Utilization Management

Horizon NJ Health has Utilization Management staff available Monday through Friday from 8 a.m. to 5 p.m., Eastern Time (ET) to respond to routine authorization requests. Physicians and health care professionals may call 1-800-682-9094.

Pre-authorizations and/or authorizations of all medical services are conducted using one of the following Horizon NJ Health-approved approaches: MCG criteria (www.careguidelines.com) or Horizon Medical Policies.

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. The clinical rationale for this determination may be requested in writing. Please address all requests to:

Horizon NJ Health
Medical Director
1700 American Boulevard
Pennington, NJ 08534

Utilization Management Decisions for Appropriate Care and Services

Horizon NJ Health follows ethical business practices and values as part of how we conduct our Medical Management Program:

  • Utilization Management (UM) decisions are made based on the member's health care needs and services and the Medicaid/NJ FamilyCare benefit.
  • Horizon NJ Health does not offer rewards or pay to those who make UM decisions.
  • Horizon NJ Health does not offer any rewards or pay to its staff who handle the UM decisions for denials of coverage or services that are needed for good health.
  • Horizon NJ Health does not give rewards or pay to hospitals, doctors and other healthcare professionals to deny or not offer covered health care services that are medically needed.