Medical Necessity Criteria

As of January 1, 2020, Horizon NJ Health will use the care guidelines from MCG Health, LLC (MCG) to make behavioral health care utilization management determinations. We will no longer apply Beacon’s medical necessity criteria.

Horizon NJ Health will continue to use American Society of Addiction Medicine (ASAM) criteria when making coverage determinations for services related Substance Use Disorders.

As of January 1 2020, MCG will be used to make behavioral health care coverage determinations for members enrolled in:

  • Horizon Medicare Advantage plans
  • Horizon NJ Health Medicaid plans - including Division of Developmental Disabilities (DDD), NJ FamilyCare and Managed Long Term Services & Supports (MLTSS) plans
  • Horizon NJ TotalCare (HMO D-SNP)

For more information, review our Frequently Asked Questions.

Important Resources