physician network or through participating Medicaid family planning providers. ( D and ADVANTAGE members may only access services through participating Horizon NJ Health physicians). Members may self-refer and go directly to a family planning clinic or call Horizon HMO Medicaid Managed Care Family Planning Unit directly. No referral from a Horizon NJ Health Primary Care Physician is necessary. A Horizon HMO representative may coordinate family planning services for a member. Family Planning Services Horizon HMO Horizon HMO is responsible for payment of all claims related to family planning services, when rendered by a participating physician, including voluntary sterilization, tubal ligation, vasectomy, or similar procedures having the purpose of pregnancy prevention. A HHS-687 Consent for Sterilization Form must be completed and signed by the member in advance of the sterilization procedures being performed. A copy of the consent form must be attached to the claim, prior to submission to Horizon HMO. A copy of the Consent for Sterilization Form is located in Appendix B. The form may also be downloaded from the Horizon NJ Health Website in the Forms and Guides section. The individual who has given voluntary consent for a sterilization procedure must be at least 21 years old at the time the consent is obtained and must not be a mentally incompetent person. Medicaid Fee-For-Service is responsible for the payment of claims from non-participating physicians. All Family Planning claims should include the member s Social Security Number and be submitted to: Horizon NJ Health P.O. Box 789 Newark, NJ Horizon NJ Health Physician and Health Care Professional Manual, January

12 Hysterectomy is a covered service, if the primary medical indication for the hysterectomy is other than sterilization. Hysterectomy is not a covered service, if it is performed solely for the purpose of sterilization. Federally prescribed documentation regulations for hysterectomies are extremely rigid. Specific Medicaid requirements must be met and documented on the Hysterectomy Receipt of Information Form (FD-189). A copy of the Hysterectomy Receipt of Information Form is located in Appendix B. The form may also be downloaded from the Horizon NJ Health Website in the Forms and Guides section. A properly completed form FC-189 must be submitted during the request for pre-certification. Claim payment for a hysterectomy, without a copy of the signed acknowledgment of sterilization information, will be made only if the physician performing the hysterectomy certifies that the hysterectomy was required, because of a life-threatening emergency situation and prior acknowledgment was not possible or if the physician certifies that the individual was already sterile at the time of the hysterectomy and states the cause of the sterility. 3.5 Obstetrical and Gynecological Care Horizon NJ Health provides a full range of obstetrical and gynecological services to members. Obstetrical and Gynecological Care Policy Members may self-refer to a participating physician for these services. No referral from the Primary Care Physician is required. C, D and ADVANTAGE members are responsible for a $5 co-payment for obstetrical/gynecological services unrelated to well visits, prenatal visits and pap smears. Please issue a receipt to the member upon collection of a co-payment. This receipt should include the physician s name, address and telephone number. The Obstetrician/Gynecologist will assume responsibility for referring the member to their Primary Care Physician (PCP) for medical services unrelated to the obstetrical/ gynecological care. Obstetrical and Gynecological Care Procedure Obstetrical/Gynecological Care physicians should refer members to the laboratory service center assigned to their office when studies are required for members. Horizon NJ Health contracts with Laboratory Corporation of America Holdings (LabCorp) for laboratory services. Please refer to the Provider Directory for the LabCorp Patient Service Center in your area. CPT Codes for OB/GYN Services For 1-3 Antepartum Care Visits, use E&M Codes Antepartum Care Only: 4-6 Visits Antepartum Care Only: 7 or More Visits Regular Vaginal Delivery Vaginal Delivery and Postpartum Care Postpartum Care Visit Only Cesarean Section Delivery Only C/S and Postpartum Care The following codes are used when billing for Maternity Support Services: Maternity Support Services Code Modifier Description HD Initial antepartum maternity health support services 59425/ None Subsequent antepartum maternity care visit (maximum of 14 visits) HD Regular Vaginal Delivery HD Postpartum care visit only AA Regular Vaginal Delivery and Postpartum 3-12 Horizon NJ Health Physician and Health Care Professional Manual, January 2011

