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. 

Stumped By Addiction Treatment Discharge Planning and Rules at Horizon Blue Cross Blue Shield of New Jersey? We Can Help.

BehaveHealth’s Revenue Cycle Management (RCM) service includes soup-to-nuts, hyper-detailed, hands-on attention to every single component of your addiction treatment billing needs. We have strong working relationships with every major insurance company in the United States. 

Even better, we’re not health care generalists.  We only work for behavioral health providers like you.

Let our team of specialists handle it all: 

• Verification of Benefits 

• Utilization Review 

• Billing and Collections 

• Patient Responsibility

• Denials and Appeals 

Get your free trial started today and see why more addiction treatment centers prefer Behave Health.