Chiropractic & Physical Medicine Services Program Frequently Asked ...

Chiropractic & Physical Medicine Services Program Frequently Asked Questions August 1, 2019

Beginning January 1, 2020, Horizon Blue Cross Blue Shield of New Jersey will collaborate with American Specialty Health (ASH) to implement and administer our Chiropractic & Physical Medicine Services Program which will include the following services:

? Acupuncture ? Chiropractic ? Occupational Therapy (OT) ? Physical Therapy (PT) ? Speech Therapy (ST)

Horizon BCBSNJ's Chiropractic & Physical Medicine Services Program, managed in coordination with ASH, integrates evidence-based utilization management guidelines with clinical best practices, specialized peer-to-peer engagement, claims review and management, and advanced reporting and analytics to promote the overall health management of impacted members.

Horizon BCBSNJ will delegate our provider network for the above services to ASH. ASH will assume the responsibility for practitioner recruitment, contracting and management, credentialing and re-credentialing, utilization management, claims processing, administration of annual limits, benefits and services, provider monitoring, online portal processes, reporting, and virtual physical therapy.

Additionally, ASH will perform pre and post service medical necessity determination (MND) reviews for the services noted above when rendered in an office setting by participating and nonparticipating practitioners. MND reviews will not be performed for services rendered in an inpatient, outpatient or home setting.

Below are answers to questions you may have about this program.

General Q1. For what services will ASH perform pre and post service MND review as part of the

Chiropractic & Physical Medicine Services Program? A1. ASH will perform MND review for the following services:

? Acupuncture ? Chiropractic ? Occupational Therapy (OT) ? Physical Therapy (PT) ? Speech Therapy (ST)

Q2. Where can Horizon BCBSNJ members receive services included in the Chiropractic & Physical Medicine Services Program?

A2. The Chiropractic & Physical Medicine Services Program ONLY applies to services rendered in an office setting.

Services rendered inpatient, outpatient or in the home are excluded from the program. Practitioners should continue to follow the existing process for MND with Horizon BCBSNJ for their patients based on the member's benefits and any Horizon BCBSNJ medical criteria guidelines.

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Q3. What Horizon BCBSNJ plans/products ARE included in this program? A3. Members enrolled in the following plans/products ARE included:

? Advantage EPO ? Direct Access ? EPO ? Federal Employee Program? (FEP?) ? HMO ? Indemnity ? Medicare Advantage ? OMNIASM Health Plans ? PPO ? POS ? State Health Benefits Program (SHBP)/ School Employees' Health Benefits

Program (SEHBP) ? Self-Insured Administrative Services Only (ASO) employer groups

BlueCard? and Medicare Advantage PPO members enrolled through other Blue Cross and/or Blue Shield plans who reside or travel in Horizon BCBSNJ's local service area will access their in-network level of benefits when they receive services in the scope of this program from an ASH network practitioner on and after January 1, 2020.

Q4. What Horizon BCBSNJ plans/products are NOT included in this program? A4. Members enrolled in the following plans/products are NOT included:

? Horizon NJ Health plans ? Horizon NJ TotalCare (HMO SNP) ? Medicare Supplemental

Providers who service members excluded from the program should continue to follow the existing process for MND with Horizon BCBSNJ for their patients based on the member's benefits and any Horizon BCBSNJ medical criteria guidelines.

Q5. Does this program apply to members enrolled in plans that include BlueCard benefits for services received from practitioners participating with another Blue Cross and/or Blue Shield plan?

A5. BlueCard members enrolled through other Blue Cross and Blue Shield Association plans who reside or travel in Horizon BCBSNJ's local service area (i.e., all NJ counties, the contiguous counties in DE, NY and PA, as well as Lehigh County, PA)1 will access their in-network level of benefits when they receive services in the scope of this program from an ASH network practitioner on and after January 1, 2020.

