Horizon Direct Access Member Rights
Your Horizon Direct Access Member Rights and Responsibilities As a Horizon Direct Access member, you have the right to: Access information - Receive information about Horizon Blue Cross Blue Shield of New Jersey and its services, policies and procedures, products, physicians, appeals procedures, coverage limitations and other information about the organization and the care provided.
- Be provided with the information needed to understand your benefits and obtain care through the Horizon Managed Care Network.
- Obtain a current directory of participating physicians in our network, upon request. The directory includes addresses, telephone numbers and a listing of physicians who speak languages other than English.
- Receive prompt notification (not more than 30 days following the effective date) of the termination or change in benefits and services; and to receive notice of termination of your Primary Care Physician (PCP), if selected, from the physician network (when applicable, 30 days' prior notice).
- Obtain information about whether a referring physician has a financial interest in the facility or services to which a referral is being made.
- Know Horizon BCBSNJ's payment method for physicians, to know if there are financial incentives or disincentives tied to medical decisions.
- Receive from your physician or health care professional, in terms you understand, an explanation of your complete medical condition, recommended treatment, risk(s) of the treatment, expected results of the treatment and reasonable medical alternatives, whether or not these are covered benefits. If you are not capable of understanding the information, the explanation shall be provided to your next of kin or guardian and documented in your medical record.
- Have full, candid discussions regarding appropriate or medically necessary diagnostic and treatment options with your participating physicians, regardless of cost or benefit coverage.
- Know your rights and responsibilities as a Horizon BCBSNJ member.
Your Primary Care Physician (PCP) - Choose and change your PCP, if selected, within the limits of your benefits and the physician's availability.
- Have access to your PCP, if selected, and available services when medically necessary.This includes the availability of care 24 hours a day, seven days a week, 365 days a year for urgent or emergency conditions.
Medical emergency and urgent care - Call the 911 emergency response system or an appropriate local emergency number in a potentially life-threatening situation, without prior approval.
- Have Horizon BCBSNJ provide coverage for a medical screening exam in an emergency facility to determine whether a medical emergency condition exists.
- Go to an Emergency Room without prior approval when it appears to you that serious harm could result from not obtaining immediate treatment.
Specialty and hospital care - Choose from appropriate, participating specialists following an authorized referral (as needed), subject to the specialist's availability to accept new patients.
- Receive assistance in locating and obtaining referrals (if applicable) to participating physicians with experience in treatment of patients who have chronic disabilities.
Approval of your care - Receive a written explanation why approval of a covered service requested by you or your physician was denied or limited under your Horizon Direct Access plan.
- Have a Horizon BCBSNJ physician determine to deny or limit your admission, service, procedure or extension of stay. Our physician who made the decision must directly communicate with your physician or supply your physician with his/her telephone number. You also have the right to know that the person denying or limiting a covered service is a physician.
- Be free from balance billing by participating physicians for medically necessary services that were authorized (as applicable) or covered by Horizon BCBSNJ. Balance billing does not include copayments, coinsurance and deductibles that you must pay under your plan.
Voice a concern - Voice complaints or file internal and external appeals about your plan or the care provided. Please see the Voicing a Concern section of your Member Handbook for full details.
- File a complaint or appeal with Horizon BCBSNJ or the New Jersey Department of Banking and Insurance. You have the right to receive an answer to your complaint or appeal within a reasonable period of time.
- Know that neither you nor your physician can be penalized for voicing a complaint or appeal about your Horizon Direct Access plan or the care provided.
Your personal rights - Participate with your physicians in decision making regarding your health care.
- Be treated with courtesy and consideration, and with respect for your privacy and dignity.
- Formulate and have advance directives implemented.
- Have access to all the rights afforded by law or regulation as a patient in a licensed health care facility, including the right to refuse medication and treatment after possible consequences of this decision have been explained in a language you understand.
- Make recommendations for changes to the Horizon BCBSNJ Member Rights and Responsibilities Policy.
As a Horizon Direct Access member, you have the responsibility to:- Read and understand your Horizon Direct Access Member Handbook, Benefit Booklet/Certificate and all other member materials.
- Coordinate most nonemergency care through your PCP, if selected.
- Make appointments for nonemergency medical care and keep your appointments. If necessary, you will give adequate notice when canceling an appointment.
- Provide, to the extent possible, information regarding your health that Horizon BCBSNJ and its physicians and health care professionals need in order to care for you.
- Know how to change your PCP, if you selected one.
- Understand your health problems and participate in developing mutually agreed-upon treatment goals and medical decisions regarding your health (to the degree possible).
- Follow the plans and instructions for care that you agreed upon with your physician. If you choose not to comply, you will advise your physician.
- Be considerate and courteous to physicians and staff.
- Make payment for copayments, deductibles and coinsurance as listed in your Benefit Booklet/Certificate.
- Pay for charges that exceed Horizon BCBSNJ's allowance for services that are covered under the policy in those instances in which service is provided by an out-of-network physician.
- Pay for charges incurred that are not covered under the policy or contract.
 
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