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Medical policies and prior authorizations

What are prior authorizations and medical policies?

Horizon BCBSNJ’s medical policy follows established clinical and preventive guidelines, so when you need care, you have access to the most appropriate options. Our medical policy includes our requirements for when a doctor or other health care professional must obtain a prior authorization (PA) or medical necessity determination (MND) before you can receive a procedure, treatment or equipment.

When a PA or MND is required, your doctor or health care professional contacts Horizon BCBSNJ to provide us with medical information about your condition and/or treatment plan. Horizon BCBSNJ reviews this information to ensure it meets our requirements under our medical policy. If so, then approval is granted if the service is available under your plan. Your doctor or health care professional is welcome to read these policies online.

Our PA/MND programs benefit our members because they help ensure our members receive the most appropriate care that also provides the greatest value. Procedures, treatments and equipment that may require approval from one of these programs include:

  • 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

You can see which services require prior authorization by signing in to Member Online Services at and clicking What’s Covered.

It’s important to know that claims for services that do not require PA may still be subject to an MND even after the service has been provided.

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. You can also see which services require prior authorization by signing in to Member Online Services at and clicking What’s Covered.

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.

This article is for informational purposes only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.