Marketplace Criteria - Doctors

OMNIA Silver Health Plan
OMNIA Health Plan
Horizon Advantage EPO Silver
Horizon Advantage EPO
Horizon Advantage Direct Access

OMNIA Silver Health Plan

OMNIA Silver Health Plan members have access to all doctors and other health care professionals who participate in the Horizon Managed Care Network.

OMNIA Silver Health Plan members maximize their benefits and lower their out-of-pocket costs when they use OMNIA Tier 1 doctors and other health care professionals. OMNIA Silver Health Plan members also have in-network access to all other doctors and health care professionals within the Horizon Managed Care Network. However, they will not have the same cost-saving opportunities that they would if they had chosen an OMNIA Tier 1 provider.

For OMNIA Silver Health Plan members, network doctors and other health care professionals are grouped into two tiers – OMNIA Tier 1 and Tier 2.

The following specialties have been selected to participate in OMNIA Tier 1 based on the criteria listed below.

  1. Allergy & Immunology
  2. Cardiology
  3. Cardiothoracic Surgery
  4. Cardiovascular Surgery
  5. Chiropractic Medicine
  6. Dermatology
  7. Endocrinology
  8. Family Practice
  9. Gastroenterology
  10. General Surgery
  11. Hematology
  12. Hematology Oncology
  13. Internal Medicine
  14. Neurological Surgery
  15. Neurology
  16. Oncology
  17. Ophthalmology
  18. Orthopedic Surgery
  19. Otolaryngology
  20. Pediatric
  21. Plastic & Reconstructive Surgery
  22. Podiatry
  23. Pulmonology
  24. Reproductive Medicine
  25. Rheumatology
  26. Urology
  27. Vascular Surgery

OMNIA Tier 1 Selection Criteria

Family Practice, Internal Medicine and Pediatrics (Primary Care Physicians) were selected for inclusion in OMNIA Tier 1 based on their participation with a group that is part of or aligned with the OMNIA Health Alliance* and Horizon BCBSNJ patient-centered programs, such as our Patient-Centered Medical Home and Accountable Care Organization programs. Some exceptions may apply.

Other specialties listed were selected for inclusion in OMNIA Tier 1 based on one or more of the following criteria (some exceptions apply):

  • Geographic access and coverage requirement and standards;
  • Hospital admitting privileges to OMNIA Tier 1 hospitals where applicable;
  • Referral patterns to OMNIA Tier 1 hospitals where applicable; and
  • Cost efficiency at the group practice level.

Doctors and other health care professionals in specialties not listed are automatically considered OMNIA Tier 1 for the OMNIA Silver Health Plan. Exceptions may apply when a doctor or other health care professional is affiliated with a practice that contains one or more of the above noted specialties. Tier status is the same for all doctors in one group.

Members’ out-of-pocket expenses are based only on group affiliation. Members are encouraged to check with their doctors about their group and participating tier status in the OMNIA Silver Health Plans prior to receiving services.

** The OMNIA Health Alliance includes selected doctors, hospitals and other health professionals in our managed care and hospital networks that are committed to assist Horizon BCBSNJ in population health management activities for Horizon BCBSNJ members living and receiving care in New Jersey.

OMNIA Health Plan

OMNIA Health Plan members have access to all doctors and other health care professionals who participate in the Horizon Managed Care Network.

OMNIA Health Plan members maximize their benefits and lower their out-of-pocket costs when they use OMNIA Tier 1 doctors and other health care professionals. OMNIA Health Plan members also have in-network access to all other doctors and health care professionals within the Horizon Managed Care Network. However, they will not have the same cost-saving opportunities that they would if they had chosen an OMNIA Tier 1 provider.

For OMNIA Health Plan members, network doctors and other health care professionals are grouped into two tiers – OMNIA Tier 1 and Tier 2.

The following specialties have been selected to participate in OMNIA Tier 1 based on the criteria listed below.