13 Code Modifier Description HD Cesarean Section Delivery Only J2790 Rho (D) Immune globin, human Neonatal Screening Testing New Jersey has expanded its statewide system of newborn biochemical testing to include disorders, which, if not detected early, can cause severe health problems, mental retardation and even death. Hospitals submit newborn blood samples to the Department of Health and Senior Services Public Health and Environmental Laboratories, which perform the tests. Examples of disorders that are screened for in New Jersey are: Phenylketonuria (PKU) Congenital hypothyroidism Galactosemia Hemoglobinapathies Biotenidase deficiency Congenital adrenal hyperplasia (CAH) Cystic Fibrosis Maple Syrup Urine Disease (MSUD) Medium chain acyl-coa dehydrogenase (MCAD) deficiency Short chain acyl-coa dehydrogenase (SCAD) deficiency Long chain acyl-coa dehydrogenase (LCAD) deficiency Very long chain acyl-coadehydrogenase (VLCAD) deficiency Citrullinemia Argininosuccinic acidema There is a critical need for timely medical evaluation, diagnostic laboratory testing, referral and treatment for these disorders. Appropriate diagnosis and management of infants with these disorders requires specialized and timely care. A physician should contact the Utilization Management Department when a newborn has a positive laboratory result. Horizon NJ Health will contact the member to coordinate care with an appropriate participating specialist. Utilization Management Department Podiatry Services When medically necessary, members are eligible for podiatry services. Members must be referred to a participating podiatrist by their PCP. Horizon NJ Health will reimburse Podiatrists for the following X-rays performed in the office with a valid referral: X-ray ankle: X-ray tibia AP & LAT: X-ray ankle-complete: X-ray foot AP & LAT Views: X-ray foot, complete, min 3 view: Calcaneus, min 2 view: Routine foot care, including nail clipping, corn and callus removal and other hygienic care, such as cleaning or soaking feet, is only provided when medically necessary. C, D and ADVANTAGE members are responsible for a $5 co-payment for specialty care visits. Please issue a receipt to the member, upon collection of a co-payment. This receipt should include the physician s name, address and telephone number. 3.7 Chiropractic Care Chiropractic care is limited to Manual Manipulation of the Subluxation of the Spine. CPT Codes 98940, 98941, and are eligible for reimbursement. Chiropractic services, including the initial visit and initial treatment, require a Primary Care Physician referral. All subsequent treatments require a prior authorization. The following evaluation and management codes are only eligible for payment when billed during the initial office visit: C members are responsible for a $5 co-payment for chiropractic visits. Please issue a receipt to the member, upon collection of a co-payment. This receipt should include the physician s name, address and telephone number. Chiropractic benefits are not covered for D and ADVANTAGE members. Horizon NJ Health Physician and Health Care Professional Manual, January

14 3.8 Organ Transplants Donor and recipient costs for non-investigational and non-experimental organ transplants are reimbursable by Horizon NJ Health. Eligible organ transplants include, but are not limited to: Heart Heart/Lung Kidney Liver Bone marrow Intestine Cornea Lung Pancreas All costs associated with the procurement and transplantation of organs for eligible members are covered by Horizon NJ Health. The Primary Care Physician will coordinate all transplant services with the specialty care physician. The specialty care physician must contact the Utilization Management Department to obtain an authorization for services. Utilization Management Department Skilled Nursing Facility Care Skilled nursing facility care is the responsibility of the Department of Human Services. The State Medicaid Program will provide reimbursement on a NJ Medicaid Fee-For-Service (FFS) basis. Inpatient rehabilitation services at a skilled nursing facility: The first 30 days of inpatient rehabilitation care, rendered at a skilled nursing facility following an inpatient acute care stay, are reimbursed by Horizon NJ Health Hospice Care The PCP must contact the Horizon NJ Health Utilization Management Department to arrange for hospice care. The Utilization Management Department will handle the coordination needs between the PCP and hospice care provider to ensure that the member receives the appropriate care. Utilization Management Department A PCP who prescribes a hospice program for a member must discuss with the member and their family the status of an Advance Directive or Living Will. Review Section for more information. Horizon NJ Health s physicians are encouraged to review the guidelines published by the New Jersey Commission on Legal and Ethical Problems in the Delivery of Health Care. The guidelines can be viewed on the Horizon NJ Health Web site at Durable Medical Equipment (DME) and Medical Supplies Horizon NJ Health will provide benefits for DME and medical supplies when medically necessary and approved. If the billed charge of the non-rental item is less than $250, the participating provider may dispense the item without prior authorization from Horizon NJ Health. However, Horizon NJ Health recommends that the provider contact the Physician & Health Care Hotline at to verify eligibility, prior to dispensing the item. Provisions have been made for participating network pharmacies to dispense certain DME and Medical Supplies, when written on a prescription. If the billed charge of the item is equal to or greater than $250, authorization must be obtained from the Horizon NJ Health Utilization Management Department before the item is dispensed. To receive authorization, the requesting provider must call the Utilization Management Department. All rental items require authorization Certain DME/Medical Supply items require the completion of a letter of Medical Necessity, prior to authorization. DME items may require a DME Assessment by an independent contractor, prior to authorization. Utilization Management Department Horizon NJ Health Physician and Health Care Professional Manual, January 2011

