The New Jersey Substance Use Disorder Law

Provider Resources

Frequently Asked Questions

General Provisions:

Q: Are all Horizon Blue Cross Blue Shield of New Jersey members/plans covered under the law as of the May 16, 2017 start date?

A: No; the law applies to all fully-insured health benefits plans issued in New Jersey, the State Health Benefits Program (SHBP) and the School Employees’ Health Benefits Program (SEHBP). Coverage provided under self-funded plans, Medicare, Medicaid, Federal Employee Program® (FEP®) and out-of-state plans are not subject to the substance use disorder requirements of the law.

The grid below indicates the effective dates for each market segment.

Market Segment Applicable Effective
Individual Yes Existing Contracts: January 1, 2018

New Contracts : May 16, 2017 or after

Small Employer Yes May 16, 2017
Midsize 51-99 Standard Yes May 16, 2017
Large Insured Group 51+ Yes Monthly renewal on or after May 16, 2017
SHBP/SEHBP Yes May 16, 2017
ASO Large Groups 51+ No – Optional Optional, on monthly renewal

Q: How will a provider know if the law applies to a specific Horizon BCBSNJ member?

A: Please call Horizon Behavioral Health℠ at 1-800-626-2212 to determine if the law applies to a particular member and the specific admission in question. Information about the applicability of the law will also be communicated to network providers at the time of notification of admission.

Q: Is the provider still required to confirm eligibility and benefits for members?

A: Yes, the provider should continue to follow the standard eligibility and benefit check processes.

Q: Do I need to get prior authorization for substance use disorder treatment?

A: Please call Horizon Behavioral Health at 1-800-626-2212 to determine if the law applies to a particular member or account, as well as to the specific admission in question. If the law applies, prior authorization is not needed for the first 180 days of inpatient or outpatient stay for the treatment of substance use disorders when determined to be medically necessary by the member’s health care professional (licensed physician, psychologist or psychiatrist).

Q: What criteria will be used when medical necessity review is allowable under the terms of the law?

A: The American Society of Addiction Medicine (ASAM) criteria.

Q: If a member is currently in treatment when the law goes into effect, do the days used count towards the 180-day continuum of care that must be provided without prior authorization?

A: Days used prior to the law becoming effective do not count towards the law’s provision of 180 days per plan year.

Q: How does this law apply if the member receives care from one year to the next?

A: Recognizing that inpatient stays and outpatient services may cross plan years, and the potential for a covered person to be in the midst of care when the law first applies to the person, the Department of Banking and Insurance offers the following example:

A person is covered under an individual plan. The person receives authorization for an inpatient stay that commences December 28, 2017. The individual plan renews and the new plan year begins January 1, 2018. Chapter 28 first applies to the plan as of January 1, 2018. The person is still confined as of January 1, 2018. The person is entitled to 28 days of inpatient care beginning January 1, 2018. During those 28 days, the carrier or its delegate may not perform prior authorization, concurrent review or retrospective review. Days prior to the start of the plan year on January 1, 2018, do not reduce the 28 days available during the plan year that begins
January 1, 2018.

Out-Of-Network Providers:

Q: Does this law apply to out-of-network providers?

A: No, unless an in-plan exception is made.

A covered person under a PPO or POS plan who voluntarily uses an out-of-network provider will not be entitled to the protections of this law (P.L. 2017, Chapter 28, The New Jersey Substance Use Disorder Law) with respect to those out-of-network services.

Q: What is an in-plan exception?

A: If there is no in-network facility immediately available for a member, Horizon Behavioral Health is required to make an in-plan exception such that the covered person could be admitted to treatment within 24 hours. To determine whether a network facility is available and suitable to treat the member, the admitting physician, psychologist, or psychiatrist must supply the member’s diagnosis and the recommended treatment plan specifying the services the member requires.

Q: Do days used at an out-of-network facility count towards to the 28-day and 180-day per plan year provisions of the law?

A: If a member elects to use an out-of-network facility when an in-network facility is available, then the admission(s) will not be subject to the requirements of the law. Any days of treatment a covered person may receive from out-of-network providers without an in-plan exception shall not reduce the 28 days and the 180 days available to the covered person from network providers.

Note: Any services a covered person receives from an out-of-network provider through an in-plan exception are counted as if rendered by a network provider.

Notification of Admission:

Q: What are the requirements for in-network providers to provide notification of admission to Horizon Behavioral Health?

A: Horizon Behavioral Health must be notified of a member’s admission and the initial treatment plan within 48 hours of the member’s admission or initiation of treatment.

Q: How is notification of admission information to be provided?

A: Please call Horizon Behavioral Health at 800-626-2212, to notify us of an admission. A reference number will be provided for documentation purposes.

Q: How will I know if the member’s initial 28 days’ period has been exhausted at the time of admission?

A: Please call Horizon Behavioral Health at 800-626-2212 to notify us of an admission and to determine how the law applies to a particular member, as well as the specific admission in question.

Q: Will I receive any written correspondence after notification of admission?

A:  After notification of admission, providers will receive a letter that acknowledges the notification of admission.

