Clinical Guidelines

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.

You may also select a category below to review details to access clinical practice guideline information employed by vendors working on our behalf.

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.

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