15 Durable Medical Equipment Available for D Members Coverage is limited to the following: Alternating Pressure Pads Bed Pans Bladder Irrigation Supplies Blood Glucose Monitors and Supplies Canes Commodes Bathroom devices permanently attached are not covered Crutches and Related Attachments Fracture Frames Gastrostomy Supplies Hospital Beds (Manual, Semi-Electric, Full Electric) and Related Equipment Ileostomy Supplies Infusion Pumps Intermittent Positive Pressure Breathing (IPPB) Treatments and Related Supplies IV Poles Jejunostomy Supplies Lancets and Related Devices Loop Heals/Loop Toe Devices Lymphedema Pumps Manual Wheelchairs and Related Equipment Motorized wheelchairs are not covered Types of covered wheelchairs include full-reclining; high-strength lightweight; heavy duty; and semi-reclining Mattress Overlays Low air loss and air fluidized bed systems are not covered Nasogastric Tubing Nebulizers and Related Supplies Needles Ostomy Supplies Over-Bed Tables Oxygen and Related Equipment and Supplies Liquid and gas systems and oxygen concentrators are covered Ventilation systems are not covered Pacemaker Monitors Parenteral Nutrition Patient Lifts Pneumatic Appliances Sitz Bath Suction Machines and Related Supplies Syringes Tracheostomy Supplies Traction/Trapeze Apparatus Urinals Urinary Pouches and Related Supplies Urine Glucose Tests Walkers and Related Attachments Wheelchair Seating/Support Systems DME and medical supplies are limited to diabetic supplies and equipment for NJ FamilyCare ADVANTAGE members Prosthetics/Orthotics Participating providers may dispense prosthetic/orthotic devices to members, when medically necessary. Prosthetics require a signed and dated prescription and a completed Medical Necessity Request form from the prescribing physician. All repair and replacement of parts for custom-made prosthetic devices require a signed and dated prescription and a complete Medical Necessity Request form. Prosthetic devices are limited to the initial provision for members. Repair and replacement services are covered, when the prosthetic is outgrown. Orthotic Devices Orthotic devices for members are pre-authorized by Horizon NJ Health. Orthotics require a signed and dated prescription and a completed Medical Necessity Request form from the prescribing physician. All repair and replacement of parts for custom-made orthotic devices require a signed and dated prescription from the physician. If the billed charge for the purchase, repair or replacement of parts is under $1,000, no prior authorization from Horizon NJ Health is required. If the billed charge for the purchase, repair or replacement of parts is equal to or greater than $1,000, prior authorization is required. Prosthetics are limited to the initial provision of a prosthetic device for D members. Orthotics and orthotic devices are not a covered benefit for, D members. Horizon NJ Health Physician and Health Care Professional Manual, January

16 3.13 Home Health Care Home Care Services are provided by Medicare Certified Agency, except for Private Duty Nursing. When medically appropriate, Horizon NJ Health encourages the use of home health care services as an alternative to hospitalization to allow early hospital discharge, avoid unnecessary admissions and allow the member to receive care in familiar surroundings. Home health care should be considered for the delivery of the following types of services: Skilled Nursing Physical Therapy ( by NJ Medicaid Fee-For-Service program) Speech Therapy ( by NJ Medicaid Fee-For-Service program) IV Therapy Personal Care Assistant ( for NJ FamilyCare or ADVANTAGE members) Home Care visits for pre-natal & post-partum needs Lead Outreach Social Work Private Duty Nursing Horizon NJ Health s Utilization Management Department shall coordinate all medically necessary home care. The Utilization Management Department will review each case to assess and authorize the length or type of service required. An authorization number will be assigned and should appear on all bills submitted for pre-authorized services provided to the member. Home Care Agencies receiving requests to provide care must contact the Utilization Management Department to verify eligibility, benefit availability and to obtain authorization for services, prior to providing the service, except in emergency circumstances. Payment of a maternity/post partum or health management home visit is contingent upon receipt of the assessment by the Health and Wellness Department. If you need a copy of the assessment form, please call our Health and Wellness Department. Health and Wellness Department Fax Number: Only one authorization number is given per case. However, the authorization number may be updated for continuance of any service, which will extend beyond the initial approval period. Contact should be made at