Continued Stay:

Q: What are the procedures for provider initiated requests for coordination of care (e.g., treatment planning, discharge planning and ICM referrals/needs of high risk members) under the new law?

A: Providers can call Horizon Behavioral Health at 1-800-626-2212 to notify us of discharge or to request assistance with care coordination and/or referrals.

Q: What happens if my patient needs treatment for substance use disorder for longer than 28 days?

A: Covered persons are entitled to 28 days of inpatient care during a plan year and a separate 28 days of intensive outpatient and partial hospitalization care per plan year.

Benefits for days 29 and after of inpatient care can be subject to concurrent review.  A request for approval of inpatient care beyond the first 28 days must be submitted for concurrent review before the expiration of the initial 28-day period.

Concurrent review is allowed at two-week intervals. If it is determined that the inpatient stay is not medically necessary, 24-hour notice is required and the stay must be covered until the day after all the appeals are exhausted even when the determination is upheld.

Benefits for days 29 and after of intensive outpatient or partial hospitalization services are subject to a retrospective review of the medical necessity of the services.

The chart below details procedures by service type:

P.L. 2017, Chapter 28,  The New Jersey Substance Use Disorder Law
Service Type DAY 1 – 28 DAYS 29 – 180 DAYS 181 – 365
Inpatient Detox / Inpatient Substance Use Rehabilitation/ Residential No prior authorization

No retrospective review of medical necessity

No concurrent review of medical necessity

Medical necessity is determined by member’s physician

Facility to provide 48-hour notice of admission and submission of initial treatment plan

NOTE: Request for approval of inpatient care beyond 28 days must be submitted before end of initial 28 day period

No prior authorization

No retrospective review of medical necessity

Concurrent review allowed, but no more frequently than 2-week interval

24 hour internal and external appeal period

Benefits provided through the day after notification of denial

Medical necessity using the ASAM Criteria

Prior authorization allowed if required by the benefit plan.

Concurrent review allowed

Retrospective review allowed

24 hour internal and external appeal period

Benefits provided through the day after notification of denial

Medical necessity using the ASAM Criteria

Intensive OP/Partial Hospitalization Services No prior authorization

No retrospective review

No concurrent review of medical necessity

Medical necessity is determined by member’s physician

No prior authorization

No concurrent review of medical necessity

Retrospective review allowed

Medical necessity using the ASAM Criteria

Prior authorization allowed, if required by the benefit plan.

Concurrent review allowed

Retrospective review allowed

Medical necessity using the ASAM Criteria

Outpatient Care/Visits

(including OP drugs)

No prior authorization or prospective UM

No concurrent review of medical necessity

No retrospective review

For OP drugs, medical necessity is determined by member’s physician

No prior authorization or prospective UM

No concurrent review of medical necessity

No retrospective review

Prior authorization allowed, if required by benefit plan design

Retrospective review allowed, if required by benefit plan design

UM allowed, if required by benefit plan design

 

 

 

 

 

 

Q: How does the 180-day clock work with the different levels of care?

A: The benefits required by the Law must be applied to days of SUD treatment.  It might be helpful to think of three buckets that are replenished each plan year. One bucket has 28 days of inpatient treatment.  A second bucket has 28 days of intensive outpatient (IOP) and partial hospitalization (PHP) services.  A third bucket has 180 days during which a member may receive outpatient visits.  The days used from each bucket are accumulated during each plan year and once 180 days have been used with any combination of services from the three buckets, the coverage required by the Law is exhausted for the remainder of the plan year.

Q: Can the benefits required by the Law exceed the 180 days of treatment per plan year covered under the Law?

A: One or more unused inpatient days may be exchanged for two outpatient visits. These additional outpatient visits do not include partial hospitalization (PHP) or intensive outpatient (IOP) care. An exchange of unused inpatient days creates an increase to the third bucket of 180 days of treatment during which the member may receive outpatient visits. See previous FAQ for additional information.

The maximum number of inpatient days that may be exchanged for additional outpatient visits is 28 days. According to the formula (i.e., one inpatient day = 2 outpatient visits), 28 unused inpatient days can be exchanged for an additional 56 outpatient visits.  Therefore, a member who uses no inpatient days could receive outpatient services subject to the requirements of the Law for 180 days plus the days associated with 56 outpatient visits. The provisions of the Law only apply beyond 180 days if outpatient visits have been obtained through the exchange of unused inpatient days. In other words, a member cannot exchange unused partial hospitalization (PHP) or intensive outpatient (IOP) days for outpatient visits. Only unused inpatient days can be exchanged for additional outpatient visits even if the exchange results in outpatient visits exceeding 180 days.

Billing:

Q: Will there be any change in how I bill?

A: No, there will be no change in provider billing as it relates to P.L. 2017, Chapter 28, The New Jersey Substance Use Disorder Law. Providers should continue to follow current billing procedures. Providers may choose to submit bills promptly to receive early feedback with retrospective review.

Contact Numbers:

Q: Who do I call if I have questions?

A: For customer service and care management, please call Horizon Behavioral Health at 800-626-2212 or 800-991-5579 for SHBP/SEHBP members.

For the National Provider Services Line, please call 800-397-1630, 8 a.m.-8 p.m., Monday through Friday, ET.