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.