least five days prior to the end date of the original authorization. Physician orders and care plans need not be submitted with claims for home care services; however, the physician must keep such information on file for presentation to Horizon NJ Health s Utilization Management Department, if requested. All claims submitted by the Home Care provider that include DME or pharmaceutical supplies must be accompanied by a physician issued prescription. All claims submitted are subject to eligibility and benefit availability. Claims submitted for Custodial and/or Domiciliary services will not be considered for payment. Home health care for the Aged, Blind and Disabled (ABD) membership is carved out to Medicaid FFS, but coordinated by Horizon NJ Health Care Management Department. Assistance can be provided by calling: Special Needs Care Management Private Duty Nursing Services require authorization in all instances. They are an EPSDT benefit and covered for children, who meet the EPSDT age requirement. They are not a covered benefit for NJ Family Care D or NJ Family Care ADVANTAGE members. For more information, please call the Utilization Management Department. For D members, home health services are limited to skilled nursing for home bound beneficiaries when provided or supervised by a registered nurse and home health aide, when the purpose of the treatment is skilled care and medical social services necessary for treatment of medical condition Therapeutic Services The following outpatient therapeutic services are not covered by Horizon NJ Health, but are covered by the NJ Medicaid Program on a Fee-For-Service (FFS) basis: 3-16 Horizon NJ Health Physician and Health Care Professional Manual, January 2011

17 Initial evaluation of physical, speech pathology and occupational therapies that are not completed by a physician Physical Therapy Speech/Pathology services Occupational Therapy Therapeutic services covered by Horizon NJ Health include, but may not be limited to: Chemotherapy Radiation Therapy Cardiac Rehabilitation Therapy The Primary Care Physician must issue a Horizon NJ Health referral for the initial evaluation by the participating provider. After the provider completes the initial evaluation, the provider must send a copy to the Utilization Management Department for review. The Utilization Management Department will discuss the recommended treatment plan with the therapist and issue an authorization for treatment. Further treatments must also be coordinated by the PCP and authorized by the Utilization Management Department. Audiology Under this program, certain members are eligible for audiology services. Audiology services are not a covered benefit for NJ FamilyCare D and ADVANTAGE members. The PCP must issue a referral to the audiologist for the initial evaluation. The audiologist must send a copy of the completed initial evaluation to the PCP. The PCP and the audiologist will discuss the recommended treatment plan for medically necessary treatment. The PCP will issue all necessary subsequent referrals to the audiologist, as required. Please refer to Section 6.0 Referrals to Specialty Care Physicians to obtain information regarding issuance of the referral form. Utilization Management Department Further treatments must also be coordinated by the PCP and authorized by the Utilization Management Department Vision Care Davis Vision administers the vision care benefit for Horizon NJ Health members, including the vision exam, eyeglasses, corrective lenses and contact lenses, if prescribed. Members may self-refer and go directly to a participating Davis Vision provider. A referral from a Horizon NJ Health Primary Care Physician is not necessary in order to receive services from a participating Davis Vision provider. If a condition that requires further treatment is detected during the annual exam, the PCP must be contacted. A participating Optometrist or Ophthalmologist may provide follow-up treatment for eye disorders. A referral from the PCP is required for all follow-up treatment, including therapeutic services. Davis Vision Optometrists or Ophthalmologists rendering therapeutic services as a result of a routine visit must contact Davis Vision to obtain an authorization. If you are a Davis Vision provider, please contact Davis Vision at to verify eligibility and to obtain a comprehensive Davis Vision Physician Manual. C, D and ADVANTAGE members are responsible for a $5 co-payment for optometry visits. Please issue a receipt to the member, upon collection of a co-payment. This receipt should include the physician s name, address and telephone number Dental Services Horizon NJ Health offers a full range of dental services to certain members. These services include preventive and diagnostic, specialty and major restorative dental services. When necessary, orthodontics are also covered for members under 21 years of age or as allowed by EPSDT. Horizon Blue Cross Blue Shield of New Jersey and its subsidiary Horizon Blue Cross Blue Shield Dental Program administer dental services for Horizon NJ Health members. Referring a member to a Dentist by one year of Horizon NJ Health Physician and Health Care Professional Manual, January

