Eligibility & Benefits
This must be obtained prior to being seen by an OON provider
What is an authorization?
This view within Prospective UM shows what room types were approved, as well as how many days were allowed in each room type
What is LOS Summary?
3 pieces of information the Provider MUST provide to verify HIPAA for the member
What is the Member ID, Name, DOB?
The system used to access rejected claims
What is DMS?
The state system utilized to verify the Member's eligiblity, DOB, and MCO enrollment
What is EMEVs?
The only exception to utilizing an OON provider
What are Emergent/Urgent cases?
A reference ID located within Facets that generally begins with the letter "H" followed by 8 numbers
What is a Facets authorization number?
The default tab in Customer Service
What is the Start a New Call Tab?
Timely Filing Exceptions
What are COB claims and Corrected claims?
Only this provider can refer the patient to a specialist
Who is the PCP?
Valid for up to 180 days or 6 months
What is a referral?
The amount of time that Utilization Management has to review and approve/deny authorization requests
What is 14 days?
*DOUBLE JEOPARDY*
Has a 250 character limitation
What is Summary?
Horizon NJ Health
Claims Processing Department
P.O. Box 24078
Newark, NJ 07101-0406
What is the Claim Submission address?
A plan that has both a copay and a premium
What is NJ FamilyCare Plan D?
*DOUBLE JEOPARDY*
Protects an individual against the risk of incurring medical expenses among individuals
What is health insurance?
When the provider places the request for authorization in Navinet, they are given this number in response to the request
What is the CareRadius Authorization Number?
Located in the top left hand corner of the Customer Service Ticket
What is the call reference number?
This form is used by hospitals, ambulatory surgery centers, and rehab facilities
What is a UB-04 claim form?
The system that is made up of the nose and nasal cavity, pharynx, larynx, trachea, bronchi, and lungs
What is the Respiratory System?
A benefit that is covered without an authorization for up to $250
What is DME?
This system allows providers to request authorization and submit online referrals
What is Navinet?
This number can be entered in to the Provider ID field in Facets in the event that the provider is unable to give you an HNJH Provider ID#, Tax ID#, or NPI#
What is the Dummy Provider ID 60178842?
This resubmission code must be added on all claims in order for them to be identified as "corrected"
What is 7?
*DOUBLE JEOPARDY*
The amount that Medicaid will pay if Medicaid's allowed is less than the Primary's paid amount
What is $0?