demaria et al. v. horizon healthcare services, inc....2016/05/17 · case 2:11-cv-07298-wjm-mf...

Exhibit A

Case 2:11-cv-07298-WJM-MF Document 88-3 Filed 05/17/16 of 71 PageID: 4010

Exhibit 1


5082558.54. FIRM:36394517v1

5. 5082558.6

UNITED STATES DISTRICT COURTDISTRICT OF NEW JERSEY

ALPHONSE A. DEMARIA, et al., on theirown behalf and on behalf of CertifiedClasses,

Plaintiffs,

- v. -

HORIZON HEALTHCARE SERVICES,INC. d/b/a HORIZON BLUE CROSSBLUE SHIELD OF NEW JERSEY, et al.,

Defendants.

::::::::::::::::::

Case No. 2:11-cv-07298(WJM)(MF)

PLAINTIFFS’ UNOPPOSED MOTIONFOR PRELIMINARY APPROVAL

OF CLASS SETTLEMENT

Plaintiffs and the Certified Classes, by their undersigned counsel, move pursuant to Fed.

R. Civ. P. 23(e) for this Court to preliminarily approve a settlement of this class action between

Plaintiffs, on behalf of certified classes, and Defendants Horizon HealthCare Services, Inc., d/b/a

Horizon Blue Cross Blue Shield of New Jersey and Horizon HealthCare of New Jersey, Inc.,

d/b/a Horizon HMO (collectively “Horizon”), and in support state:

1. On June 1, 2015, this Court certified two classes in this action, an ERISA Class and

a Non-ERISA Class (Dkt. 75). On August 20, 2015, the Third Circuit denied Horizon’s petition

for appeal under Rule 23(f).

2. After lengthy and time consuming negotiations, the parties on May 6, 2015 reached

a final agreement in principle to settle this action, subject to reduction to, and execution of, a

final written agreement. The parties have since executed a written Settlement Agreement (the

“Settlement” or the “Settlement Agreement”) (a copy of which is an exhibit to the attached


25082558.5

2. FIRM:36394517v13. 5082558.6

Memorandum). The Settlement Agreement is fair, reasonable, and adequate.

3. In support of this Motion, Plaintiffs attach a Memorandum of Law (the

“Memorandum”) with exhibits, including proposed Mailed Notice, proposed Publication Notice,

proposed Long Form Notice, and the proposed Judgment.

4. Plaintiffs request that this Court preliminarily approve the Settlement Agreement,

and enter a Preliminary Approval Order in the form substantially as attached (the “Order),

including ordering the following procedure for disseminating notice of the proposed Settlement

to the Class:

a. Authorizing and directing Plaintiffs and Class Counsel to retain Epiq Class

Action & Claims Solutions, Inc., 10300 Southwest Allen Boulevard, Beaverton, OR 97005 as

Settlement Administrator (the “Settlement Administrator”).

b. Authorizing Class Counsel and the Settlement Administrator to operate a

Web site – www.NJChiroClassAction.com (the “Web site”) – for the dissemination of

information related to this case.

c. Class Counsel shall cause the Settlement Administrator, within fourteen (14)

calendar days of entry by the Court of the Order of Preliminary Approval, to mail the Mailed

Notice to Class Members at the address of each such person as set forth in the Claims Data, or

who otherwise may be identified through further reasonable effort;

d. Class Counsel shall cause, as soon as practicable after entry by the Court of

the Order of Preliminary Approval, the Publication Notice to be published as set forth in ¶ 26 of

the Settlement Agreement;

e. Class Counsel shall cause the Settlement Administrator, within seven (7)

calendar days of entry by the Court of the Order of Preliminary Approval, to post and publish on


35082558.5

2. FIRM:36394517v13. 5082558.6

the Web site the Long Form Notice; and

f. Class Counsel shall file their Motion for Attorneys’ Fees, payment of

Litigation Expenses, and payment of Service Awards, together with supporting memorandum

and papers, no later than thirty-nine (39) days after the date of the Order of Preliminary

Approval.

5. Plaintiffs also request that this Court order that any Class Member who wishes to

object to the proposed Settlement must file with the Court, and serve on Class Counsel and

Defendant’s Counsel, a written statement of objection no later than seventy-five (75) days after

the date of the Order of Preliminary Approval, which statement must contain the information set

forth in the Order of Preliminary Approval.

6. Plaintiffs also request that this Court order that any Class Member who wishes to

opt out of the Class must complete and mail to the Settlement Administrator a Request for

Exclusion that is postmarked no later than seventy-five (75) calendar days from the date of the

Order of Preliminary Approval, which Request for Exclusion must contain the information set

forth in the Order of Preliminary Approval.

7. Plaintiffs also request that this Court schedule a Final Approval Hearing at which

the Court will consider: (a) whether the Settlement should be finally approved as fair, reasonable,

and adequate for the Class, including any timely objections thereto; (b) whether the Judgment

granting approval of the Settlement and dismissing the Class Action with prejudice should be

entered; (c) whether Class Counsel's application for attorneys’ fees and payment of Litigation

Expenses should be granted; and (d) whether Class Counsel’s application for Service Awards to

Plaintiffs should be granted.

8. Counsel for Horizon has reviewed this Motion, and Horizon does not oppose this


45082558.5

2. FIRM:36394517v13. 5082558.6

Motion or the relief sought.

WHEREFORE, Plaintiffs respectfully request that this Court preliminarily approve the

Settlement and enter the proposed Order, which is attached.

Dated: May __, 2015 Respectfully submitted,

/s/ John W. LeardiJohn W. Leardi, Esq.BUTTACI LEARDI & WERNER LLC103 Carnegie Center, Suite 323Princeton, New Jersey [email protected]@buttacilaw.comTel: (609) 799-5150Fax: (609) 799-5180

William K. MeyerZUCKERMAN SPAEDER LLP100 East Pratt Street, Suite 2400Baltimore, MD [email protected]: (410) 332-0444Fax: (410) 659-0436

D. Brian HuffordJason S. CowartZUCKERMAN SPAEDER LLP399 Park Avenue, 14th FloorNew York, NY [email protected]@[email protected]: (212) 704-9600Fax: (212) 704-4256

Attorneys for Plaintiffs


55082558.5

2. FIRM:36394517v13. 5082558.6

CERTIFICATE OF SERVICE

I HEREBY CERTIFY that on this ___th day of May 2016, a copy of Plaintiffs’

Unopposed Motion for Preliminary Approval of Class Settlement, supporting Memorandum of

Law and exhibits thereto was (a) emailed and (b) sent by first class mail, postage prepaid, to:

James P. Flynn, Esq.EPSTEIN BECKER & GREEN, P.C.One Gateway CenterNewark, NJ 07102

Attorneys for Defendants

/s/ John W. LeardiJohn W. Leardi


Exhibit 2


5082585.3


ALPHONSE A. DEMARIA, et al., on theirown behalf and on behalf of certifiedclasses,

Plaintiffs,

- v. -


Defendants.

