Horizon Blue - also known as Horizon Blue Cross Blue Shield of New Jersey - provides health insurance to over 3.2 million people residing in the state. They are the only BCBS franchisee in the state of New Jersey.
Today, we’ll look at how addiction treatment discharge planning and utilization management works at Horizon Blue, learn what types of addiction treatment require prior authorization, when Horizon Blue requires that discharge planning starts (hint: it’s before treatment ever begins) and how discharge decisions and medical necessity determinations are made at Horizon Blue for behavioral health patients.
Addiction Treatment Discharge Planning at Horizon Blue is an Integral Part of the Payer’s Utilization Management Program
Discharge planning falls under the rubric of utilization review undertaken by Horizon Blue.
Other utilization management activities include:
Verifying medical necessity of procedures/treatments
Preauthorizations
Concurrent reviews
Retrospective reviews
Case management
Coordination of care between clinicians
Horizon Blue directs all providers to submit all authorization requests and other utilization management documents, including discharge planning documentation, on their Utilization Management Review Tool hosted by NaviNet.
Here’s the Addiction Treatment Services at Horizon Blue That Require Prior Authorization
In network providers as well as out of network providers must obtain prior authorization before engaging patients in:
Intensive outpatient treatment for addiction
Medically managed detox
Medically monitored detox
Inpatient treatment for addiction
Residential treatment for addiction
Partial hospitalization for addiction
You can see an even more exhaustive list of treatments requiring prior authorization at Horizon Blue here.
It’s important to note that all out of network providers are required to obtain prior authorization before providing any level of behavioral healthcare, including all outpatient addiction treatment. In-network providers at Horizon Blue do NOT have to obtain prior authorization before providing outpatient treatment for behavioral health.
Addiction Treatment Authorization Requests at Horizon Blue Must Demonstrate Discharge Planning From the Start
All authorization requests (aka pre-authorization or prior authorization requests) at Horizon Blue must include information on discharge planning before the patient ever begins treatment. A complete pre-authorization request at Horizon Blue includes:
Reason for admission
Diagnosis information
Medication plan
Treatment plan
Discharge plan
Horizon Blue Uses MCG Health, LLC’s Criteria to Make Medical Necessity and Discharge Decisions Around Addiction Treatment
Although Horizon Blue used to use Beacon’s medical necessity rules when making utilization management decisions for addiction treatment patients, they stopped using that criteria in 2020. Now, Horizon Blue uses MCG Health, LLC (MCG)’s rules to make behavioral health care decisions around medical necessity. These rules affect how long Horizon Blue allows addiction treatment episodes of care to continue, how often they are allowed to continue and also when discharge happens (or doesn’t happen).
It can be helpful to understand these rules and read up on MCG Health’s decision making criteria to understand why Horizon Blue makes the utilization management decisions that it does for addiction treatment patients. Understanding these rules means you can make more effective appeals and provide more compelling arguments against decisions that are contraindicated in terms of medical necessity and Horizon Blue’s own internal clinical guidelines.
Horizon Blue Has Several In-House Resources Available to Providers With Questions About Addiction Treatment Discharges and Other Behavioral Healthcare Rules
Horizon Blue’s Behavioral Health online hub of information for addiction treatment providers is a helpful resource for all of your questions about addiction treatment utilization management rules at Horizon Blue.
You can also consult Horizon Blue’s Behavioral Health Hospital Manual for a quick summary of how claims submissions work at this payer.
Finally, you can call Horizon Blue’s Behavioral Health Care Management team directly and pose questions to the source. The main number for their team is 1-800-626-2212.
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