![]() If a claim is denied for what a member or provider believes is missing information or a simple mistake, there are generally two appeal options: Administrative and Medical. Understanding the specifics of your policy’s coverage and reimbursement parameters is the best way to avoid confusion, unnecessary appeals or a bill you weren’t expecting. To reach Horizon, use the online chat feature, submit your question through email or give customer service a call. If you are still not sure, contact us - or, if you get your coverage through your employer, speak with the company’s health benefits administrator. physical therapy is one of the more common forms of Horizon claim disputes).īefore jumping into the appeals process, take a minute to check with the terms of your policy on the Member Portal (). If the massage was administered by a masseuse the appeal would not be approved. The claim denial should be appealed if the massage was administered by a physical therapist. While the massage is a covered benefit, it is likely only covered when the service is administered by a licensed physical therapist, but not when administered by a massage therapist. For example, let’s say you have shoulder pain and go to a massage therapist because you know physical therapy is covered. For instance, a service may be covered under some circumstances, but not others. Out of policyīy signing into your Member Online Services account, you can learn what’s covered and what’s not, and better avoid claim denials. For some procedures, health insurers require information to establish “medical necessity” - records demonstrating that the test or procedure is appropriate and meets the standards of care established by the independent medical organizations that insurers rely on for their medical policy. It may be because your doctor’s office inadvertently excluded a page or other piece of documentation when submitting the request. You can appeal an incomplete claimĪ request for a pre-authorization for a medical procedure may get declined, but not because your benefits don’t cover it. Those denials are, generally speaking, not appealable. Below are two examples that differentiate between a claim denial due to a mistake - which can be appealed - versus one denied because your health insurance plan does not include coverage for that particular service. There are rare instances when a claim is declined due to an error, mistake or omission that could be on the part of the insurer, the doctor or the policyholder. The appeals process is there to make sure that coverage decisions are based on the facts – facts about your specific insurance policy, your claim and the current medical evidence and standards. Still, if it happens to you, it’s a big deal. But it does happen - in 2018, of the 60 million claims filed with Horizon Blue Cross Blue Shield of New Jersey (BCBSNJ), just 8,438 were appealed. But, what if your policy doesn’t cover something you expected it to and you need to file an appeal?įortunately, that’s a rare event. That’s a big reason why we buy health insurance. In life, we learn quickly to expect the unexpected. The new Omnia health insurance plans provide access to all of Horizon's network hospitals with some of them being designated as Tier 1 with greater cost savings for consumers.By Thomas Vincz, Public Relations Manager In January 2016, Horizon BCBS announced their newest endeavor to improve care quality and lower costs through their Omnia Health Alliance. The insurance provider has long been based in Newark, for many years occupying 33 Washington Street, and now owning its own building at Penn Plaza East. ![]() The company later became the nation's first Blue Cross Plan. ![]() was formed as a multi-hospital prepayment plan. Horizon BCBSNJ traces its history back to 1932 when Associated Hospitals of Essex County, Inc. Horizon Blue Cross Blue Shield of New Jersey is best known for their managed care and traditional indemnity plans for individuals and employers. It is a not-for-profit health service corporation with a 17-member Board of Directors which governs the company for its members. Horizon Blue Cross Blue Shield of New Jersey, headquartered in Newark, New Jersey is the only licensed Blue Cross and Blue Shield Association plan in New Jersey, providing health insurance coverage to over 3.2 million people throughout all of New Jersey. Horizon Blue Cross Blue Shield of New Jersey Office in Newark, New Jersey 3 Penn Plaza East ![]()
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