Q6. How can I check the benefits of my Horizon BCBSNJ patients? A6. You may review member benefit information on NaviNet?. Simply log in to

and select Horizon BCBSNJ from the My Health Plans menu. Mouse over Eligibility & Benefits and select Eligibility & Benefits Inquiry. If you do not have access to NaviNet, you may obtain member benefit information by calling Physician Services at 1-800-624-1110, Monday through Friday, from 8 a.m. to 5 p.m., Eastern Time (ET).

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1 Services provided in Contiguous Counties does not apply to FEP members. Only services that are performed in New Jersey would apply for FEP members.

Network Management

Q1. What is ASH's role in the Chiropractic & Physical Medicine Services Program? A1. Horizon BCBSNJ will delegate our participating provider network of chiropractors,

acupuncturists, physical therapists, occupational therapists and speech therapists to ASH to assist in our ongoing efforts to provide quality services to our members. As a result of this new arrangement, ASH will assume responsibility for:

? Network management (including recruitment, credentialing, recredentialing, contract administration and online portal processes)

? Clinical performance (medical necessity determination (MND) reviews) ? Claim processing ? Eligibility and benefit services

Q2. What happens to my Horizon BCBSNJ Provider Agreement after being "delegated" to ASH?

A2. The Horizon BCBSNJ Provider Agreement(s) of practitioners who participate with ASH will be "de-activated" and considered part of the ASH network effective January 1, 2020.

In the event that we end our relationship with ASH in the future, your Horizon BCBSNJ Provider Agreement(s) would be reactivated, and utilization management, billing submission and claims payment would revert to Horizon BCBSNJ. If this were to occur, you would be provided with sufficient prior notice.

Q3. How will practitioners transition from the Horizon BCBSNJ network(s) to the ASH network?

A3. On or about August 1, 2019, impacted practitioners will receive detailed information about this program and all applicable documents for credentialing and contracting with ASH.

Practitioners must complete the Horizon BCBSNJ Subordination Agreement Amendment and ASH recruitment package by November 1, 2019.

If you do not sign the Horizon BCBSNJ Subordination Agreement Amendment and contract with ASH by November 1, 2019, your Horizon BCBSNJ Provider Agreement(s) will terminate effective in accordance to your agreement and applicable state law.

Q4. What is the effective date of the ASH network for participating providers? A4. Credentialed practitioners will begin on the effective date of January 1, 2020.

Providers should continue to follow the existing process for MND with Horizon BCBSNJ for their patients based on the member's benefits and any Horizon BCBSNJ medical criteria guidelines through December 31, 2019. Providers can contact Horizon BCBSNJ Utilization Management Department at 1-800-664-2583 or visit .

After January 1, 2020, all ASH contracted and credentialed providers will follow ASH's clinical performance program and medical necessity review guidelines that will be subject to Horizon BCBSNJ Health Plan Client Summary and Fee Schedules.

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Q5. How will the contracting/credentialing process work for multi-specialty groups that have chiropractic, acupuncture, or PT/OT/ST practitioners?

A5. The contracting/credentialing process differs for those chiropractors, acupuncturists and physical/occupational/speech therapists who are part of a multi-specialty group practice. Horizon BCBSNJ & ASH have identified these multi-specialty group practices. The ASH contracting team will work directly with the impacted group practice to contract and credential their affiliated chiropractors, acupuncturists and physical/occupational/speech therapists.

Chiropractors, acupuncturists and physical/occupational/speech therapists will need to be contracted with ASH by the January 1, 2020 effective date to be eligible for in-network services and receive reimbursement.

There will be no change to the Provider Agreements or credentialing/recredentialing process of practitioners with specialties outside the scope of this program who are affiliated with these identified multi-specialty group practices.

Q6. What is ASH's contracting/credentialing application process? A6. The ASH contracting team will work with all impacted Horizon BCBSNJ network

practitioners prior to the Chiropractic & Physical Medicine Services Program effective date.

Practitioners who do not already participate with ASH should complete and submit the required materials to ASH by November 1, 2019 to be considered participating in the Chiropractic & Physical Medicine Services Program.

