This chart provides information about the type of documentation that Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ) requires for preservice requests and post-service claims. The list of codes is not an exhaustive list. It includes the major codes applicable to the medical policy referenced. Codes may be subject to changes made by the American Medical Association (AMA).
Providing the documentation indicated is not a guarantee of payment. Payment is determined based on all terms, conditions, limitations and exclusions of the member’s benefit plan, including the medical necessity of the services provided; the member’s eligibility at the time the services are provided; the agreement between the physician or other health care professional and Horizon BCBSNJ, if applicable; and the out-of-network fee schedule for the member’s benefit plan, if applicable.
The fact that a health care professional prescribes, orders, recommends or approves of a service, treatment, procedure, equipment, device, supply or drug does not make them medically necessary. Further, the fact that no prior authorization is required for a particular service, treatment, procedure, equipment, device, supply, or drug does not mean it is medically necessary.
Decisions regarding treatment and treatment plans and the corresponding documentation are the responsibility of physicians and other health care professionals. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. Physicians and other health care professionals remain responsible for the quality and type of health care services provided to Horizon BCBSNJ members.