Important - Please Read

The purpose of Horizon NJ Health’s Policies, which includes medical, pharmacy, dental and utilization management, and the Horizon Blue Cross Blue Shield of New Jersey’s Medical and Dental Policies utilized by Horizon NJ Health (“Horizon NJ Health Medical/Dental Policies”), is to provide general information applicable to the administration of health benefits that Horizon NJ Health administers for the NJ Medicaid/NJ FamilyCare members.

If a member’s contract benefits, as set forth in the NJ Medicaid State Contract differ from a policy, the Contract prevails. Applicable Federal and/or State regulations must be considered in the determinations. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. Horizon NJ Health’s Policies are not intended to direct the course of clinical care a physician or dentist provides to a member, and do not replace a physician or dentist’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon NJ Health members. Horizon NJ Health is not responsible for, does not provide, and does not hold itself out as a provider of medical or dental care. The physician and dentist remains responsible for the quality and type of health care services provided to a Horizon NJ Health member.

Horizon NJ Health’s Policies do not constitute medical or dental advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.

Policies can be highly technical and are designed for use by the Horizon NJ Health professional staff in making coverage determinations. Members referring to a Horizon NJ Health Policy should discuss the policy with their treating physician or dentist, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.

Horizon NJ Health Policies have been developed by the various Horizon NJ Health Policy Committees (the “Committees”) consistent with generally accepted standards of medical and dental practice, and reflect Horizon NJ Health’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. The policies also consider, in part, whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, the policies consider whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. They also consider whether the services, supplies or procedures are more costly than an alternative equally effective service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching conclusions regarding what it considers to be generally accepted standards of medical and dental practice, the Committees review and consider the following: all credible scientific evidence published in peer-reviewed medical and dental literature generally recognized by the relevant medical community, dental community, physician, dentist and health care provider specialty society recommendations, the views of physicians, dentists and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.

Horizon NJ Health’s Policies are proprietary. They are to be used only as authorized by Horizon NJ Health and its owners or affiliates. The contents of the Horizon NJ Health Policies are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon NJ Health. The contents of these Policies may be updated or changed without notice, unless otherwise required by law and/or regulation. Benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy.

Horizon NJ Health and its owners or affiliates make no representations and accept no liability with respect to the content of any external information cited or relied upon in the Horizon NJ Health Policies. Any discussions contained in the Horizon NJ Health Policies, which refer to a specific product, process or service by name, trademark or manufacturer reflect Horizon NJ Health’s opinion and are made without any attempt to defame.

In addition to the Horizon NJ Health Policies contained herein, Horizon NJ Health and its owners or affiliates may use other tools developed by third parties to assist in administering health benefits including, but not limited to:

  • Healthcare Management Guidelines, Milliman USA (most current version)
  • Inpatient and Surgical Care (Milliman USA)
  • Recovery Facility Care (Milliman USA)
  • Interqual 2003, Advanced Imaging Services Clinical Criteria for UM Decision Making
  • St. Anthony’s Medicare Coverage Manual (for durable medical equipment) (2004)
  • CMS- Local Medical Review Policies