We track 50 documented policy changes from Horizon BCBS NJ across DE, NJ, NY, PA. Each entry includes an AI-generated plain-English summary, effective date, affected billing codes, and a direct link to the original Horizon BCBS NJ notice. Use the related links below to narrow results by specialty or state, or create a free alert to get new Horizon BCBS NJ updates by email (daily or weekly, your choice, on every plan).
Horizon Blue is transitioning pharmacy prior authorization submissions to electronic Prior Authorization (ePA) through vendors like CoverMyMeds or SureScripts. Beginning January 1, 2027, New Jersey State Mandate will require ePA for all pharmacy prescription drug prior authorization requests (formulary exceptions, tier exceptions, quantity limit reviews).
Horizon Blue Cross Blue Shield of New Jersey is encouraging providers to submit medication prior authorizations electronically using ePA tools (CoverMyMeds or SureScripts) through Prime Therapeutics, with no cost to practices. This aligns with a New Jersey state mandate requiring electronic PA submission beginning January 1, 2027.
Effective June 27, 2026, Horizon Blue Cross Blue Shield will implement a new Prior Authorization requirement for 12 categories of outpatient elective surgical procedures for New Jersey State Health Benefits Program (SHBP) members only. PA reviews will assess medical necessity and/or Site of Service appropriateness for Hospital Outpatient Department (HOPD) procedures, though Ambulatory Surgery Center (ASC) procedures are exempt from SOS review.
Effective June 1, 2026, Horizon Blue Cross Blue Shield will no longer accept claim disputes submitted by phone for Horizon NJ Health (Medicaid) and Federal Employee Program (FEP) members. All claim disputes must be submitted through the Provider Portal (Availity Essentials). Claim appeals remain unchanged and must continue to be submitted in writing.
Effective January 1, 2026, Horizon Blue implemented a new prior authorization policy for GLP-1 medications used for non-diabetic indications (weight loss) on fully insured Public Sector plans and certain ASO plans. Prior authorization requests now require documentation of baseline BMI ≥35, at least one qualifying comorbidity, and ongoing lifestyle interventions. Initial approvals for obesity treatment are valid for up to 3 months; all other indications up to 6 months, with renewals available for up to 6 months if criteria are met.
CMS will resume Risk Adjustment Data Validation (RADV) audits in 2026, beginning with payment year 2020 claims dating back to 2017. These audits verify that submitted diagnoses are supported by complete, signed medical record documentation. Providers must ensure timely submission of requested medical records to avoid diagnosis disallowance, financial penalties, and potential program exclusion from Medicare Advantage, ACA, or Medicaid.
This is a new Medicare Part D Star Ratings measure (SUPD) effective for 2026 that evaluates whether patients ages 40-75 with diabetes on antidiabetic medications are also receiving statin therapy. Billing teams must ensure proper documentation and ICD-10 coding of exclusionary diagnoses to accurately track eligible patients and avoid measure performance penalties. Claims must include appropriate exclusion codes when patients have contraindications to statin therapy.
Effective August 1, 2025, Braven Health is expanding its Site of Service policy for select outpatient elective surgical procedures to include additional non-urgent elective procedures. The insurer will now review non-emergent elective services performed in Hospital Outpatient Department (HOPD) settings and may require procedures to be performed in lower-cost settings (e.g., ambulatory surgery centers) if members lack specific medical indications, conditions, or comorbidities outlined in the medical policy.
HearUSA is designated as the exclusive in-network provider for all audiology and hearing aid services (routine hearing exams, fittings/evaluations, and hearing aids) under Braven Health Medicare Advantage plans. HearUSA will administer benefits and process claims on behalf of the plan. Billing teams must route all audiology/hearing aid claims through HearUSA and direct patients to HearUSA network locations.
Horizon and Horizon NJ Health now require recredentialing every three years for most hospital-based physicians and healthcare professionals (excluding Radiologists, Anesthesiologists, Pathologists, and Emergency Room Physicians). Failure to complete recredentialing by the required deadline will result in loss or restriction of network participation and termination of provider agreements.
Horizon Blue has issued a reminder about medical record retention requirements and compliance obligations. Healthcare providers must maintain medical records according to specific timelines: 10 years for Medicare Advantage members, 7 years for non-MA members, and 20 years for hospital discharge summaries. Failure to comply with medical records requests from Horizon or its vendor Inovalon can result in network termination.
This policy clarifies coding and documentation requirements for Horizon Blue, emphasizing that only conditions that are Monitored, Evaluated, Assessed, and/or Treated (MEAT) during a visit should be coded and reported. Providers must document diagnoses in the Assessment/Plan section of records, not just in problem lists or history/physical exams, and must follow specific SOAP format requirements. Documentation must support face-to-face or telehealth encounters and include provider credentials with signatures dated within 30 days of service.
