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Horizon Medicare Blue TotalCare(HMO SNP) - Participating Physician Responsibilities

Participating network

Member enrolled in Horizon Medicare Blue TotalCare(HMO SNP) must use physicians and other health care professionals, facilities and pharmacies that participate in the Horizon Managed Care Network.

There are no benefits available (excluding certain emergency care and family planning services) for services provided outside the Horizon Managed Care Network or for covered services that are not provided or reffered by a PCP.

Referrals

Horizon Medicare Blue TotalCare (HMO SNP) members select a Primary Care Physician (PCP) who will either provide the necessary care or refer them to the appropriate specialist or facility.

Prior Authorization

Certain services require prior authorization (PA). A list of services that require PA (including medical day care and personal care assistant services) is available online.

Prescription Drug Prior Authorization

Certain prescription drugs require prior authorization. This process requires the prescribing physician to provide the following information to help determine medical necessity:

  • The member's diagnosis.
  • The duration of proposed treatment.
  • The member's treatment plan.
  • A description of failed treatment, if any exists.

Upon receipt of this information we will consider your request and provide you with our answer. Physicians are encouraged to prescribe appropriate first line agents before using alternative drugs.

Consent Forms

Claims submitted for Hysterectomy, tubal ligation or vasectomy provided to MA SNP members must be accompanied by a completed and signed consent form. Consent forms must be signed no more than 30 days prior to a procedure and submitted along with the claim. Claims for any of the above-listed services not accompanied by a signed and completed consent form will be denied.

Consent forms are available online.

Balance Billing

Horizon Medicare Blue TotalCare (HMO SNP) is a zero cost plan for enrolled members. Members enrolled in Horizon Medicare Blue TotalCare (HMO SNP) have no copayments or cost sharing responsibilities for in-network services (and some out-of-network services) they receive. Physicians and other health care professionals are prohibited from balance billing these members for any amounts.

  • Participating physicians and other health care professionals, based on the terms or their participating agreement with Horizon Healthcare of New Jersey, Inc., are prohibited from balance billing any members enrolled in a Horizon Medicare Blue TotalCare (HMO SNP) plan.
  • Out-of-network physician and other health care professionals are also prohibited from balance billing members for eligible services based on Federal statute.

 

 

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