Horizon Healthcare Services, Inc.
Horizon Omnia EPO SILVER
Small Group Health Benefits Amendment
Effective Changes: As of January 1, 2017
The Policy is changed as specified below. Refer to the sections of the policy referenced below to see how these changes affect those sections.
1. Under the Preventive Provision, Maternity Care has been updated to stipulate that no copayment, deductible, and coinsurance apply to preventive prenatal care in the SCHEDULE OF INSURANCE.
2. The Pre-Approval section of the SCHEDULE OF INSURANCE is amended to remove authorization for Nutritional Counseling.
3. The SCHEDULE OF INSURANCE is amended to include the following benefit limitation under the payment limits section:
Vision Lenses Once every 12 months
Vision Hardware Once pair of frames from the Davis Collection or $125 allowance for non –collection frames every 12 Months
4. The PARTICIPATION REQUIREMENTS of the CLAIMS PROVISION section is amended as to include:
If a Full-Time Employee is not covered by this Policy because:
5. The PAYMENT OF CLAIMS of the CLAIMS PROVISION section is amended as to
Horizon BCBSNJ uses reimbursement policy guidelines that were developed
through evaluation and validation of standard billing practices as indicated in the
most recent edition of the Current Procedural Terminology (CPT) as generally
applicable to claims processing or as recognized and utilized by Medicare. Horizon
BCBSNJ applies these reimbursement policy guidelines to determine which
charges or portions of charges submitted by the Facility or the Practitioner are
Covered Charges under the terms of the Policy.
********The definitions section has also been amended.
Please look out in the mail for the Full Health Benefits Amendment letter with additional changes #6 through #13.