ASH's NCQA and URAC accredited credentialing process includes a peer review committee by specialty. Recredentialing is typically conducted every three years through the ASH credentialing process.

Q7. What is ASH's credentialing/recredentialing turnaround times? A7. ASH's credentialing process averages between 45 and 60 days to complete (once all

required documentation is received). ASH will make the credentialing of participating Horizon BCBSNJ practitioners a priority to ensure that all practitioners are credentialed before the Chiropractic & Physical Medicine Services Program effective date.

Practitioners who have a current CAQH ProViewTM profile can expect a shorter credentialing turnaround time of between 30 to 45 days.

If you don't already have a CAQH ProView profile, we strongly encourage you to visit to self-register to obtain your unique CAQH ID number.

Q8. Does the ASH network provide sufficient access to eligible Horizon BCBSNJ members under this program?

A8. Yes. ASH meets or exceeds adequacy standards for access in the geographic areas servicing Horizon BCBSNJ members. Provider adequacy is monitored on a quarterly basis.

Q9. How are the ASH Fee Schedules developed and implemented? A9. ASH's Fee Schedule is developed and implemented in accordance with Horizon BCBSNJ

and ASH clinical policies. ASH uses a combination of several factors including but not limited to competitive information on rates, public information, resource-based relative value scale (RBRVS), and Medicare fee information.

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ASH's methodology also incorporates the prevalence and acceptance of existing fee schedules that providers have agreed to, historical utilization data from claims administration practices, and current competitive characteristics and market factors. Client Summaries and fee schedules are evaluated on a regular basis and adjustments are made based on business need, regulatory updates and/or market conditions.

It is each individual provider's business decision to accept or reject the contracted fee schedule. Fee schedule information should not be discussed or shared among independent provider contractors or with their state association.

Reimbursement for covered services is subject to the insured's covered benefits, medical necessity verification and the Fee Schedule amount for billed CPT? codes listed on the

Client Summaries.

Q10. A10.

Can I review the ASH contract and fee schedule information prior to applying for participation? Yes. The recruitment process includes a presentation (via phone or in person meeting) of the provider contract and fee schedule. The credentialing materials will be sent to all practitioners who currently participate with Horizon BCBSNJ but do not participate in ASH's network. The materials will include the provider services agreement including the client summary and fee schedule.

If you do not participate with ASH, you will be contacted by ASH representatives during the contracting period in advance of the program effective date. You can also call ASH directly at 1-888-511-2743, option 1, Monday to Friday, 8 a.m. to 9 p.m., ET.

Q11. A11.

I am currently participating in ASH's network. How can I find out more information about the Horizon BCBSNJ program with ASH? All ASH participating practitioners will receive notice of the new Horizon BCBSNJ program. Participating ASH practitioners can access ASHLink, the ASH provider online portal, for their new Horizon BCBSNJ Client Summary and Fee Schedule effective January 1, 2020 for the in-scope members.

Q12. A12.

Does ASH offer self-service tools to manage account transactions? Yes. ASH provides participating practitioners with access to online capabilities via ASHLink. ASHLink is ASH's secure provider website. Once contracted, you can complete transactions and access important resources including the Practitioner Operations Manual and clinical practice guidelines.

Participating ASH practitioners use ASHLink for important communications, resources, clinical practice guidelines and to conduct transactions such as eligibility verification, submission of medical information (when needed) and claims processing. Participating ASH practitioners can also call ASH Customer Service Agents for assistance at 1-800-972-4226, option 2, Monday to Friday, 8 a.m. to 9 p.m., ET.

Q13. A13.

Will ASH's network management of the in-scope specialties impact my Horizon BCBSNJ OMNIA tier, Inner Circle, or Medicare Blue Advantage status? If a provider becomes a participating provider with ASH, their OMNIA tier, Inner Circle and/or Medicare Blue Advantage status will remain as is.

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