::::::::::::::::::


[PROPOSED] ORDERPRELIMINARILY APPROVINGCLASS ACTION SETTLEMENT

Upon consideration by this Court of Plaintiffs’ Unopposed Motion for Preliminary

Approval of Class Settlement in which Defendants concur (the “Motion”), and after review of

Plaintiffs’ supporting Memorandum of Law and exhibits (the “Memorandum”), including the

Settlement Agreement executed between the parties (the “Settlement” or “Agreement”), and it

appearing to this Court that good cause for the relief therein prayed has been shown, it is this

_____ day of _________________, 2016 by the United States District Court for the District of

New Jersey,

ORDERED that the Motion be, and the same hereby is, GRANTED, as set forth herein.

The Court makes the following findings and orders:

1. As used herein, words with initial capitalization shall have the same meaning as set

forth in the Agreement, except where otherwise noted.

2. The Court preliminarily approves the Settlement Agreement, finding that there is


25082585.3

sufficient basis for concluding that the Settlement as fair, reasonable, and adequate under Fed. R.

Civ. P. 23(e), such as to warrant dissemination of notice of the proposed Settlement to the Class

as provided by the Motion and the Settlement Agreement. The Court finds that the Settlement

contains no obvious deficiencies and that the parties entered into the Agreement in good faith,

following arms-length negotiation between their respective counsel.

3. The Court authorizes and directs Plaintiffs and Class Counsel to retain Epiq Class

Action & Claims Solutions, Inc., 10300 Southwest Allen Boulevard, Beaverton, OR 97005 as the

Settlement Administrator to implement the terms of the proposed Settlement, and authorizes and

directs such Settlement Administrator to (a) mail the Mailed Notice, (b) publish the Publication

Notice, and (c) post the Long Form Notice and exhibits thereto on the Web site

(www.NJChiroClassAction.com), as provided by the Settlement. The Court also authorizes the

Settlement Administrator to carry out such other responsibilities as are provided for in the

Agreement or may be agreed to by the Parties in this Class Action.

4. The Court approves, as to form and content, the Mailed Notice, the Publication

Notice, and the Long Form Notice, attached to the Memorandum as Exhibits D, E, and F,

respectively.

5. The Court also approves the procedure for disseminating notice of the proposed

Settlement to the Class as set forth in the Agreement, to wit:

a. Class Counsel shall cause the Settlement Administrator, within fourteen (14)

calendar days of entry by the Court of the Preliminary Approval Order, to mail the Mailed

Notice to Class Members at the address of each such person as set forth in the Claims Data, or

who otherwise may be identified through further reasonable effort;

b. Class Counsel shall cause the Settlement Administrator, as soon as


35082585.3

practicable after entry by the Court of the Preliminary Approval Order, to cause to be published

the Publication Notice as set forth in ¶ 12(y) of the Settlement;

c. Class Counsel shall cause the Settlement Administrator, within seven (7)

calendar days of entry by the Court of the Preliminary Approval Order, to post and publish on

the Web site the Long Form Notice; and

d. Class Counsel shall cause the Settlement Administrator to make available on

the Web site, as soon as practicable after filing, Class Counsel’s Motion for Attorneys’ Fees,

payment of Litigation Expenses, and payment of Service Awards, together with supporting

memorandum and papers.

6. The Court finds that the notice to be given constitutes the best notice practicable

under the circumstances, and constitutes valid, due, and sufficient notice to the Class in full

compliance with the requirements of applicable law, including the Due Process Clause of the

United States Constitution.

7. At or before the Final Approval Hearing (defined below), the Settlement

Administrator shall provide the Court with a declaration showing that notice was disseminated in

accordance with this Order and the Settlement.

8. A hearing on final approval of the Settlement, an award of attorneys’ fees and

payment of Litigation Expenses to Class Counsel, and award of Service Awards to Plaintiff (the

“Final Approval Hearing”) shall be held at on _____________________ ____, 2016 at ______

before the undersigned, at the United States District Court for the District of New Jersey, Martin

Luther King Building & U.S. Courthouse, 50 Walnut Street, Room 4015

Newark, NJ 07101, Courtroom MLK 4B. At the Final Approval Hearing, the Court will

consider: (a) whether the Settlement should be finally approved as fair, reasonable, and adequate


45082585.3

for the Class; (b) whether a judgment granting approval of the Settlement and dismissing the

Class Action with prejudice should be entered; (c) whether Class Counsel's application for

attorneys’ fees and payment of Litigation Expenses should be granted; and (d) whether Class

Counsel’s application for Service Awards to Plaintiffs should be granted.

9. Objections.

a. Any Class Member who complies with the requirements of this paragraph

may object to any aspect of the proposed Settlement either on his or her own or through an

attorney hired at his or her expense.

b. Any Class Member who wishes to object to the proposed Settlement must

file with the Court, and serve on Class Counsel and Defendant’s Counsel, at the addresses set

forth below, a written statement of objection no later than seventy-five (75) days after the date of

this Order. Such statement shall include: (a) the objecting Class Member’s full name, address

and telephone number and that of his or her counsel, if any; (b) all tax identification or social

security numbers under which the Class Member submitted claims for reimbursement to Horizon

during the Class Period; (c) all objections and any evidence the objecting Class Member wishes

to introduce in support of the objection; (c) a statement as to whether the Class Member intends

to appear at the Final Approval Hearing, either individually or through counsel; (d) the objecting

Class Member’s signature, (e) the case name and case number set forth in the caption of this

Order; and (f) a detailed list of any other objections submitted by the Class Member, or his/her

counsel, to any class actions submitted in any court, whether state or otherwise, in the United

States in the previous five (5) years. If the Class Member or his/her counsel has not objected to

any other class action settlement in any court in the United States in the previous five (5) years,

he/she shall affirmatively state so in the written materials provided in connection with the


55082585.3

objection.

c. Any Class Member who does not timely file and serve a written objection

pursuant to the terms hereof shall be deemed to have waived, and shall be foreclosed from

thereafter raising, any objection to the Settlement. Any objection that is not timely made shall be

barred. The filing of an objection allows Class Counsel or Defendant’s Counsel to notice such

objecting person for and take his or her deposition consistent with the Federal Rules of Civil

Procedure at an agreed-upon location, and to seek any documentary evidence or other tangible

things that are relevant to the objection. Failure by an objector to make himself or herself

available for a deposition or to comply with expedited discovery requests may result in the Court

striking said objector’s objection and otherwise denying that person the opportunity to make an

objection or be further heard. The Court reserves the right to tax the costs of any such discovery

to the objector or the objector’s counsel should the Court determine that the objection is

frivolous or is made for an improper purpose.

d. The procedures and requirements for filing objections in connection with the

Final Approval Hearing are intended to ensure the efficient administration of justice and the

orderly presentation of any Class Members’ objection to the Settlement, in accordance with the

due process rights of all Class Members.

e. Any Class Member who files and serves a timely written objection pursuant

to the terms of this Order and complies with the requirements of this paragraph may also appear

at the Final Approval Hearing either in person or through counsel retained at the Class Member’s

expense. Class Members or their attorneys intending to appear at the Final Approval Hearing

must serve on Class Counsel and Defendant’s Counsel, and file with the Court, no later than

thirty (30) calendar days before the Final Approval Hearing, a notice of intention to appear,


65082585.3

setting forth the case number, and the name, address, telephone number, and, if available, email

address of the Class Member (and, if applicable, the name, address, telephone number, and email

address of the Class Member’s attorney). Any Class Member who does not timely file and serve

a notice of intention to appear pursuant to the terms of this Order shall not be permitted to

appear, except for good cause shown.