Horizon Blue Cross Blue Shield of New Jersey is mandating that all laboratory services be directed to in-network preferred labs (LabCorp, Quest Diagnostics, BioReference Laboratories) across their commercial, Medicaid, and Medicare Advantage plans. Specific labs including Natera, Sema4/GeneDx, Invitae, Myriad Genetics, Sherman Abrams Laboratory, and Clarity Labs are now out-of-network and should not be used. Billing teams must update lab referral protocols and specimen routing to avoid claim denials.
Horizon Blue has published 2022 Access Standard Survey results showing that participating practices must comply with appointment availability and response time guidelines for PCPs, Ob/Gyns, Specialists, and Behavioral Health providers. The policy emphasizes that all staff must follow these standards when offering first-available appointments, responding to after-hours calls, and monitoring office wait times. Survey data reveals significant gaps in compliance, particularly for urgent care, emergent care, and after-hours response times across all provider types.
ACCU Reference Laboratory is now out-of-network for all Horizon and Braven Health members across all lines of business. Billing teams must redirect all laboratory services to preferred networks (LabCorp, Quest Diagnostics, or BioReference Laboratories) to avoid claim denials. Exception: Pathology services in hospital settings for Horizon managed care members remain allowed.
Horizon Blue has partnered with eviCore to administer the Radiology and Imaging Services program. All in-network freestanding radiology/imaging centers must notify eviCore of operational changes (ownership, TINs, locations, closures, equipment, licenses, accreditations) and respond timely to site assessment appointment requests to maintain compliance and avoid prior authorization denials.
Horizon Blue has implemented a preferred laboratory network requirement for managed care plans without out-of-network benefits. Effective immediately, all testing samples from patients in these plans must be sent to LabCorp or Quest Diagnostics only. Patients in plans with out-of-network benefits may use alternative labs only if they elect out-of-network coverage and complete required consent forms. Non-compliance may result in network termination.
This is a new guidance document from Horizon Blue Cross Blue Shield of New Jersey explaining how to navigate pharmacy benefits, check medication formulary status, identify prior authorization and quantity limit requirements, and submit coverage determination requests through Prime Therapeutics. The policy provides step-by-step instructions for Commercial, Medicare Part D, Braven Health, and Horizon NJ TotalCare (HMO D-SNP) members.
Horizon BCBSNJ is requiring providers to refer patients enrolled in managed care plans without out-of-network benefits to preferred labs (Horizon's network labs only, excluding LabCorp or Quest Diagnostics). Providers must direct testing samples to in-network facilities or face potential network termination. This applies to specific managed care plans; providers must verify plan type before ordering labs.
This is a risk management guidance document emphasizing that accurate, specific documentation in the assessment/plan section is required for all diagnoses to be coded and reported on claims. The policy clarifies that conditions must be actively monitored, evaluated, assessed, and treated during the encounter (MEAT framework) to be billable—simply listing them in problem lists or history/physical is insufficient. Up to 12 diagnoses per claim can be reported when properly documented.
This is a fraud alert regarding telemarketing schemes involving DME products (urinary catheters, glucose monitoring supplies, COVID-19 tests, orthotic braces, wound care supplies). Telemarketers cold-call beneficiaries, submit questionnaires to providers for signature, and bill for unnecessary or non-dispensed DME. Providers must implement safeguards to protect NPI numbers, monitor claims, secure prescription pads, and avoid employment arrangements involving phone-based patient referrals for DME.
Horizon Blue has clarified that adding modifiers 1P, 2P, 3P, or 8P to CPT Category II quality reporting codes disqualifies practices from receiving credit for quality measures. To receive credit for reviewed-but-not-performed services, report CPT Category II codes WITHOUT these modifiers. This applies to HEDIS reporting and NCQA guidelines.
Horizon Blue has issued a fraud alert warning providers about DME telemarketing schemes involving unnecessary equipment (urinary catheters, glucose monitors, COVID tests, orthotic braces, wound care supplies). Telemarketers illegally solicit referrals without established patient relationships, misuse provider NPIs, and violate state licensure requirements. Providers must implement protective measures including NPI safeguarding, claims monitoring, and employment opportunity vetting to avoid compliance violations and fraud liability.
eviCore now requires that all Prior Authorization (PA) and Medical Necessity Determination (MND) requests include specific key medical information. The policy directs providers to consult eviCore's Medical Information Requirements documentation to ensure completeness. eviCore will process standard cases within three business days once all required clinical information is received.
Horizon Blue Cross Blue Shield has mandated that all testing samples for patients enrolled in Horizon managed care plans without out-of-network benefits must be referred exclusively to Labcorp or Quest Diagnostics. Patients with out-of-network benefits may use other labs only if they elect out-of-network coverage and complete required consent forms. Non-compliance may result in network termination.
