The guidelines of this program is planned to apply to members who are enrolled in fully insured, Federal Employee Program® (FEP®), Medicare Advantage, and self-funded Administrative Services Only (ASO) groups. The guidelines of this program will apply to fully insured members enrolled in programs through other Blue Cross and Blue Shield plans that include BlueCard benefits when these members reside or travel in Horizon BCBSNJ's local service area and receive services from a participating practitioner. Members enrolled in the following plans/products are NOT included:
• Horizon NJ Health plans
• Horizon NJ TotalCare (HMO SNP)
• Medicare Supplement
What to Know
In anticipation of the January 1 launch, providers must complete the Horizon BCBSNJ amendment and ASH recruitment package sent by ASH by November 1, 2019. This package includes ASH’s credentialing application and contracting materials.
The eligible in-scope practitioners who return the required materials to ASH by November 1, 2019 can continue to treat members at an in-network level of benefits. Credentialed practitioners will become effective with the ASH network on January 1, 2020.
Horizon BCBSNJ will continue to manage services through December 31, 2019 for practitioners who treat members with managed care benefit plans.
After January 1, 2020, all contracted and credentialed providers will follow ASH’s clinical performance program and medical necessity review guidelines.
What if I don’t contract with ASH? In order for you to continue to be a credentialed practitioner with Horizon BCBSNJ, you must sign the Horizon BCBSNJ Subordination Agreement Amendment and contract with ASH by November 1, 2019.
If you do not sign the Horizon BCBSNJ Subordination Agreement Amendment and contract with ASH by November 1, 2019, your Horizon BCBSNJ Provider Agreement(s) will terminate in accordance with your agreement.
The Horizon BCBSNJ Chiropractic & Physical Medicine Services Program is subject to regulatory approval.
For questions about this program
•Call ASH at 1-888-511-2743 Monday through Friday from 10 a.m. to
8 p.m. Eastern Time (ET), or Horizon BCBSNJ Physician Services at
1-800-624-1110, Monday through Friday, 8 a.m. to 5 p.m. ET.
American Specialty Health Group, Inc. is an independent company that supports Horizon Blue Cross Blue Shield of New Jersey in the administration of chiropractic and physical medicine services. American Specialty Group, Inc. is independent from and not affiliated with Horizon Blue Cross Blue Shield of New Jersey.
NEW MODIFIERS TO IDENTIFY SERVICES FURNISHED BY PTA/OTA COMING SOON!
In the CY 2019 PFS proposed and final rules CMS established two modifiers—one to identify services furnished in whole or in part by a physical therapist assistant (PTA) and the other to identify services furnished in whole or in part by an occupational therapy assistant (OTA).
The modifiers are defined as follows:
• CQ Modifier: Outpatient physical therapy services furnished in whole or in part by a physical therapist assistant.
• CO Modifier: Outpatient occupational therapy services furnished in whole or in part by an occupational therapy assistant.
In the CY 2019 PFS final rule, CMS clarified that the CQ and CO modifiers are required to be used when applicable for services furnished on or after January 1, 2020, on the claim line of the service alongside the respective GP or GO therapy modifier to identify services furnished under a PT or OT plan of care.
In PFS rulemaking for CY 2019, CMS identified certain situations when the therapy assistant modifiers do apply. The modifiers are applicable to:
• Therapeutic portions of outpatient therapy services furnished by PTAs/ OTAs, as opposed to administrative or other non-therapeutic services that can be performed by others without the education and training of OTAs and PTAs.
• Services wholly furnished by PTAs or OTAs without physical or occupational therapists.
• Evaluative services that are furnished in part by PTAs/OTAs (keeping in mind that PTAs/OTAs are not recognized to wholly furnish PT and OT evaluation or re-evaluations).
CMS also identified some situations when the therapy assistant modifiers do not apply. They do not apply when:
• PTAs/OTAs furnish services that can be done by a technician or aide who does not have the training and education of a PTA/OTA.
• Therapists exclusively furnish services without the involvement of PTAs/OTAs.
CMS finalized a de minimis standard under which a service is considered to be furnished in whole or in part by a PTA or OTA when more than 10 percent of the service is furnished by the PTA or OTA.
Beginning January 1, 2020, in order to provide support for application of the CQ/CO modifier(s) to the claim CMS proposes to add a requirement that the treatment notes explain, via a short phrase or statement, the application or non-application of the CQ/CO modifier for each service furnished that day.
CMS also clarified in the CY 2019 PFS final rule that the CQ and CO modifiers will trigger application of the reduced payment rate for outpatient therapy services furnished in whole or in part by a PTA or OTA, beginning for services furnished in CY 2022.