10. Exclusions.

a. Any Class Member may request to be excluded (or “opt out”) from the

Class. A Class Member who wishes to opt out of the Class must complete and mail to the

Settlement Administrator a Request for Exclusion that is postmarked no later than seventy-five

(75) calendar days from the date of this Order. The Request for Exclusion must be personally

signed by the Class Member requesting exclusion and contain a statement that indicates a desire

to be excluded from the Class. No person may opt-out of the Class any other person, or be opted-

out by any other person, and no person shall be deemed opted-out of the Class through any

purported “mass” or “class” opt-outs. So-called “mass” or “class” opt-outs shall not be allowed.

b. Except for those persons who have properly and timely submitted Requests

for Exclusion, all Class Members will be bound by the Settlement if finally approved, and the

Judgment and Order Approving Settlement, if entered, including the Release contained within

the Settlement, regardless of whether they receive any monetary relief.

c. Any Class Member who properly requests to be excluded from the Class

shall not: (a) be bound by any orders or judgments entered in the Class Action relating to the

Settlement; (b) be entitled to relief under, or be affected by, the Settlement; (c) gain any rights by

virtue of the Settlement; or (d) be entitled to object to any aspect of the Settlement.


75082585.3

11. Supplemental Filing Deadlines.

a. The (a) Motion for Final Approval of the Settlement and Certification of the

Settlement Class, together with the supporting memorandum and papers, and (b) Class Counsel’s

Motion for Attorneys’ Fees, payment of Litigation Expenses, and payment of Service Awards,

together with supporting memorandum and papers, shall be filed no later than

_____________________ ____, 2016.

b. The Parties may each file a supplemental brief no longer than twenty-five

(25) pages in length to address any objections filed by Class Members. Said supplemental briefs

shall be filed no later than seven (7) calendar days before the Final Approval Hearing.

12. If any deadline set forth in this Order falls on a Saturday, Sunday or federal holiday,

then such deadline shall extend to the next Court business day.

13. The Court reserves the right to adjust the date of the Final Approval Hearing and

related deadlines. In that event, the revised hearing date and/or deadlines shall be posted on the

Settlement Website referred to in the Class Notice, and the Parties shall not be required to re-

send or re-publish the Class Notice.

14. Pending the Final Approval Hearing, all proceedings in the Class Action, other than

proceedings necessary to carry out and enforce the terms and conditions of the Settlement and

this Order, are hereby stayed.

15. The Court approves and adopts the termination provisions of Section VIII of the

Agreement.


85082585.3

16. Names and addresses:

a. Class Counsel:

John W. Leardi, Esq.Vincent N. Buttaci, Esq.Paul D. Werner, Esq.BUTTACI LEARDI &WERNER LLC103 Carnegie Center, Suite 323Princeton, NJ 08540

William K. MeyerZUCKERMAN SPAEDER LLP100 East Pratt Street, Suite 2400Baltimore, MD 21202

D. Brian HuffordJason S. CowartZUCKERMAN SPAEDER LLP399 Park Avenue, 14th FloorNew York, NY 10022

b. Defendants’ counsel:

James P. Flynn, Esq.EPSTEIN BECKER & GREEN, P.C.One Gateway CenterNewark, NJ 07102

c. Settlement Administrator

Epiq Class Action & Claims Solutions, Inc.10300 Southwest Allen BoulevardBeaverton, OR 97005

SO ORDERED

________________________________________William J. MartiniUnited States District Judge


Exhibit 3


5082366.8

[Class Member Name][Street Address][City, State, ZIP]

THIS IS NOT JUNK MAIL.THIS POSTCARD

PROVIDES IMPORTANTINFORMATION ABOUTYOUR LEGAL RIGHTS INA CLASS ACTION CASE.

PLEASE READ.

PRE-SORTEDFirst-Class MailUS Postage Paid

City, STPermit No. XXXX

Why Are You Receiving This Notice? This Notice is about the settlement of a class action lawsuit concerning the denial by Horizon BlueCross Blue Shield of New Jersey (“Horizon”) of reimbursement claims submitted by chiropractors, DeMaria et al. v. Horizon et al. (the“Lawsuit”). As the result of a proposed Settlement of the Lawsuit, you may be entitled to the payment of money for certain evaluation andmanagement services (“E/M”) or physical therapy (“PT”) modalities provided on the same day as chiropractic manipulative therapy(“CMT”). You are receiving this Notice because Horizon’s claims data identifies you as a chiropractor who provided E/M and/or PT on thesame day as CMT but Horizon only paid for CMT.

What Is the Lawsuit About? Horizon “bundled” (i.e., did not pay separately) claims submitted by NJ chiropractors for certain evaluationand management services (“E/M”) or physical therapy (“PT”) modalities provided on the same day as CMT. In 2009, the NJ Department ofBanking and Insurance ordered Horizon to cease and desist this “bundling” practice as of April 10, 2010. The Lawsuit sought remedies forHorizon’s “bundling” practice before that date. The Court certified the Lawsuit as a Class Action on June 1, 2015. Horizon denies that it didanything wrong, but the parties to the Lawsuit have reached a Settlement, which the Court has preliminarily approved.

What is the Settlement? Horizon will pay $33,000,000 into an Escrow Account to be administered by a Court-appointed SettlementAdministrator. After payment of fees and costs associated with the Lawsuit, the Settlement Administrator will distribute the balance of theEscrow Account, on a pro rata basis, to chiropractors whose claims for E/M and PT services on the same day as CMT services weredenied by Horizon, for dates of service from Dec. 16, 2005 until April 10, 2010. Counsel for the Class will also ask the Court to awardattorneys’ fees up to 33% of the settlement amount and to pay litigation expenses.

What Do I Need to Do Now? Because your rights are affected, you have a choice to make now:

DO NOTHING: By doing nothing, you will automatically receive your pro rata share of the Settlement. However, you give up the rightto sue Horizon separately about the legal claims raised in this Lawsuit; or

ASK TO BE EXCLUDED OR OBJECT: If you ask to be excluded, you won’t share in the Settlement. However, you keep the right tosue Horizon separately about the legal claims raised in the Lawsuit. You can also object to the Settlement. For instructions on requestingexclusion or objecting, visit the website listed below or contact the Settlement Administrator using the contact information below. It isimportant to note that the deadline for requesting exclusion is [Month 00, 2016].

Where Can I Get More Information? You can obtain a detailed notice about the Lawsuit and other important court documents atwww.NJChiroClassAction.com; or by calling the Settlement Administrator at 877-341-4577. Do not call Horizon.

Questions? Call 1-877-341-4577 or visit www.NJChiroClassAction.com

DeMaria v. Horizon Class Action Settlement AdministratorPO Box 4390Portland, OR 97208-4390


Exhibit 4


5084865.13

UNITED STATES DISTRICT COURT FOR THE DISTRICT OF New Jersey

If you are a Chiropractor who received

payment from Horizon Blue Cross Blue Shield

of New Jersey from 2005 to 2010, you could

get a payment from a class action settlement.A federal court authorized this notice. This is not a solicitation from a lawyer.