18 age, and every year thereafter, is recommended. Referral to a dentist is mandatory, when a member reaches three years of age and annually thereafter, through age 20 years. Dental services include an initial examination and any required dental services determined to be dentally necessary. Horizon Blue Cross Blue Shield Dental Program coordinates all pre-certifications for the provision of inpatient dental care. Please contact Horizon Blue Cross Blue Shield Dental Program at the telephone number below to obtain more information about covered benefits. Horizon Blue Cross Blue Shield Dental Program DENTAL ( ) Dental claims should be mailed to: Horizon Blue Cross Blue Shield Dental Program PO Box 1938 Newark, NJ Except for preventive dentistry services, C members are responsible for a $5 co-payment for dental services. Preventive Dental benefits for D members are limited to children under the age of 19 years, including oral examinations, oral prophylaxis, topical applications of fluorides, X-rays and sealants. Preventive Dental benefits for ADVANTAGE members are limited to children under the age of 12 years, including oral examinations, oral prophylaxis, topical applications of fluorides, X-rays and sealants Medical Versus Dental Services Horizon NJ Health recognizes that medical conditions may exist and can exhibit one or more dental components. These dental components/conditions may be 1) causative to the medical situation of the patient, 2) completely unrelated, or 3) the sequelae of the medical condition or its treatment. A physician or oral surgeon may perform procedures that may be considered medical or dental (e.g. surgical procedures for fractured jaw or removal of cyst). Please see Section 8.2, Pre-Certification Process to obtain the authorization process or you may call the Horizon NJ Health Utilization Management Department. A broad definition of dental services would be those procedures used to treat the dental structures, including primary and permanent dentition and supporting structures including the periodontium and alveolar bone. Specific procedures that would fall under the category of dental treatment are: Restoration of tooth structure lost by decay, fracture, attrition or erosion using synthetic materials. This can include intra-coronal restorations, such as amalgam, gold or composite, full or partial coverage crowns and tooth strengthening and retention enhancement for endodontically treated teeth. Endodontic treatment of teeth, including re-treatment, if necessary, and any necessary periapical or sectioning surgical intervention. Surgical services and post-op treatment performed on the dental supporting structures that include treatment of periodontal disease, osseous surgery and any other surgery to the periodontium. Replacement of missing teeth using full dentures, removable partial dentures or fixed prostheses and related services. Removal of teeth and re-implantation of teeth and associated services. Orthodontic treatment, even if a component of an eligible medical condition or treatment. Obtain authorization by calling Horizon NJ Health s Utilization Management Department at least five business days prior to the inpatient or outpatient procedure, if the procedure requires anesthesia or is performed in an inpatient setting or non-participating ambulatory surgical center. Utilization Management Department Mental Health and Substance Abuse Services Horizon NJ Health s physicians will systematically identify and address behavioral 3-18 Horizon NJ Health Physician and Health Care Professional Manual, January 2011

19 health needs for all Horizon NJ Health members at the earliest possible time following initial enrollment with Horizon NJ Health or after the onset of the condition, through a behavioral health screening tool administered by the member s PCP. PCPs and other physicians shall utilize mental health/substance abuse screening tools, as well as other mechanisms, to facilitate early identification of behavioral health needs for treatment. For your reference, the behavioral health screening tool is included in Appendix B. The State shall retain a separate behavioral health system for members who are not clients of the Division of Developmental Disabilities (DDD) through the NJ Medicaid Fee-For-Service program. Horizon NJ Health PCPs shall refer non-ddd members to a NJ Medicaid Fee-For-Service behavioral health professional. Horizon NJ Health shall provide behavioral health benefits to Horizon NJ Health members who are clients of the Division of Developmental Disabilities (DDD) through the Magellan Behavioral Health Network. Horizon NJ Health s Care Management Department will coordinate the behavioral health services for DDD members with the PCP, Magellan Behavioral Health and their professional network. The PCP shall perform a medical diagnostic work-up to formulate a diagnosis or to effect the treatment of a behavioral health disorder and ongoing medical care for any member with a behavioral health diagnosis, as well as to coordinate the care with the behavioral health professional. This includes physical examinations, neurological evaluations, laboratory testing and radiologic examinations and any other diagnostic procedures necessary to make the diagnostic determination between a primary behavioral health disorder and an underlying physical disorder, as well as