Horizon

Delay in Policy Update Implementation: E&M Codes Appended with Modifier 25 
Horizon has decided to change the reimbursement procedure of certain E&M codes included on professional claims. This will come into effect on November 1, 2022.  
The baseline for these changes is mentioned in the ‘Evaluation & Management Edits’ subsection of the reimbursement policy.  
At present, when an E&M service appended with Modifier 25 is submitted as another procedure code that represents services with a global surgical period of 0, 10 or 90 days the claim processing system of Horizon considers this at 100% of the appropriate allowance.  
From November 1, 2022, the same will be considered at 50% of Horizon’s appropriate allowance. Note that, this guideline will not impact preventive or non-preventive E&M services when provided in a hospital Emergency Room setting.  
Following patients are included in this change: 

• Horizon Medicare Advantage plans 
• Horizon fully insured commercial plans 
• Administrative Services Only group employer plans including the New Jersey SHBP and SEHBP. 
• Braven Health Medicare Advantage plans 

Source: https://www.horizonblue.com
Update on the First Level UM Appeals for Horizon MA and Braven Health
EviCore healthcare will no longer carry out First Level Utilization Management (UM) Appeals of adverse benefit determinations for patients enrolled in Braven Health Medicare Advantage plans and Horizon Medicare Advantage plans. This will come into effect on August 26, 2022. 
After this date, kindly submit first-level UM appeals to Horizon that will be reviewed by EviCore as part of the following programs: 

• Radiation Therapy Program 
• Cardiology Imaging Program 
• Radiology/Imaging Services 
• Musculoskeletal Program for Pain Management 

You may fax these appeals to 1-609-583-3028 or mail them to: 
Braven Health Medical Appeals PO Box 10195 Newark, NJ 07101 
Horizon Medicare Advantage Medical Appeals PO Box 10195 Newark, NJ 07101