Coverage decisions

Have you ever wondered how Horizon BCBSNJ makes coverage decisions?

We want you to know that Horizon BCBSNJ:

• Makes utilization management (UM) decisions based on the medical necessity and appropriateness of care and service within the guidelines of your benefit coverage.
• Does not offer incentives to our employees or delegates performing medical management reviews incentives to encourage denials of coverage or service, and does not provide financial incentives to doctors to withhold covered health care services that are medically necessary and appropriate.
• Emphasizes access to the delivery of medically necessary and cost-effective health care services for members.
• Encourages the reporting, investigation and elimination of underutilization or overutilization, both of which can result in costly and improper uses of services, and are not helpful to you.
• Underutilization is when you aren’t getting enough care or services to properly meet your needs.
• Overutilization is when you undergo treatments, tests and studies that you don’t need.

For more information, please call Member Services at 1-800-355-BLUE (2583).