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«STATE OF NEW JERSEY DEPARTMENT OF THE TREASURY DIVISION OF PENSIONS AND BENEFITS Horizon HMO MEMBER HANDBOOK FOR EMPLOYEES AND RETIREES ENROLLED IN ...»

-- [ Page 11 ] --

• The subrogation and reimbursement rights and liens apply to any recoveries made by

the Member as a result of the injuries sustained, including but not limited to the following:

✔ Payments made directly by a third party, or any insurance company on behalf of a third party, or any other payments on behalf of the third party.

✔ Any payments or settlements, judgment or arbitration awards paid by any insurance company under an uninsured or underinsured motorist coverage, whether on behalf of a Member or other person.

✔ Any other payments from any source designed or intended to compensate a Member for injuries sustained as the result of negligence or alleged negligence of a third party.

✔ Any Workers’ Compensation award or settlement.

✔ Any recovery made pursuant to no-fault insurance.

✔ Any medical payments made as a result of such coverage in any automobile or homeowners insurance policy.

• The Plan shall recover the full amount of benefits provided hereunder without regard to any claim of fault on the part of any Member, whether under comparative negligence or otherwise.

–  –  –

Generally you will not have to submit any claim forms to Horizon HMO for reimbursement for treatment from a network provider. You will simply pay the provider the required copayment amount and the provider will submit claims directly to Horizon HMO for the appropriate reimbursement.

If you receive emergency treatment out-of-network, claims must be submitted for reimbursement to:

–  –  –

Horizon HMO must be given written proof of a loss for which a claim is made under Horizon HMO. This proof must cover the occurrence, character, and extent of the loss. It must be furnished within one year and 90 days of the end of the calendar year in which the services were incurred. For example, if a service were incurred in the year 2016, you would have until March 31, 2018, to file the claim.

A claim will not be considered valid unless proof is furnished within the time limit shown above. If it is not possible for you to provide proof within the time limit, the claim may be considered valid upon appeal if the reason the proof was not provided in a timely basis was reasonable.

Itemized Bills are Necessary You must obtain itemized bills from the providers of services for all medical expenses. The

itemized bills must include the following:

• Name and address of provider;

• Provider's tax identification number;

• Name of patient;

• Date of service;

• Diagnosis;

• Type of service;

• CPT 4 code; and

• Charge for each service.

Foreign Claims Bills for emergency services that are incurred outside of the United States must include an English translation and the charge for each service performed. The exchange rate at the time of service should also be indicated on the bill that is submitted for reimbursement.

Filling Out the Claim Form Be sure to fill out the claim form completely. Include the identification number that appears on your Horizon HMO identification card. Fill out all applicable portions of the claim form and sign it. A separate claim form must be submitted for each individual and each time you file a claim.

60 — HORIZON HMO MEMBER HANDBOOK

MEDICARE CLAIM SUBMISSION

If a member is a New Jersey resident, has Medicare primary coverage, and receives care within New Jersey, claims will be transmitted automatically from the Medicare carrier to the Horizon HMO.

QUESTIONS ABOUT CLAIMS

If you have questions about a hospital claim, hospital benefits, a medical claim, or medical benefits or if you need a claim form, call Horizon HMO member services at 1-800-414-SHBP (7427).

If for any reason the claim is not eligible, you will be notified of its ineligibility within 90 days of receipt of your claim. To request a review of the claim, you should follow the instructions described in the “Appeal Procedures” section.

APPEAL PROCEDURES

SHBP/SEHBP MEDICAL APPEAL PROCEDURE

Member appeals that involve medical judgment made by Horizon BCBSNJ are considered medical appeals. An adverse benefit determination involving medical judgment is (a) a denial; or (b) a reduction from the application of clinical or medical necessity criteria; or (c) a failure to cover an item or service for which benefits are otherwise provided because Horizon HMO determines the item or service to be experimental or investigational, cosmetic, or dental, rather than medical. Adverse benefit determinations involving medical

judgment may usually be appealed up to three (3) times as outlined below:

� First Level Medical Appeal – The First Level Medical Appeal of an adverse benefit determination.

� Second Level Medical Appeal – The Second Level Medical Appeal of an adverse benefit determination available to you after completing a First Level Medical Appeal.

� External Appeal – The third Level Medical Appeal of an adverse benefit determination, which, at your request, would generally follow a Second Level Medical Appeal.





An External Appeal provides you the right to appeal to an Independent Review Organization (IRO).

An overview of the medical appeal procedure is provided below. A Horizon HMO Medical Appeals Procedure brochure will be provided with every adverse benefit determination involving medical judgment. The brochure provides a comprehensive description of the procedures.

NEW JERSEY DIVISION OF PENSIONS AND BENEFITS —

First Level Medical Appeal First Level Medical Appeals may be submitted in writing or verbally. Verbal appeals may be directed to Horizon HMO Utilization Management at 1-888-221-6392. Written appeals

may be sent to:

–  –  –

The member, physician, or authorized representative has one (1) year following your receipt of the initial adverse benefit determination letter to request a Medical Appeal.

To initiate a First Level Medical Appeal, the following information must be provided:

• Name and address of the member or provider(s) involved.

• Member’s identification number.

• Date(s) of service.

• Nature and reason behind your appeal.

• Remedy sought.

• Clinical documentation to support your appeal.

First Level Medical Appeals will be reviewed and decided in the following time frames:

• Standard First Level Medical Appeals are reviewed and decided within 15 calendar days of receipt.

• First Level Expedited (urgent and emergent) Medical Appeals are decided as soon as possible in accordance with the medical urgency of the case, but will not exceed 72 hours from Horizon HMO’s receipt of the appeal request.