  1. Allergy & Immunology
  2. Cardiology
  3. Cardiothoracic Surgery
  4. Cardiovascular Surgery
  5. Chiropractic Medicine
  6. Dermatology
  7. Endocrinology
  8. Family Practice
  9. Gastroenterology
  10. General Surgery
  11. Hematology
  12. Hematology Oncology
  13. Internal Medicine
  14. Neurological Surgery
  15. Neurology
  16. Oncology
  17. Ophthalmology
  18. Orthopedic Surgery
  19. Otolaryngology
  20. Pediatric
  21. Plastic & Reconstructive Surgery
  22. Podiatry
  23. Pulmonology
  24. Reproductive Medicine
  25. Rheumatology
  26. Urology
  27. Vascular Surgery

OMNIA Tier 1 Selection Criteria

Family Practice, Internal Medicine and Pediatrics (Primary Care Physicians) were selected for inclusion in OMNIA Tier 1 based on their participation with a group that is part of or aligned with the OMNIA Health Alliance* and Horizon BCBSNJ patient-centered programs, such as our Patient-Centered Medical Home and Accountable Care Organization programs. Some exceptions may apply.

Other specialties listed were selected for inclusion in OMNIA Tier 1 based on one or more of the following criteria (some exceptions apply):

  • Geographic access and coverage requirement and standards;
  • Hospital admitting privileges to OMNIA Tier 1 hospitals where applicable;
  • Referral patterns to OMNIA Tier 1 hospitals where applicable; and
  • Cost efficiency at the group practice level.

Doctors and other health care professionals in specialties not listed are automatically considered OMNIA Tier 1 for the OMNIA Health Plan. Exceptions may apply when a doctor or other health care professional is affiliated with a practice that contains one or more of the above noted specialties. Tier status is the same for all doctors in one group.

Members’ out-of-pocket expenses are based only on group affiliation. Members are encouraged to check with their doctors about their group and participating tier status in the OMNIA Health Plans prior to receiving services.

** The OMNIA Health Alliance includes selected doctors, hospitals and other health professionals in our managed care and hospital networks that are committed to assist Horizon BCBSNJ in population health management activities for Horizon BCBSNJ members living and receiving care in New Jersey.

Horizon Advantage EPO Silver

Members in our Horizon Advantage EPO Silver plans may seek treatment from any doctor and other health care professional in the Horizon Managed Care Nehvork. Quality, member experience or cost-related measures are not factored into the selection process. However, doctors and other health care professionals participating in Horizon Advantage EPO Silver plans must meet strict credentialing criteria and be approved for participation by the Horizon BCBSNJ Credentials Committee.

Horizon Advantage EPO

Members in our Horizon Advantage EPO plans may seek treatment from any doctor or other health care professional in the Horizon Managed Care Network. Quality, member experience or cost-related measures are not factored into the selection process. However, doctors and other health care professionals participating in Horizon Advantage EPO plans must meet strict credentialing criteria and be approved for participation by the Horizon BCBSNJ Credentials Committee.

Horizon Patient-Centered Advantage EPO Silver

With our Horizon Patient-Centered Advantage EPO Silver plans, members have access to all doctors, facilities and other health care professionals in the Horizon Managed Care Nehvork. However, members can lower their cos. when they preselect and use a Primary Care Physician affiliated with one of our established Patient-Centered Medical Home or Accountable Care Organization practices.

Patient-centered doctors in this plan work collaboratively with Horizon BCBSNJ to improve and lower the cost of care while enhancing the member experience. The practice must be selected by 500 or more members to qualify. However, there are no specific quality, member experience or cost-related measures factored into Horizon BCBSNJ, selection process. Once interest is established, Horizon BCBSNJ mee. with the practice to discuss the requiremen. and expectations of the program.

Horizon Patient-Centered Advantage EPO

With our Horizon Patient-Centered Advantage EPO plans, members have access to all doctors, facilities and other health care professionals in the Horizon Managed Care Network. However, members can lower their costs when they preselect and use a Primary Care Physician affiliated with one of our established Patient-Centered Medical Home or Accountable Care Organization practices. Patient-centered doctors in this plan work collaboratively with Horizon BCBSNJ to improve and lower the cost of care while enhancing the member experience. The practice must be selected by 500 or more members to qualify, but there are no specific quality, member experience or cost-related measures factored into Horizon BCBSNJ's selection process. Once interest is established, Horizon BCBSNJ meets with the practice to discuss the requirements and expectations of the program.

Horizon Advantage Direct Access

Members in our Horizon Advantage Direct Access plans may seek treatment from any doctor or other health care professional in the Horizon Managed Care Network. Quality, member experience or cost-related measures are not factored into the selection process. However, doctors and other health care professionals participating in Horizon Advantage Direct Access plans must meet strict credentialing criteria and be approved for participation by the Horizon BCBSNJ Credentials Committee.