Clinical and Preventive Guidelines and Policies

At Horizon NJ Health, we follow clinical and preventive guidelines for our Disease Management Programs and for the care we give to our members. These guidelines are determined by evidence-based medicine and rigorous review of published medical literature. Our medical policies (Medical Policy Manual) are developed and approved by the Medical Policy Committee at Horizon Blue Cross Blue Shield of New Jersey as well as by the Utilization Management and Continuous Quality Improvement Committees at Horizon NJ Health. Pre-authorizations and/or authorizations of all medical services are conducted using one of the following Horizon NJ Health-approved approaches: MCG criteria or Horizon Medical Policies.

American Society of Addiction Medicine (ASAM) criteria will be used when making coverage determinations for services related to Substance Use Disorders.

Members and providers can obtain a copy of the benefit provision, guideline, protocol or other criteria on which decisions are based at no cost by contacting Horizon NJ Health at 1-800-682-9094 ext. 89469.

Vision

We contract with Davis Vision to provide vision benefits to Horizon NJ Health members. Please visit Davis Vision at www.davisvision.com for more information on Davis Vision policies.

Outpatient Imaging

National Imaging Associates (NIA) provides outpatient imaging management services for Horizon NJ Health. NIA radiation oncology policies have been adopted for Horizon NJ Health. NIA guidelines are currently available on their website at http://www.radmd.com/. RadMD is available Monday through Friday 5:00 a.m. to 12:00 a.m., Eastern Time (ET) and Saturday 8:00 a.m. to 1:00 p.m., ET. For assistance or technical support, please call 1-877-80-RadMD (877-807-2363).

Dental

SKYGEN USA administers dental services for Horizon NJ Health members. For more information, please contact SKYGEN USA 1-855-878-5368.

“Dental necessity” or “dentally necessary” means or describes a dental service that a dental care provider, exercising prudent clinical judgment, would provide to a covered person for the purpose of evaluating, diagnosing or treating a dental illness, injury, disease or its symptoms and that is: in accordance with the generally accepted standards of dental practice; clinically appropriate, in terms of frequency, extent, site and duration, and considered effective for the covered person’s dental illness, injury or disease; not primarily for the convenience of the covered person or the dental care provider; and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that covered person’s dental illness, injury or disease.