Horizon Blue has issued a reminder that missing or illegible signatures on claims are a leading cause of denials. Billing teams must implement a quality assurance step to verify all signatures comply with CMS requirements before claim submission to prevent rejections.
Horizon BCBSNJ is mandating that participating providers refer patients with managed care plans lacking out-of-network benefits to Horizon's preferred labs (excluding LabCorp and Quest Diagnostics, or route samples through those vendors only). Non-compliance may result in network termination. Providers must verify patient plan type to determine lab referral requirements.
Horizon Blue has issued an urgent policy to prevent claims from being routed to individual practitioners instead of group practices. When submitting 837P claims for a group practice, billing teams must use the group's Tax Identification Number (TIN) and group Type 2 NPI in Loop 2010AA, not the individual practitioner's Type 1 NPI. Incorrect formatting is causing reimbursement errors and payment delays.
This policy reinforces CMS signature requirements for medical documentation to prevent claim denials. All claims must include clear, legible, and verifiable signatures (handwritten matching a signature log or electronic with date/timestamp). Providers using scribes must personally sign entries to authenticate care provided or ordered.
Horizon Blue is emphasizing that accurate ICD-10-CM diagnosis coding and comprehensive clinical documentation at every visit are critical for Risk Adjustment and HCC reporting. Providers must document all current and coexisting diagnoses to the highest level of specificity and revalidate chronic conditions annually to ensure accurate health status reporting and appropriate care management.
Horizon Blue will now seek to recover out-of-network laboratory and pathology payments from referring providers for Managed Care plan members. Providers must route all lab/pathology samples to preferred network laboratories unless the specific test is unavailable in-network. This chargeback policy creates direct financial liability for providers who refer to out-of-network labs without medical justification.
Horizon Blue now requires that all facility claims for children ages 6-12 diagnosed with ADHD and prescribed ADHD medication must include attending provider details (first name, last name, and NPI with appropriate taxonomy code) to ensure proper recognition and compliance with HEDIS ADD-E quality measures. This applies to both the Initiation Phase (30-day follow-up) and Continuation & Maintenance Phase (270-day follow-up period) of care tracking.
Horizon Blue is mandating electronic submission of Utilization Management (UM) appeals through Availity Essentials portal instead of mail. Billing teams must transition all appeal submissions to the online portal and ensure third-party vendors are also submitting electronically to reduce delays and enable real-time status tracking.
Horizon Blue Cross Blue Shield of New Jersey is requiring all network providers to register with Availity Essentials, their provider portal, to participate in the network. This portal consolidates eligibility checks, claims submission, authorization requests, and profile management into a single platform.
Horizon Blue Cross Blue Shield of New Jersey and its affiliates (Braven Health, Horizon NJ Health) have migrated their provider portal from NaviNet to Availity Essentials. All practice business functions—eligibility, benefits, claims, authorizations, and referrals—must now be conducted through the new Availity Essentials portal. NaviNet access is no longer available.
Horizon Blue Cross Blue Shield has updated their process for submitting prior authorization requests for pharmacy prescription drugs, effective June 1, 2026. This policy change affects how providers must request approval for certain medications before they can be covered.
FEP Blue launched a 2026 Provider Quality Incentive Program (May 1–December 31, 2026) that rewards practices for closing HEDIS care gaps in preventive and chronic care services. Billing teams must monitor monthly gap reports on HorizonDocs Outreach, coordinate patient outreach, and submit claims or supplemental data to earn incentives tied to completed care activities.
Horizon Blue has updated its 2026 Risk Adjustment Programs with new incentive structures for In-Office Assessments (IOAs), increasing maximum payment to $150 ($50 for IOA completion + $100 for Comprehensive Gap Assessment Program requirements), with full incentive available for assessments completed within 60 days and reduced payment ($135 maximum) for those completed after 60 days. The policy also emphasizes Annual Wellness Visits and In-Home Assessments as core preventive care initiatives.
FEP Blue Cross Blue Shield has launched a new Provider Quality Incentive Program for 2025 that pays practices $20-$35 per closed care gap for preventive and chronic disease services delivered June 1 - December 31, 2025. Billing teams must submit claims with correct CPT II codes by January 31, 2026, or use alternative supplemental data submission methods by specified deadlines to earn incentive payments distributed in Q1 and Q3 2026.
This is historical material (published December 2022, discovered October 2026) announcing a self-service tool available on Horizon Blue's NaviNet portal for checking member eligibility, benefits, cost-sharing, and prior authorization requirements for Commercial and Medicare Advantage plans with member IDs containing '3HZN'. The tool eliminates the need to call Provider Services for this information.