• A settlement will provide $33,000,000 to resolve claims, as more fully explained below, forunreimbursed services performed by a certified class of chiropractors under healthcare plansadministered and/or funded by Horizon between December 15, 2005 and April 10, 2010.

• The settlement resolves a class action lawsuit over whether Horizon unlawfully “bundled”payment for Evaluation and Management Services (“E/”M”) and certain physical therapymodalities (“PT”) with payment for Chiropractic Manipulative Therapy (“CMT”). Thesettlement avoids costs and risks to you from continuing the lawsuit; pays money to chiropractorsand other class members like you; and releases Horizon and its plans from liability.

• Court-appointed lawyers for the certified class will ask the Court for up to $11,000,000 (1/3 of the$33,000,000) to be paid as fees and expenses for investigating the facts, litigating the case, andnegotiating the settlement.

• Your legal rights are affected whether you act, or don’t act. Read this notice carefully.

YOUR LEGAL RIGHTS AND OPTIONS IN THIS SETTLEMENT:

DO NOTHING

You will remain in the Class and receive a payment if you previouslysubmitted claims to Horizon for E/M and PT that qualify forreimbursement under the settlement.

EXCLUDE YOURSELF

Get no payment. This is the only option that allows you to ever be partof any other lawsuit against Horizon, about the legal claims in this case.

OBJECT

Write to the Court about why you don’t like the settlement. You willremain a part of the Class and entitled to payment if you qualify, butmay still object to the settlement.

GO TO A HEARING Ask to speak in Court about the fairness of the settlement.

• These rights and options—and the deadlines to exercise them—are explained in this notice.

• The Court in charge of this case still has to decide whether to approve the settlement. Payments willbe made if the Court approves the settlement and after appeals are resolved. Please be patient.

QUESTIONS? CALL 1-877-341-4577 TOLL FREE

PARA UNA NOTIFICACIÓN EN ESPAÑOL, LLAMAR O VISITAR NUESTRO WEBSITE


- 2 -5084865.13

WHAT THIS NOTICE CONTAINS

BASIC INFORMATION

1. Why did I receive notice of the proposed settlement?2. What is this lawsuit about?3. Why is this a class action?4. Why is there a settlement?

WHO IS IN THE SETTLEMENT

5. How do I know if I am part of the settlement?6. Are there exceptions to being included?7. I’m still not sure if I am included.

THE SETTLEMENT BENEFITS—WHAT YOU GET

8. What does the settlement provide?9. How much will my payment be?10. Will I have to pay taxes on any payments?

HOW YOU GET A PAYMENT— DO NOTHING

11. How can I get a payment?12. When would I get my payment?13. What am I giving up to get a payment or stay in the Class?

EXCLUDING YOURSELF FROM THE SETTLEMENT

14. How do I get out of the settlement?15. If I don’t exclude myself, can I sue Horizon for the same thing later?16. If I exclude myself, can I get money from this settlement?

THE LAWYERS REPRESENTING YOU

17. Do I have a lawyer in the case?18. How will the lawyers be paid? Will the Class Representatives receive anything beyond their share ofclaims?

OBJECTING TO THE SETTLEMENT

19. How do I tell the Court that I don’t like the settlement?20. What’s the difference between objecting and excluding?

THE COURT’S FAIRNESS HEARING

21. When and where will the Court decide whether to approve the settlement?22. Do I have to come to the hearing?23. May I speak at the hearing?

IF YOU DO NOTHING

24. What happens if I do nothing at all?

GETTING MORE INFORMATION

25. Are there more details about the settlement?26. How do I get more information?


35084865.13

BASIC INFORMATION

1. Why did I receive notice of the proposed settlement?

Your name is included in claims data from Horizon as a chiropractor who, during the period of December16, 2005 through April 10, 2010 (“Class Period”), performed on the same patient a CMT on the same dayas E/M and PT, but Horizon only paid for the CMT, and you received at least one direct payment fromHorizon during the Class Period. This makes you a member of the Class (“Class Member”).

The Court ordered you to receive notice because you have a right to know about a proposed settlementof this class action lawsuit, and about all of your options, before the Court decides whether to approvethe settlement. If the Court approves it and after objections and appeals are resolved, an administratorapproved by the Court will make payments that the settlement allows. You will be informed ofdevelopments on the settlement web site. Information provided in this Notice explains the lawsuit,the settlement, your rights, what benefits are available, who is eligible for them, and how to getthem.

The Court in charge of the case is the United States District Court for the District of New Jersey, and thecase is known as DeMaria et al. v. Horizon HealthCare Services, Inc., et al., Case No. 2:11-cv-07298(WJM)(MF). The people who sued are Plaintiffs, and the Horizon entities they sued are Defendants.

2. What is this lawsuit about?

The lawsuit claimed that Horizon unlawfully refused to pay separately—or “bundled”—claims forreimbursement for E/M and PT provided on the same day to the same patient as CMT. In October,2009, The New Jersey Department of Banking and Insurance ordered Horizon to cease that “bundling”practice which Horizon did as of April 10, 2010. The lawsuit sought relief for that “bundling” practice,which occurred between December 16, 2005 and April 10, 2010.

3. Why is this a class action?

In a class action, one or more people called Class Representatives (in this case Alphonse DeMaria,D.C., James Proodian, D.C., and T. Leonard Probe, D.C.), sued on behalf of people who have similarclaims. All these people are a Class or Class Members. One court resolves the issues for all ClassMembers, except for those who exclude themselves from the Class. U.S. District Judge William J.Martini is in charge of this class action.

4. Why is there a settlement?

The Court did not decide in favor of Plaintiffs or Defendants. Instead, the Court ruled that if Plaintiffswere to win at trial, the Class would not receive damages but only be entitled to have Horizon re-process Class Members’ claims – without the “bundling” policy but with other relevant claimexclusions and limitations. Both sides think they would have won at trial, but to avoid the costs anduncertain results of both a trial and re-processing by Horizon, the parties have agreed to a settlement.


45084865.13

The settlement means that Class Members will get compensation – without the cost, time, uncertainty,appeals, and medical necessity reviews associated with re-processing by Horizon. The ClassRepresentatives and the attorneys think the settlement is best for all Class Members.

WHO IS IN THE SETTLEMENT

5. How do I know if I am part of the settlement?

If you received a postcard notice about this settlement from Class Counsel, it is becausethe claims data reflects that you may meet the criteria for Class membership. You willbe part of this settlement unless you fall within an exclusion (see question 6) or excludeyourself from the settlement (see question 14).

6. Are there exceptions to being included?

You are not a Class Member if you did not receive at least one direct payment from Horizonfor CMT claims that were performed on the same day as the unpaid E/M and/or PT claimsthat are the subject of this settlement.

You are also not a Class Member if you only submitted claims toHorizon for patients coveredunder the Federal Employee Program (“FEP”); or if you were a Non-Participating (“out-of-network”) provider who only submitted claims through Horizon’s Multi-Plan Liaison(“MPL”) program involving labor union plans. The Court has ruled that those FEP and MPLclaims are not part of this lawsuit because those claims were resolved by those plansthemselves, not Horizon.

7. I’m still not sure if I am included.

If you are still not sure whether you are included, you can ask for free help. You can call the court-appointed Settlement Administrator, Epiq Class Action and Claims Solutions, Inc. (“Epiq”), at 1-877-341-4577 for more information. DO NOT CALL HORIZON.