for medical work-ups required for medical clearances prior to the provision of psychiatric medication or electroconvulsive therapy (ECT), or for transfer to a psychiatric/substance abuse facility. Behavioral health services shall include, but are not limited to, comprehensive intake evaluation, off-site crisis intervention, family therapy, family conference, psychological testing and medication management. Any member may be referred to a behavioral health professional by the PCP and other physicians, family members, state agencies, Horizon NJ Health or a member may self-refer. The PCP shall notify the behavioral health professional of the medical examination and diagnostic testing results within 24 hours of receipt for urgent cases and five business days of receipt for non-urgent cases. The PCP shall notify the behavioral health professional by telephone with follow-up in writing, when feasible. This notification shall apply to DDD and non-ddd members. Diagnoses which are categorized as altering the mental status of an individual, but are of organic origin, will be eligible as a covered service under Horizon NJ Health. Horizon NJ Health will assume responsibility for the provision of medical care in these cases for all members. This includes, but is not limited to, the diagnoses in the following ICD-9CM series: Senile dementia, uncomplicated Presenile dementia Senile dementia with delirium Vascular dementia Other specific senile psychotic conditions Unspecified senile psychotic condition Alcohol induced persisting amnestic disorder Alcohol induced persisting dementia Drug induced persisting dementia Unspecified drug induced mental disorders Acute delirium due to conditions classified elsewhere Subacute delirium Amnestic syndrome Dementia in conditions classified elsewhere Other persistent specified organic brain syndromes Unspecified, persistent organic brain syndrome Tobacco use disorder Horizon NJ Health Physician and Health Care Professional Manual, January

20 310.0 Frontal lobe syndrome Postconcussion syndrome Other specified nonpsychotic mental disorder following organic brain damage Unspecified, nonpsychotic mental disorder following organic brain damage Magellan Behavioral Health can be contacted at the address and telephone number listed below. Magellan Behavioral Health 199 Pomeroy Avenue Parsippany, NJ Mental Health and Substance Abuse Well-Being Screening Tool Primary Care Providers are required to assess the behavioral health needs of enrolled members. To help facilitate your assessment, please use the Well-being Screening Tool in Appendix B as a screening tool to assess early identification of behavioral health needs for each Horizon NJ Health member, prior to treatment. The form may also be downloaded from the Horizon NJ Health Website in the Forms and Guides section. A copy of the completed questionnaire should be placed in the member s medical record. If a behavioral health need is identified, please refer the member for behavioral health services, as indicated below. Horizon NJ Health member and Client of the Division of Developmental Disabilities (DDD) Physicians may call Horizon NJ Health s Utilization Management Department at Our Utilization Management Department will coordinate the behavioral health services for DDD members with medical providers and Magellan Behavioral Health physicians. Physicians and/or Horizon NJ Health members may call Magellan Behavioral Health, toll free, at A Magellan Behavioral Health Representative is available 24 hours a day, 7 days a week to coordinate the behavioral health services for DDD members. Horizon NJ Health member and not a Client of the Division of Developmental Disabilities (DDD): Please call or refer the Horizon NJ Health member to a participating Medicaid behavioral health professional Outpatient Laboratory Services All physicians must utilize the exclusive clinical laboratory provider for Horizon NJ Health, when studies are required for members. Horizon NJ Health contracts with Laboratory Corporation of America Holdings (LabCorp) for laboratory services. Horizon NJ Health has contracted with MedTox to provide filter paper method lead screening, statewide. For additional information, contact the Physician & Health Care Hotline at Physicians are responsible for notifying members of laboratory results, as follows. Urgent/Emergent results Members must be notified of laboratory and radiology results, within 24 hours of receipt of results in urgent or emergent cases. Urgent/emergent appointment standards must be followed. See Section for Appointment Scheduling Standards. Rapid strep test results must be available to the member, within 24 hours of the test. Routine results Members must be notified of routine laboratory and radiology results within 10 business days of receipt of the results. Routine testing related to the administration of methadone and atypical antipsychotic drugs and their generic equivalents are covered by Horizon NJ Health for members who are clients of the Division of Developmentally Disabled (DDD). Routine testing related to the administration of the above drugs for all other Horizon NJ Health members is covered on a Fee-For-Service basis by NJ Medicaid Horizon NJ Health Physician and Health Care Professional Manual, January 2011