This is historical material (published December 2022, discovered October 2026) documenting Horizon BCBS NJ's claim payment determination appeal process for fully insured plans. It establishes a mandatory internal appeal requirement within 90 days before external arbitration through Maximus under the New Jersey PICPA program. The policy outlines two-level appeals, a 30-calendar-day internal review window, and clarifies that audit interactions are not considered formal appeals.
This is historical material (source published 2023-01-01, discovered 2026-10-10). Braven Health Medicare Advantage plans in New Jersey eliminated referral requirements for 2022 and 2023. The policy stated that referrals were NOT required for Braven Medicare Choice (PPO), Braven Medicare Freedom (PPO), and Braven Medicare Plus (HMO). Billing teams should verify current applicability, as this guidance pertains to plan years that have elapsed.
This policy clarifies Horizon Blue's framework for making coverage decisions, emphasizing medical necessity, appropriateness, and cost-effectiveness while prohibiting financial incentives to deny coverage. The policy mandates balanced utilization management to prevent both underutilization (necessary care denied) and overutilization (unnecessary treatments provided). Billing teams must ensure all claim submissions align with these coverage decision principles.
Horizon BCBS New Jersey is introducing a self-service online Eligibility and Benefits Cost Share Estimator tool for members with IDs containing '3HZN'. This tool eliminates the need to call for eligibility verification, cost-share estimates, and prior authorization requirements, and is accessible through NaviNet with diagnosis and CPT/Revenue code-level detail. Billing teams can now obtain prior authorization information and patient cost estimates online rather than through phone calls.
Horizon Blue has issued NCQA HEDIS quality measure requirements for behavioral health follow-up care. Providers must ensure patients receive mental health or substance use follow-up appointments within 7 or 30 days after emergency department visits or inpatient/high-intensity admissions. This is a quality reporting measure that tracks follow-up compliance but does not change billing codes or reimbursement rates.
Horizon BCBS NJ has established a formal process for returning improper or excess claim reimbursements. Billing teams must use the Credit Balance Adjustment Request Form to report all outstanding credit balances of 30+ days and submit documentation to the specified contact. This formalizes the procedure for identifying and returning overpayments to maintain compliance.
Horizon Blue has launched a new Horizon Data Submission Template for providers to update demographic information and meet quarterly data validation requirements. Providers must request the template via email, complete it according to specific formatting rules, and return it within 10 business days using a secure reply link. The old Enterprise PDM mailbox is no longer accepted for updates except through the Provider Data Maintenance Tool on NaviNet for most changes.
Horizon Blue has launched a self-service online tool (Eligibility and Benefits Cost Share Estimator) in NaviNet for Commercial Braven Health plans (member IDs containing "3HZN") that allows providers to check patient eligibility, estimated out-of-pocket costs, and prior authorization requirements without calling Provider Services. Billing teams should transition to using this tool for faster access to pre-service member information at the diagnosis, CPT, or HCPCS code level.
This is an informational policy from Horizon Blue explaining the RADV (Risk Adjustment Data Validation) audit process that CMS conducts annually. The policy clarifies that practices must return 100% of RADV medical record requests within 30 days and outlines how the validation process works through IVA and SVA entities. No billing workflow changes are mandated, but practices should understand their obligations to respond promptly to RADV record requests to avoid audit discrepancies.
This policy provides updated guidance for Horizon Blue Cross Blue Shield of New Jersey members on how to navigate formulary utilization management, including checking medication formulary status, identifying prior authorization (PA) and quantity limit (QL) requirements, and submitting requests for formulary exceptions, tier exceptions, prior authorization, and quantity limit reviews. The policy clarifies the process for Medicare Part D, Braven Health, and Commercial plan members through the Prime Therapeutics portal (myprime.com).
Network, contract and program news from the payers we track.
Horizon has implemented VPI (Veradigm Payor Insights), a new tool integrated into EMRs that automatically alerts providers to open risk adjustment gaps at the point of care.
GeoBlue is being rebranded to Blue Cross Blue Shield Global Solutions over an 18-month transition period, with full brand retirement by end of 2027.
Horizon Blue has released a new online resource to help providers understand social determinants of health and barriers patients face in accessing care.
Horizon Blue has released a new online resource to help providers and staff understand social determinants of health and barriers patients face in accessing care.
Horizon Blue is actively recruiting pediatric specialists to expand their pediatric network across underserved counties. This is a provider recruitment initiative, not a billing or coverage policy change.
Horizon Blue is launching a new monitoring program for State Health Benefits Program/School Employees' Benefits Program (SHBP/SEHBP) members to identify concurrent opioid and benzodiazepine use due to serious safety risks including…
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