The member will receive a letter documenting Horizon HMO’s First Level Medical Appeal decision. The letter will include the specific reasons for the determination.

Expedited Review Horizon HMO Medical Appeal procedures may be expedited in circumstances involving urgent or emergent care.

First and Second Level Medical Appeals are automatically handled in an expedited manner for all determinations regarding urgent or emergent care, an admission, availability of care, continued stay, or health care services for which the claimant received emergency services but has not been discharged from the facility. Furthermore, if you feel that the Horizon HMO decision will cause serious medical consequences in the near future, you have the right to an Expedited Medical Appeal. You also have the right to an 62 — HORIZON HMO MEMBER HANDBOOK Expedited Medical Appeal if in the opinion of a physician with knowledge of your medical condition, your condition is as described above or that you will be subject to severe pain that cannot be adequately managed without receiving the denied medical services.

Expedited Medical Appeals are initiated by calling a Horizon HMO Appeals Coordinator at 1-888-221-6392.

Second Level Medical Appeals If you disagree with the First Level Medical Appeal decision, you have one (1) year following receipt of Horizon HMO’s original determination letter to request a Second Level Medical Appeal. If you wish to make a Second Level Medical Appeal, you may do so by

sending your appeal in writing to the following address:

Horizon HMO Appeals Department Mail Station PP-14E P.O. Box 420 Newark, NJ 07101-0420 You may also initiate a Second Level Medical Appeal by calling a Horizon HMO Appeals Coordinator at 1-888-221-6392.

To initiate a Second Level Medical Appeal, the following information must be provided:

• Name and address of the member or provider(s) involved.

• Member’s identification number.

• Date(s) of service.

• Nature and reason behind your appeal.

• Remedy sought.

• Clinical documentation to support your appeal.

If a Second Level Medical Appeal is received, it is submitted to the Horizon HMO Appeals Committee. The Appeals Committee is made up of Horizon Medical Directors and staff, physicians from the community, and consumer advocates. A smaller subcommittee reviews Expedited Second Level Medical Appeals. The Appeals Coordinator will advise you of the date of your hearing. You have the option of attending the hearing in person or via telephone conference. You may also elect to have the Appeals Committee review and decide your Second Level Medical Appeal without your appearance.

Second Level Medical Appeals will be reviewed and decided in the following time frames:

• Standard Second Level Medical Appeals are reviewed and decided within 15 calendar days of Horizon HMO’s receipt.

• Second Level Expedited (urgent and emergent circumstances, as previously described) Medical Appeals are decided as soon as possible in accordance with the medical urgency of the case, but will not exceed 72 hours from Horizon HMO’s receipt of your First Level Medical Appeal request.

NEW JERSEY DIVISION OF PENSIONS AND BENEFITS —

If you participate in the hearing, you will be notified of the Appeals Committee’s decision verbally by telephone on the day of the hearing whenever possible. Written confirmation of the decision is sent to you and/or your physician or other authorized representative who pursued the Second Level Medical Appeal on your behalf. If you choose not to appear at the hearing you will be notified of the Appeals Committee’s decisions in writing within five (5) business days of the decision. Horizon HMO’s letter will include the specific reasons for the determination. If Horizon HMO’s decision is not in your favor, you have the right to pursue an External Appeal through an Independent Review Organization (IRO).

Expedited Review of Second Level Medical Appeals If the circumstances previously described in the “Expedited Review” section apply in your case (see page 62), you have the same right to an expedited review of your Second Level Medical Appeal.

EXTERNAL APPEAL RIGHTSStandard External Appeals

If you are dissatisfied with the results of Horizon HMO’s internal appeals process, and you wish to pursue an External Appeal with an Independent Review Organization (IRO), you must submit a written request within four (4) months from your receipt of Horizon HMO’s final adverse benefit determination of your Appeal. To initiate a Standard External

Appeal, you should submit a written request to the following address:

Horizon HMO Appeals Department Mail Station PP-14E P.O. Box 420 Newark, NJ 07101-0420 Upon receipt of your written request, a preliminary review will be conducted by Horizon

HMO and completed within five (5) business days to determine:

• Your eligibility under your group health plan at the time the service was requested or provided.

• That the adverse benefit determination does not relate to your failure to meet eligibility requirements under the terms of your group health plan (e.g. worker classification or similar).

• The internal appeals process has been exhausted (if required).

• You have provided all the information and forms required to process the external review.

After the completion of this preliminary review, written notification will be issued informing you of Horizon HMO’s determination regarding the eligibility of your request for external review. If your request for an external review meets the eligibility requirements, your 64 — HORIZON HMO MEMBER HANDBOOK appeal will be assigned to an IRO by Horizon HMO. The IRO will notify you in writing of your request’s eligibility and acceptance for external review. The IRO will review all of the information and documents received and will provide its written final external review decision to the claimant and Horizon HMO within 45 days after the IRO first received the request for the external review. Upon receipt of a final external review decision reversing an adverse benefit determination, Horizon HMO will provide coverage or payment for the claim(s) or service(s) involved. If the final external review decision upholds the adverse benefit determination, no further action is taken and the Horizon HMO Medical Appeals Process is complete.

The Standard External Appeal rights described may be expedited in the following

circumstances:

The initial adverse benefit determination involving medical judgment concerns a medical condition such that the completion of a Standard Internal Appeal would seriously jeopardize the life or health of the member or would jeopardize the member’s ability to regain maximum function, and the member has filed a request for an Expedited Internal Appeal;



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