THE SETTLEMENT BENEFITS—WHAT YOU GET

8. What does the settlement provide?

Horizon has agreed to create a $33,000,000 fund to resolve claims brought by the Class.Payments to Class members will be based upon claims previously submitted to, and deniedby, Horizon. YOU DO NOT HAVE TO SUBMIT A NEW CLAIM. PAYMENTSWILL BE BASED ON CLAIMS YOU ALREADY SUBMITTED.


55084865.13

9. How much will my payment be?

Your share of the $33 million settlement fund will depend on two things: (1) what the Courtawards in attorneys’ fees and other litigation expenses (see question 18, below); and (2) yourpro rata share of the total claims that you and other Class members submitted to Horizon.

(1) If the Court grants all the requested fees and reimbursement of expenses, there willbe approximately $21,000,000 (more or less) left in the settlement fund available fordistribution to Class Members.

(2) Based on Horizon’s claims data, Class counsel estimates that the total amount ofE/M and PT claims that Class Members submitted to Horizon to be approximately $92million in eligible charges. Thus, the money available in the settlement fund for distributionto Class Members should pay approximately 23% (more or less) of claims submitted. ClassCounsel and the Class Representatives believe this is a good settlement because (a)historically, reimbursement on submitted chiropractic claims that are paid has beensubstantially reduced from charges submitted; and (b) settlement avoids the risks, delays,and uncertainty of both trial and re-processing (including alternative bases for denial orlimitation) that the Court has already determined is the only available relief.

The proposed Plan of Allocation is available on the settlement web site,www.NJChiroClassAction.com. It provides payment details for Class Members (as definedabove) based on each Class Member’s respective share as calculated under the Plan ofAllocation of denied E/M and PT claims performed on the same patient on the same day as apaid CMT claim, for all claims submitted to Horizon by Class Members during the ClassPeriod. The Settlement covers all denied E/M and PT claims performed on the same day asa paid CMT claim, even if the CMT payment was not made directly to the Class Member, aslong as the Class Member received at least one direct payment from Horizon during theClass Period.

10.Will I have to pay taxes on my payment?

You may have to pay taxes on your payment. You should consult your tax preparer when you fileyour tax returns. The Settlement Administrator will send you a Form 1099.


65084865.13

HOW YOU GET A PAYMENT—Do NOTHING

11.How can I get a payment?

You do not have to do anything to get a payment. You will automatically receive a check, based onreimbursement claims you previously submitted to Horizon. You do not have to submit any new claimforms. Payments will be based on claim forms previously submitted.

12.When would I get my payment?

The Court will hold a hearing on [DATE] to decide whether to approve the settlement. If JudgeMartini approves the settlement after that, there may be appeals. It’s always uncertain whether theseappeals can be resolved, and resolving them can take time, perhaps more than a year. Class Counselwill continue to update the progress of the case on the settlement website,www.NJChiroClassAction.com. Please be patient.

13.What am I giving up to get a payment or stay in the Class?

Unless you exclude yourself, you are staying in the Class. That means that you can’t sue,continue to sue, or be part of any other lawsuit against Horizon about the legal issues in thiscase. It also means that all of the Court’s orders will apply to you and legally bind you. It alsomeans that a “Release of Claims” that is part of the Settlement Agreement will apply to anyclaims you may have had against Horizon related to this lawsuit.

EXCLUDING YOURSELF FROM THE SETTLEMENT

If you don’t want a payment from this settlement, but you want to keep the right to sue or continue tosue Horizon, on your own, about the legal issues in this case, then you must take steps to get out. Thisis called excluding yourself—or is sometimes referred to as “opting out” of the Class.

14.How do I get out of the settlement?

To exclude yourself from the settlement, you must send a letter by mail saying that you want to beexcluded from DeMaria et al. v. Horizon. Be sure to include your name, address, telephonenumber, and your signature. You must mail your exclusion request postmarked no later than[DATE] to:

DeMaria v. Horizon ExclusionPO Box 4390Portland, OR 97208-4390

You can also use the Request for Exclusion form available for download on the seettlementwebsite, www.NJChiroClassAction.com. If you ask to be excluded, you will not get anysettlement payment, and you cannot object to the settlement. You will not be legally bound byanything that happens in this lawsuit.


75084865.13

15.If I don’t exclude myself, can I sue Horizon for the same thing later?

No. Unless you exclude yourself, you give up any right to sue Horizon for the claims that thissettlement resolves. If you have a pending lawsuit speak to your lawyer in that case immediately. Youmust exclude yourself from this Class to continue your own lawsuit. Remember, the exclusiondeadline is [DATE].

16.If I exclude myself, can I get money from this settlement?

No. If you exclude yourself, you will not receive any payment. But, you may sue, continueto sue, or be part of a different lawsuit against Horizon.

THE LAWYERS REPRESENTING YOU

17.Do I have a lawyer in this case?

The Court appointed the following law firms to represent you and other Class Members. Theselawyers are called Class Counsel. You will not be charged for these lawyers. If you want to berepresented by your own lawyer, you may hire one at your own expense.

John W. Leardi, Esq.Vincent N. ButtaciPaul D. Werner, Esq.BUTTACI LEARDI & WERNER LLC103 Carnegie Center, Suite 323Princeton, NJ 08540


D. Brian HuffordJason S. CowartZUCKERMAN SPAEDER LLP399 Park Avenue, 14th FloorNew York, NY 10022

18.How will the lawyers be paid? Will the Class Representatives receive anything beyond theirshare of claims?

The Settlement Agreement allows Class counsel to ask the Court to approve payment of up to$11,000,000 (1/3 of the settlement) for attorneys’ fees, and a separate award to reimburse Class Counselfor out-of-pocket expenses incurred to prosecute this case. The Court may award less than theseamounts. The attorneys’ fees would pay Class counsel for their work over the last six years toinvestigate the facts, litigate the case, and negotiate the settlement – all without receiving anycompensation to date. On or about [date], Class Counsel will post on the settlement website,www.NJChiroClassAction.com, their petition for attorneys’ fees and reimbursement of expenses,which will specify the amounts requested and the reasons why Class counsel believe they are entitled tothose payments.


85084865.13

Pursuant to the Settlement Agreement, Class counsel will also ask the Court to award separatepayments of $45,000 each to Drs. DeMaria, Proodian, and Probe for their services as ClassRepresentatives.

Whatever awards the Court orders will reduce the $33,000,000 settlement fund. Horizon will also payEpiq (the Settlement Administrator) the first $160,000 of the costs to administer the settlement(estimated at approximately $211,000), with any remaining costs paid from the settlement fund.

OBJECTING TO THE SETTLEMENT

You can tell the Court that you don’t agree with the settlement or some part of it.

19.How do I tell the Court that I don’t like the settlement?

