Three Penn Plaza East Newark, NJ 07105-2200 HorizonBlue.com October 2014 <Group Name <Address> <City> <State> <Zip Code> Re: Non-participation with Horizon Advance EPO Products Dear <Group Practice>: Horizon Blue Cross Blue Shield of New Jersey has completed our annual re-evaluation of the physicians, other health care professionals, facilities and ancillary providers participating with our Horizon Advance EPO products. As a result of our re-evaluation, your practice, <Practice Name>, <(TIN #)>, has not been selected to participate in Horizon Advance EPO products as of January 1, 2015. All physicians and other health care professionals who are affiliated with, and practice under or on behalf of, the above-noted TIN are excluded from participating with Horizon Advance EPO products on and after January 1, 2015. Horizon Advance EPO products are offered to the most price-sensitive health insurance consumers purchasing coverage. To meet the needs of this population, Horizon Advance EPO products have limited access to physicians than other less price-sensitive Horizon BCBSNJ products. Our Physician Agreements allow us to select physicians and other health care professionals for participation in certain products without requiring the inclusion of all existing in-network practitioners. As previously communicated, our criteria for participation with Horizon Advance EPO products include risk-adjusted cost efficiency at the group practice level using Episode Treatment Group (ETG) data, admitting privileges/referral patterns to Preferred Tier 1 hospitals, geographic access and coverage standards. As Preferred Tier 1 hospital designations change, we must implement changes to account for physician and/or other health care professional Preferred Tier 1 admitting privileges and referral patterns. Enclosed for your review is a current list of the Horizon Hospital Network that includes Preferred Tier 1 designations effective January 1, 2015. This change: Pertains only to physicians and other health care professionals participation with Horizon Advance EPO products. It does not change or impact the participation of these physicians and other health care professionals with any other Horizon BCBSNJ products. Does not impact the participation status with Horizon Advance EPO products of the physicians or other health care professionals who also are affiliated with another group practice. Such practitioners will need to communicate with each affiliated group to understand that group s participation status with the Horizon Advance EPO products. Physicians and other health care professionals are encouraged to access our online Provider Directory at HorizonBlue.com/directory on and after January 1, 2015 to review their Horizon Advance EPO participation status. (Over, please) 2430 (W1112) CMC0006660 (0914) An Independent Licensee of the Blue Cross and Blue Shield Association.
You can view a listing of physicians and/or other health care professionals affiliated with your group online by accessing our Provider Data Maintenance tool. Registered NaviNet users may log on to NaviNet.net and: Select Horizon BCBSNJ Plan Central. Select Provider Data Maintenance and then Group Maintenance. From the options listed, select Remove a practitioner from a practice location. We are directing you to this page to view the listing of providers associated with your group. You do not need to take any action unless there are inaccuracies with the information presented on this page. If you need to change your practice demographics or add or remove a practitioner, you may update the information directly within the Group Maintenance section. Please reference the enclosed Frequently Asked Questions for more information about Horizon Advance EPO products. To minimize disruption of our Horizon Advance EPO members care, members currently receiving treatment from one of your physicians may be eligible to continue care for up to four months after the date indicated above, if medically necessary, at an in-network level of benefits. A longer period of continuation of care may be required in the case of: Pregnancy to postpartum evaluation, up to six weeks after delivery. Post-operative follow-up care, for a period of up to six months. Oncological treatment, for a period of up to one year. Psychiatric treatment, for a period of up to one year. We will mail letters to impacted members in advance of January 1, 2015 to advise them of our actions and to provide them with a copy of our Request for Continuity of Practitioner Care for Horizon Advance EPO Medical Benefits form to be completed and returned to us so that eligibility for continuation of care may be determined. If you have questions or would like to request a listing of physician(s) affiliated with your practice, please call Physician Services at 1-800-624-1110. If your questions are related to your participation status, please select the prompt for More Options and then Network Relations. Thank you for your continued participation in Horizon BCBSNJ networks and for the quality care you provide your patients, our members. Sincerely, James Dell Arena Director Network Services and Strategy Enclosures: Frequently Asked Questions Listing of Preferred Tier 1 hospitals
