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 adopted 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.
Click a topic below to review the clinical guideline information for that topic.
National Heart, Lung and Blood Institute’s (NHLBI) 2020 Focused Updated to the Asthma Management Guidelines
2017 ACC/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America
Congestive Heart Failure
2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America
Chronic Kidney Disease
KDOQI Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification, and Stratification
Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2021.
Hypertension 2017 Clinical Practice Guidelines
2020 International Society of Hypertension Global Hypertension Practice Guidelines
Centers for Disease Control and Prevention tools from Former Smokers Healthcare Providers: Tools and Resources
You may also select a category below to review details to access clinical practice guideline information employed by vendors working on our behalf.
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.
eviCore Healthcare (eviCore) provides outpatient imaging management services for Horizon NJ Health. eviCore radiation oncology policies have been adopted for Horizon NJ Health. eviCore guidelines are currently available on their website at eviCore.com. To speak to a representative, call eviCore at 1-866-496-6200, weekdays, 7 a.m. to 7 p.m.
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.
If you would like a printed copy of any information, please contact your Network Specialist.
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.
This content was last revised on March 24, 2022 and may be subject to change.