If you’re a Class Member, you can object to the settlement if you don’t like any part of it. You cangive reasons why you think the Court should not approve it. The Court will consider your views. Toobject, you must use the Objection Form, which is available on the settlement website,www.NJChiroClassAction.com. You may also send a letter, provided it contains the sameinformation as requested on the Objection Form. You must mail the objection to the following fourdifferent addresses postmarked no later than [DATE]:

Court Clerk of the CourtUnited States District Court for the District of New JerseyMartin Luther King Building & U.S. Courthouse50 Walnut Street, Room 4015Newark, NJ 07101

Class Counsel John W. LeardiBUTTACI LEARDI & WERNER LLC103 Carnegie Center, Suite 323Princeton, NJ 08540


Defense Counsel James P. Flynn, Esq.EPSTEIN BECKER & GREEN, P.C.One Gateway CenterNewark, NJ 07102


95084865.13

Please note: Judge Martini has ordered that, if you object, Class Counsel and Defense Counsel maytake your deposition, and review any relevant documents you may have, concerning your objection tothe settlement. Neither Class Counsel nor Defense Counsel would represent you in thoseproceedings. If you desired to have legal representation in connection with such a deposition, youwould have to obtain—and pay—for that yourself.

20. What’s the difference between objecting and excluding?

Objecting is simply telling the Court that you don’t like something about the settlement. You canobject only if you stay in the Class. Excluding yourself is telling the Court that you don’t want tobe part of the Class. If you exclude yourself, you have no basis to object because the case no longeraffects you.

THE COURT'S FAIRNESS HEARING

The Court will hold a hearing to decide whether to approve the settlement. You may attendand you may ask to speak, but you don’t have to.

21.When and where will the Court decide whether to approve the settlement?

The Court will hold a Fairness Hearing at [DATE AND TIME], at the United States District Court for theDistrict of New Jersey, Martin Luther King Building & U.S. Courthouse, 50 Walnut Street, Room 4015Newark, NJ 07101, Courtroom MLK 4B. At this hearing the Court will consider whether the settlement isfair, reasonable, and adequate. If there are objections, the Court will consider them. Judge Martini will listento people who have asked to speak at the hearing. The Court may also decide how much to pay to ClassCounsel. After the hearing, the Court will decide whether to approve the settlement. We do not know howlong these decisions will take.

22.Do I have to come to the hearing?

No. Class Counsel will answer questions Judge Martini may have. But, you are welcome to come atyour own expense. If you send an objection, you don’t have to come to Court to talk about it. As longas you mailed your written objection on time, the Court will consider it. You may also pay your ownlawyer to attend, but it’s not necessary.

23.May I speak at the hearing?

You may ask the Court for permission to speak at the Fairness Hearing. To do so, you must send aletter saying that it is your “Notice of Intention to Appear in DeMaria v. Horizon.” Be sure toinclude your name, address, telephone number, and your signature. Your Notice of Intention toAppear must be postmarked no later than [Date], and be sent to the Clerk of the Court, Class


105084865.13

Counsel, and Defense Counsel, at the four addresses in question 18. You cannot speak at thehearing if you excluded yourself.

IF YOU DO NOTHING

24.What happens if I do nothing at all?

If you do nothing, you’ll get your pro rata share of the settlement fund, based on claims that youalready submitted to Horizon. But, unless you exclude yourself, you won’t be able to start a lawsuit,continue with a lawsuit, or be part of any other lawsuit against Horizon about the legal issues in thiscase, ever again.

GETTING MORE INFORMATION

25.Are there more details about the settlement?

This notice summarizes the proposed settlement. More details can be found on the settlementwebsite, www.NJChiroClassAction.com. These documents include the following:

• Settlement Agreement

• Court’s June 1, 2015 Opinion and Order Granting Class Certification

• Plan of Allocation

• Request for Exclusion Form

• Objection Form

26.How do I get more information?

You can call 1-877-341-4577 toll free; write to DeMaria v. Horizon Class Action SettlementAdministrator, PO Box 4390, Portland, OR 97208-4390; or visit the settlement website,www.NJChiroClassAction.com. Please do not contact Horizon.


Exhibit 5


5119955.15119955.35119955.7

If you are a Chiropractor who filed claims with Horizon Blue Cross Blue Shield of NewJersey from 2005 to 2010, you could get a payment from a class action settlement.

This Notice is about the settlement of a class action lawsuit concerning the denial by Horizon Blue Cross Blue Shield of NewJersey (“Horizon”) of reimbursement claims submitted by chiropractors, DeMaria et al. v. Horizon et al. (the “Lawsuit”). As theresult of a proposed Settlement of the Lawsuit you may be entitled to the payment of money for certain evaluation andmanagement services (“E/M”) or physical therapy (“PT”) modalities provided on the same day to the same patient aschiropractic manipulative therapy (“CMT”).

What Is the Lawsuit About? Horizon “bundled” (i.e., did not pay separately) claims submitted by chiropractors for certainevaluation and management services (“E/M”) or physical therapy (“PT”) modalities provided on the same day as CMT. In 2009,the NJ Department of Banking and Insurance ordered Horizon to cease and desist this “bundling” practice as of April 10, 2010.The Lawsuit sought remedies for Horizon’s “bundling” practice before that date. The Court certified the Lawsuit as a ClassAction on June 1, 2015. Horizon denies that it did anything wrong, but the parties to the Lawsuit have reached a Settlement,which the Court has preliminarily approved.

What is the Settlement? Horizon will pay $33,000,000 into an Escrow Account to be administered by a Court-appointedSettlement Administrator. After payment of fees and costs associated with the Lawsuit, the Settlement Administrator willdistribute the balance of the Escrow Account, on a pro rata basis, to chiropractors whose claims for E/M and PT services on thesame day as CMT services were denied by Horizon, from Dec. 16, 2005 until April 10, 2010 (the “Class Period”). Counsel forthe Class will also ask the Court to award attorneys’ fees up to 33% of the settlement amount and to pay litigation expenses.

Your Rights May Be Affected. If you were a chiropractor who submitted CMT, E/M, and/or PT claims to Horizon during theClass Period, your rights may be affected, and you have a choice to make now:

DO NOTHING: By doing nothing, you will automatically receive your pro rata share of the Settlement. However, you giveup the right to sue Horizon separately about the legal claims raised in this Lawsuit; or

ASK TO BE EXCLUDED OR OBJECT: If you ask to be excluded, you won’t share in the Settlement. However, you keepthe right to sue Horizon separately about the legal claims raised in the Lawsuit. You can also object to the settlement. Forinstructions on requesting exclusion or objecting, visit the website listed below or contact the Settlement Administrator using thecontact information below. It is important to note that the deadline for requesting exclusion is [Month 00, 2016].

Where Can I Get More Information? You can obtain a detailed notice about the Lawsuit and other important courtdocuments at www.NJChiroClassAction.com; or by calling the Settlement Administrator at 877-341-4577. Do not call Horizon.


Exhibit 6


5137549.5


ALPHONSE A. DEMARIA, et al., on theirown behalf and on behalf of certifiedclasses,

Plaintiffs,

- v. -


Defendants.

::::::::::::::::::


[PROPOSED] ORDERAND FINAL JUDGMENT

This matter came before the Court for hearing under this Court’s Order, dated

_____________________, 2016 (“Preliminary Approval Order”), on Plaintiffs’ Motion (the

“Motion”) for Final Approval of a Settlement Agreement dated May 6, 2016 (the “Settlement

Agreement”). Due and adequate notice having been given to the certified ERISA Class and the

certified Non-ERISA Class (collectively, the “Class”) as required in the Preliminary Approval

Order, and the Court having considered all papers filed and proceedings herein and otherwise

being fully informed, and good cause appearing therefore, IT IS HEREBY ORDERED,

ADJUDGED AND DECREED that:

1. This Judgment incorporates the Settlement Agreement’s definitions by reference,

and all terms used herein shall have the meanings set forth in the Settlement Agreement.