Horizon Blue Cross Blue Shield of New Jersey Horizon Advance EPO Products Physician or Other Health Care Professionals Frequently Asked Questions Q1. When will changes to Horizon Advance EPO participation take effect? A1. Changes being made to Horizon Advance EPO participation as a result of our annual re-evaluation will be effective January 1, 2015. Physicians and other health care professionals are encouraged to access our online Provider Directory to review their Horizon Advance EPO products participation status for each location. Q2. How are physicians and other health care professionals practices selected for inclusion with Horizon Advance EPO products? A2. Group practices are selected from our existing Horizon Managed Care Network for participation with Horizon Advance EPO products based on one or more of the following criteria: Risk-adjusted cost efficiency at the group practice level using Episode Treatment Group (ETG) data. To qualify for the ETG analysis, providers were required to have a minimum of 50 episodes of care from June 2012 through July 2013. Admission privileges/referral patterns to Preferred Tier 1 hospitals, where applicable. Geographic access and coverage standards. Q3. Is participation with Horizon Advance EPO products at the group level or the practitioner level? A3. To help minimize member confusion, participation with Horizon Advance EPO products will be at the group level so that all physicians and other health care professionals practicing within the group are included or excluded. All physicians and other health care professionals affiliated with a participating Tax Identification Number (TIN) will be considered in network when practicing with/on behalf of that participating group practice as it pertains to services rendered to Horizon Advance EPO members. If a physician or other health care professional also happens to be affiliated with a group practice that is not participating with this product, that physician will be considered out of network for the Horizon Advance EPO products when practicing with/on behalf of that nonparticipating group practice as it pertains to services rendered to Horizon Advance EPO members. (Over, please) CMC0006660 (0914) CMC0006661 (0914) An Independent Licensee of the Blue Cross and Blue Shield Association.
Q4. Which specialties are evaluated for efficiency? A4. The following specialties are evaluated for efficiency on an annual basis: Allergy & Immunology Cardiology Cardiovascular Surgery Cardiothoracic Surgery Chiropractic Medicine Dermatology Endocrinology Gastroenterology General Surgery Hematology Hematology/Oncology Neurological Surgery Neurology Ophthalmology Orthopedic Surgery Otolaryngology Plastic Surgery Podiatry Pulmonology Reproductive Endocrinology Rheumatology Urology Vascular Surgery All other specialties that were not evaluated for efficiency will be considered included in Horizon Advance EPO. Some exceptions may apply for multi-specialty groups. Q5. Where can I find additional information regarding Horizon Advance EPO products and a listing of participating network physicians and other health care professionals? A5. Our administrative policy, Physician and Health Care Professional Participation Status in Products that Utilize a Subset of an Existing Horizon Network and product information is accessible through NaviNet.net under Provider Reference Materials. On January 1, 2015, our online Provider Directory will reflect the in-network participation status of all affiliated physicians and other health care professionals. Q6. Which hospitals are included in Horizon Advance EPO products? A6. All hospitals in our current Horizon Hospital Network participate with Horizon Advance EPO products, but at different tiered status. Please view the enclosed hospital listing. Q7. Can other group practices apply for participation with Horizon Advance EPO products? A7. Horizon BCBSNJ will evaluate participation with Horizon Advance EPO products annually and will make periodic changes to include or exclude existing and new providers based upon changes within the above criteria. Other group practices cannot apply for participation in Horizon Advance EPO.
