Medical Necessity Criteria
Effective January 1, 2020, Horizon NJ Health will begin using 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.
Effective 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 SNP)
For more information, review our Frequently Asked Questions.
¹Behavioral health outpatient services for Horizon NJ Health members who are not DDD or MLTSS are covered through Medicaid Fee for Service and not impacted by this change.
New to Horizon NJ Health?
Access the Quick Reference Guide for Horizon Behavioral Health Providers for important information about working with us.