2. This Court has jurisdiction over the Class Action and over all parties to the Class

Action, including all Class members.


25137549.5

3. The Court finds that the Motion should be, and hereby is, GRANTED.

4. The Court finds that the Settlement Agreement is, in all respects, fair, just,

reasonable and adequate to the Class and, therefore, finally approves the Settlement under Fed.

R. Civ. P. 23(e), and directs the Settlement Agreement’s terms to be performed as stated therein.

Except as otherwise expressly provided in the Settlement Agreement, Horizon shall have no

responsibility whatsoever for the administration of the Settlement or the allocation of funds

related thereto, and shall have no liability whatsoever to any person, including, but not limited to,

Class Members, in connection with any such administration or allocation.

5. The Class Action and all its claims, including all Settlement Claims (except for

any individual claims of Class members, identified in Exhibit 1 hereto, who have validly and

timely requested exclusion from the Class), are dismissed with prejudice. The Parties shall bear

their own costs, except as otherwise provided in the Settlement Agreement.

6. On the Effective Date: (a) Plaintiffs and each and all Class members shall be

deemed to have, and by operation of the Judgment shall have, fully, finally, and forever released,

relinquished and discharged all Settlement Claims against the Horizon Parties; and each and all

Class members are hereby forever barred and enjoined from asserting, commencing or

prosecuting any and all Settlement Claims against Horizon or the Horizon Parties; and (b)

Horizon and the Horizon Parties shall be deemed to have, and by operation of the Judgment shall

have, fully, finally, and forever released, relinquished and discharged all Released Parties’

Claims against Plaintiffs and any member of the Class; and Horizon and the Horizon Parties are

hereby forever barred and enjoined from asserting, commencing or prosecuting any and all

Released Parties’ Claims against Plaintiffs or any member of the Class, provided, however, that

nothing herein shall release the Parties from their obligations under the Settlement Agreement.


35137549.5

7. The Mailed Notice, Publication Notice, and Long Form Notice published on the

Web site (collectively, the “Notice”) given to the Class was the best notice practicable under the

circumstances, including individual notice to all Class members who could be identified through

reasonable effort, and said Notice fully satisfied the requirements of applicable law, including

Rule 23(c)(2), and the Due Process Clause of the United States Constitution.

8. The Settlement and the Settlement Agreement, and any act performed or

document executed under or in furtherance of the Settlement and the Settlement Agreement or

any negotiation, discussion or proceedings in connection with the Settlement and the Settlement

Agreement shall not be offered or received against any Party for any reason including, without

limitation, as evidence of or construed as or deemed to be evidence of any presumption,

concession, or admission by any of the Defendants with respect to the truth of any fact alleged by

Plaintiffs or the validity of any claim that was or could have been asserted in the Class Action, or

in any litigation, or the deficiency of any defense that was or could have been asserted in the

Class Action, or in any litigation, or of any liability, negligence, fault, or wrongdoing of any or

all Defendants.

9. Without affecting this Judgment’s finality in any way, this Court hereby retains

continuing jurisdiction over implementation of the Settlement Agreement and all Parties for the

purpose of construing, enforcing and administering the Settlement Agreement.

10. The Court finds that during the course of the Action, the Parties and their

respective counsel at all times complied with the requirements of Fed. R. Civ. P. 11.

11. If the Settlement does not become effective in accordance with the Settlement

Agreement, then (i) this Judgment shall be rendered null and void to the extent provided by and

in accordance with the Settlement Agreement and shall be vacated and, in such event, all orders


45137549.5

entered and releases delivered in connection herewith shall be null and void to the extent

provided by and in accordance with the Settlement Agreement, and (ii) the parties shall

immediately revert to their litigation positions as of May 6, 2016.

12. The Court hereby GRANTS Plaintiffs’ Motion for Attorneys’ Fees, and awards

Class Counsel attorneys’ fees of $ ________________, and Litigation Expenses of

$_____________________, to be paid immediately to Class Counsel from the Settlement Fund

in accordance with paragraph 20 of the Settlement Agreement. Pursuant to paragraph 20(d) of

the Settlement Agreement, Class Counsel shall have sole authority and responsibility for

allocating awarded attorneys’ fees and Litigation Expenses among counsel. The Court notes that

Horizon took no position with respect to Class Counsel’s applications to the Court as set forth in

¶ 20(b) of the Settlement Agreement, leaving the reasonableness and timing of such awards to

the Court’s determination under applicable law. Horizon further shall have no responsibility for

said allocations (nor for any refunds or repayments, if necessary, under paragraph 20(d) of the

Settlement Agreement) or to any other person or entity which shall assert any claims relevant

thereto.

13. The Court finds that this Order and Judgment constitutes a final adjudication on

the merits of the Class Action, and should be entered without delay. Accordingly, the Clerk is

directed to enter this Judgment forthwith.

SO ORDERED

________________________________________William J. MartiniUnited States District Judge


Exhibit 7


UNITED STATES DISTRICT COURT DISTRICT OF NEW JERSEY

ALPHONSE A. DEMARIA, et al., on their own behalf and on behalf of all others similarly situated,

Case No. 2:11-cv-07298(WJM)(MF) Plaintiffs,

- v. -

HORIZON HEALTHCARE SERVICES, INC. d/b/a HORIZON BLUE CROSS BLUE SHIELD OF NEW JERSEY, et al.,

Defendants.

STIPULATION CONCERNING DEFENDANTS' CLAIMS DATA

The parties, by counsel, stipulate to the following facts concerning benefit claims data

maintained by Defendants.

1. As used in this Stipulation, the following terms have the prescribed meanings:

a. "Class Period" means December 16, 2005 to April 10, 2010.

b. "Claims Data" means data created, maintained, and stored by Defendants related to

(i) claims for health care benefits submitted by chiropractors to Defendants during

the Class Period, which was (ii) produced to Plaintiffs on or about May 25, 2014.

c. "Horizon Plan" means a plan of health insurance insured and/or administered by

Defendants

d. "Claims Engine" means a rule-based collection of software, files, protocols, and

databases that processes, adjudicates, and pays claims for health care benefits

pursuant to Horizon Plans.

4561293.6


e. "Member" means an individual who, as a Subscriber or through association with a

Subscriber, is eligible to receive health care benefits under a Horizon Plan.

f. "Subscriber" means an individual through whom coverage is provided to Member

under the Horizon Plan applicable to that Subscriber and Member.

g. "CPT code" means the set of American Medical Association Current Procedural

Terminology codes used on submitted claims to denote the services performed by

the provider for which a claim for benefits was being made.

h. "CMT" means services denoted by CPT codes 98940, 98941, 98942, and 98943.

i. "E/M" means services denoted by CPT codes 99201, 99202, 99203, 99204, 99205,

99211, 99212, 99213, 99214, 99215, 99241, 99242, 99243, 99244, and 99245.

j. "PT" means services denoted by CPT codes 97010, 97012, 97014, 97022, 97024,

97026, 97028, 97032, 97110, 97112, 97124, 97140, and 97530.

k. "ASO" means a Horizon Plan for which Defendants provide administrative

services only, i.e., a Horizon Plan that is self-funded.

