Medical policies and prior authorizations

Horizon BCBSNJ and its network of quality doctors, health care professionals and facilities provide you access to the most appropriate medical care available, when you need it.

Horizon BCBSNJ has medical policies that reflect the most current medical industry standards. These medical policies, along with prior authorization reviews, ensure that you are receiving the most appropriate care in the appropriate location.

Generally, medical policies are guidelines that outline whether or not Horizon BCBSNJ considers certain services, supplies or prescription drugs medically necessary.

Your doctor or health care professional is welcome to view our medical policies.

Medical treatments or services that require prior authorization may include but are not limited to:

  • Computer tomography scan (CT)
  • Durable Medical Equipment (DME)
  • Home health or visiting nurse care
  • Infused or specialty medications
  • Inpatient facility stay (overnight stays including charges for room and board)
  • Magnetic resonance imaging (MRI)
  • Nuclear medicine, including nuclear cardiology

When prior authorization is required, your doctor or health care professional contacts Horizon BCBSNJ to provide us with medical information about your condition and/or treatment plan. If the medical policy and/or medical necessity criteria are met, then approval is granted if the service is available under your plan. Claims for services that do not require prior authorization may still be subject to medical necessity review even after the service has been rendered.

Please review the Utilization Review section of your health plan policy to determine which services require prior authorization or medical necessity review. Information about prior authorization and medical necessity is in your member handbook. You may also view the member handbook in the Education Center.

Approval is not a guarantee of payment. The benefits of your policy at the time of service are still applied, including in-network vs. out-of-network benefits, exclusions, limitations, copayments, deductibles and/or coinsurance. A service or treatment may be medically necessary but not covered under your specific health benefits plan.