If you choose to participate in the Case Management Program, a Horizon BCBSNJ Case Manager will work with you, your physician(s) and other health care personnel involved in your care to help you understand and explore the health care alternatives available to you.

As a participating member of the Horizon BCBSNJ Case Management Program, you have the right to:

• Request a description of the rationale used for selecting you as a candidate to receive case management services.
• Know how to contact your Case Manager for services when he/she is on duty.
• Have input into your case management plan.
• Refuse treatment or services, including Case Management services, and be advised of the implications of such refusal relating to benefits eligibility and/or health outcomes.
• Obtain information regarding the criteria we use for discontinuing case management services and case closure.
• Receive notification and a rationale when case management services are changed or terminated.
• Be treated with courtesy and respect.
• Complain or appeal any decision that was made in connection with your case by calling Member Services at the number located on the back of your ID card for complaints, and for Appeals the number located on your denial letter.

As a participating member of the Horizon Case Management Program, you should know that Horizon BCBSNJ’s Utilization Management (UM) decision-making process adheres to the following principles:

• Decisions are based on the medical necessity and appropriateness of care and service within the parameters of the member’s benefit package.
• Horizon BCBSNJ does not compensate those responsible for making UM decisions in a manner that provides incentives for them to deny coverage for medically necessary and appropriate services.
• Horizon BCBSNJ does not offer its employees, or its contracted delegates performing UM reviews, incentives to encourage denials for coverage of service that are medically necessary and appropriate, and does not provide financial incentives to providers to withhold covered health care services that are medically necessary and appropriate.
• Horizon BCBSNJ emphasizes the provision of medically necessary and cost effective health care services to members, and encourages the reporting, investigation and elimination of underutilization of medically necessary services.

You have the responsibility to:

• Send any forms that are needed for your enrollment in the Case Management Program.
• Give correct information to your physician(s) and your Case Manager.
• Let your Case Manager know of any changes in your health care.
• Let your Case Manager know of any changes in your address or phone number.
• Follow your physician’s advice regarding your treatment plan.
• Speak with your physician and/or Case Manager, if you have any questions or concerns.