HORIZON HOSPITAL NETWORK (NJ 62 Hospitals/77 Locations) (PA 12 Hospitals/13 Locations) (NY 2 Hospitals/2 Locations) (DE 1 Hospital/1 Location) Effective 1/1/2015 ATLANTIC COUNTY Atlanticare Regional Medical (Atlantic City, Pomona, *Hammonton ) Shore Medical BERGEN COUNTY Englewood Hospital and Med. Ctr. Hackensack University Medical Ctr. HackensackUMC at Pascack Valley Holy Name Medical The Valley Hospital BURLINGTON COUNTY Deborah Heart & Lung Lourdes Medical of Burlington Virtua - Memorial Hospital of Burlington County Virtua - West Jersey Health System (Marlton) CAMDEN COUNTY Cooper University Hospital Kennedy Memorial Hospitals - University Medical - Cherry Hill location - Stratford location Our Lady of Lourdes Medical Ctr. Virtua - West Jersey Health System (Berlin, *Camden, Voorhees) CAPE MAY COUNTY Cape Regional Medical CUMBERLAND COUNTY Inspira Medical Vineland *Inspira Medical Bridgeton ESSEX COUNTY St. Michael s Medical Clara Maass Medical East Orange General Hospital HackensackUMC Mountainside Newark Beth Israel Medical Saint Barnabas Medical University Hospital GLOUCESTER COUNTY Kennedy Memorial Hospitals - University Medical - Washington Twn. location Inspira Medical Woodbury HUDSON COUNTY Bayonne Medical Christ Hospital Jersey City Medical Meadowlands Hospital Medical Hoboken University Medical HUNTERDON COUNTY Hunterdon Medical MERCER COUNTY Capital Health System - Fuld Capital Health Medical - Hopewell Hospital Hamilton Saint Francis Medical MIDDLESEX COUNTY JFK Medical Raritan Bay Medical - Old Bridge location - Perth Amboy location Hospital Saint Peter s University Hospital University Medical of Princeton at Plainsboro MONMOUTH COUNTY Bayshore Community Hospital CentraState Medical Jersey Shore University Medical Monmouth Medical Riverview Medical MORRIS COUNTY Chilton Hospital Morristown Medical Saint Clare s Hospital - Denville location - Dover location OCEAN COUNTY Community Medical Monmouth Medical, Southern Campus Ocean Medical (Brick, *Point Pleasant ) Southern Ocean County Hospital PASSAIC COUNTY St. Joseph s Hospital & Medical St. Joseph s Wayne Hospital St. Mary s Hospital SALEM COUNTY The Memorial Hospital of Salem County, Inc. Inspira Medical Elmer SOMERSET COUNTY Hospital Somerset SUSSEX COUNTY *Saint Clare's Hospital/Sussex Newton Medical UNION COUNTY *JFK Medical - Muhlenberg Campus Overlook Medical (Summit, *Union) Hospital Rahway Trinitas Regional Medical WARREN COUNTY Hackettstown Regional Medical Saint Luke s Warren Hospital PHILADELPHIA COUNTY, PA Children s Hospital of Philadelphia Fox Chase Cancer Hahnemann University Hospital Hospital of the University of Penn. Jeanes Hospital Pennsylvania Hospital St. Christopher s Hospital for Children Temple University Hospital Thomas Jefferson University Hospital (Main Campus and Methodist Campus) University of Pennsylvania Medical - Presbyterian DELAWARE COUNTY, PA Crozer Chester Medical (Springfield Hospital, Taylor Hospital Campuses) Delaware County Memorial Hospital NEW YORK (ORANGE COUNTY) Bon Secours Community Hospital St. Anthony Community Hospital DELAWARE A.I. dupont Hospital for Children Preferred Tier 1 Hospital Hospital-Based Physicians * No inpatient services/limited outpatient services available. Note: All other in-network hospitals without are considered Tier 2 hospitals for the Horizon Advance EPO plan. The list of Preferred Tier 1 hospitals is subject to change. As hospitals convert to Preferred Tier 1, the physicians affiliated with that hospital shall undergo an evaluation for participation in Horizon Advance EPO. Not all Hospital Based Physicians are participating. Hospital Based Physicians are identified as Anesthesiologists, Radiologists, Pathologists and ER Physicians providing services within the hospital. Horizon Blue Cross Blue Shield of New Jersey is an independent licensee of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. The Horizon name and symbols are registered marks of Horizon Blue Cross Blue Shield of New Jersey. 2014 Horizon Blue Cross Blue Shield of New Jersey. Three Penn Plaza East, Newark, New Jersey 07105.