1. "Par" means a chiropractor who is a participant in Defendants' network of

providers, i.e., an "in-network" provider.

m. "Non Par" means a chiropractor who is not a participant in Defendants' network of

providers, i.e. , an "out-of-network" provider.

2. During the Class Period, Defendants used two Claims Engines to process and

determine chiropractic claims: NASCO and QBlue.

3. The Claims Data accurately reflects and records: (a) certain attributes of claims

submitted by chiropractors to Defendants during the Class Period; and (b) determinations of those

claims, e.g., paid or denied.

4. Among the data fields within the Claims Data are:

2 4561293.6


a. PRODUCT: The Horizon product (e.g. HMO, Direct Access, PPO, etc.) associated

with the Subscriber and/or Member whose benefits are the subject of a submitted

claim.

b. CHG AMT: The charge submitted on a submitted claim, expressed in dollars.

c. ALLW AMT: The amount Defendants allowed on a submitted claim.

d. AMT PAID or PAID AMT: The amount Defendants paid on a submitted claim.

e. FST DOS and LST DOS: The first and last dates of service for a submitted claim.

f. PAYEE CD: The person or entity to whom Horizon made its benefits claim check

payable, with the field entries "P" referring to the provider, "S" referring to the

Subscriber, and "M" referring to the member.

g. PROV NM: The name of the provider or group of providers who submitted the

claim.

h. PAR IND: Whether the provider was Par (indicated by "P") or Non Par (indicated

by "N") at the time the service was performed.

i. PROV SPEC: The code used by Defendants to indicate the provider's specialty,

with 503 indicating chiropractor. In the Claims Data, PROV_SPEC is always 503.

j. PROV DESC: A description of the provider's specialty. In the Claims Data,

PROV DESC is always chiropractor.

k. PROV ADDR: The address of the provider. The Claims Data also includes data

fields for the provider's state, city, and ZIP code.

1. REND TIN: The tax identification number associated with the provider or group

of providers who submitted the claim.

m. LN_MOD, LNMOD2 and LN_MOD3: Fields which capture any CPT code

modifier included as part of the submitted claim.

3 4561293.6


n. SYS: The system which processed the submitted claim (with "QMX" indicating the

QB1ue engine and "NAS" indicating NASCO claims engine) or a system (such as

MPL) through which a claim was sent outside Horizon for claim determination

decisions .

o. MSG CD: A code associated with a claim determination that indicates the

message Defendants included on communications to providers, Subscribers, or

maintained within the Claims Engine itself regarding the submitted claim.

p. MSG TYP CD: The intended audience for the message, with "PRV" indicating

provider, "MBR" indicating Member, and "SYS" indicating the particular system as

defined in paragraph 4(n).

q. LN_ELIG_CHG_AMT: Charges Defendants considered for payment.

r. CLM _INELIG_CHG_AMT: Charges Defendants did not consider for payment.

s. PROC CD: The CPT code submitted by the provider.

t. LINE STAT: Whether the claim recorded on a particular claim line was paid ("P")

or denied ("D").

u. CLM NUM: A unique claim number for a single line claim or a series of

associated claim lines.

v. SUB _ID: A unique identification number for each Subscriber.

w. PDYEAR: The year a claim was finally determined.

x. PD DT: The month and day when a claim was finally determined.

y. ASO IND: Whether the claim was associated with a fully-insured plan or an ASO

plan, with "N" referring to fully-insured plans and "Y" referring to ASO plans.

z. RECEIVED DT: The date a claim was received by the Claims Engine.

4 4561293.6


5. In the Claims Data, claim lines associated with the same claim number but having

different CPT codes indicate that the provider submitted for multiple services performed on the

same day.

6. In the Claims Data, claim lines associated with the same claim number but having

different CPT codes for CMT, E/M, and PT services indicate that the chiropractor submitted those

different services performed on the same day.

7. It is possible to determine from the Claims Data instances when Defendants (i) paid

claims submitted by chiropractors for CMT services, but (ii) denied claims submitted by

chiropractors for E/M and PT services performed on the same day as the paid CMT service.

8. It is possible to ascertain from the Claims Data the tax ID numbers (REND TIN)

under which providers submitted claims where Defendants (i) paid claims submitted by

chiropractors for CMT services, but (ii) denied claims submitted by chiropractors for E/M and PT

services performed on the same day as the paid CMT service.

Dated: July t, 2014

4561293.6 5


John W. Leardi, Esq. Paul D. Werner, Esq. BUTTACI & LEARDI, LLC 103 Carnegie Center, Suite 101 Princeton, New Jersey 08540 [email protected] [email protected] Tel: (609) 799-5150 Fax: (609) 799-5180

William K. Meyer ZUCKERMAN SPAEDER LLP 100 East Pratt Street, Suite 2400 Baltimore, MD 21202 [email protected] Tel: (410) 332-0444 Fax: (410) 659-0436

D. Brian Hufford Jason S. Cowart Brian K. Mahanna ZUCKERMAN SPAEDER LLP 1185 Avenue of the Americas, 31st Fl. New York, NY 10036 [email protected] [email protected] [email protected] Tel: (212) 704-9600 Fax: (212) 704-4256

Attorneys for Plaintiffs'

2, Jai . Flynn, Esq. Am Hatcher, Esq. EPSTEIN BECKER & GREEN, P.C. One Gateway Center Newark, NJ 07102 [email protected] [email protected] Tel: (973) 642-1900 Fax: (973) 642-0099

Attorneys for Defendants

4561293.6

6


Exhibit 8


5138207.3

AGREED PUBLIC STATEMENT

On ______________, Zuckerman Spaeder LLP and Buttaci Leardi & Werner LLC asclass counsel for the chiropractic classes in ALPHONSE A. DEMARIA, et al., on theirown behalf and on behalf of certified classes v. HORIZON HEALTHCARE SERVICES,INC. d/b/a HORIZON BLUE CROSS BLUE SHIELD OF NEW JERSEY, et al., ,announced an agreement to resolve the DeMaria class action lawsuits pending before theUnited States District Court for the District of New Jersey. If the court approves thesettlement, the agreement will conclude the lawsuit against Horizon Blue Cross BlueShield of New Jersey (“Horizon BCBSNJ”).

Horizon BCBSNJ has agreed to place $33 million into an escrow fund from which ClassMembers will receive payments related to the denial of submitted claims for certainevaluation and management services (“E/M”) or physical therapy (“PT”) modalities thatClass Members performed on the same date on which they performed and were paiddirectly by Horizon for chiropractic manipulative therapy (“CMT”) treatments for thesame patient for the period of December 16, 2005 through April 15, 2010.

The fund will also see to the payment of the attorneys’ fees and litigation expenses forClass Counsel.

This settlement, once approved, will end litigation originally filed in 2011. ClassMembers will be paid without the need for re-submission, reprocessing or re-evaluationof claims.

For more information regarding this settlement, please contact William Meyer, Esq.at Zuckerman Spaeder LLP, 410-332-1240 or [email protected].


demaria et al. v. horizon healthcare services, inc....2016/05/17 · case 2:11-cv-07298-wjm-mf...

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