MCG Care Guidelines

For certain services within the categories listed below, the administration of plan benefits in relation to member and group insured contracts and Administrative Services Only (ASO) accounts (except those where Horizon BCBSNJ is secondary to Medicare or to another commercial carrier) is based upon MCG Care Guidelines:

• Ambulatory Care
• Inpatient and Surgical Care
• General Recovery Care
• Recovery Facility Care
• Home Care
• Behavioral Health Care

If the insured’s contract benefits differ from the MCG Care Guidelines, the contract prevails.
Applicable federal and/or state regulations must be considered in the determinations. Coverage determinations are made on a case-by-case basis. Although a procedure or technology may be medically necessary, it may be excluded in a member’s benefit plan. If a service/supply is not eligible for coverage, a member and the treating health care professional may proceed with that service/supply knowing plan benefits are not available.

Horizon BCBSNJ coverage determinations are benefit decisions only, and are not the provision of medical care. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself as a provider of medical care. Only the treating health care professional can render medical care and be responsible for the quality or appropriateness of the medical care provided, or the skill with which it is provided.

MCG Care Guidelines can be highly technical and are used by our professional staff in making coverage determinations. Members and/or their covered dependents who are provided with a copy of a particular MCG Care Guideline should discuss the information with the treating health care professional, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.

MCG Care Guidelines do not constitute medical advice, authorization, certification, approval, Explanation of Benefits, offer of coverage, contract, or guarantee of payment.

MCG Care Guidelines are written to address the clinical circumstances of the majority of people. However, an individual’s unique clinical circumstances will be considered in light of these policies and peer-reviewed, evidence-based scientific literature.

Benefit determinations are made in the context of MCG Care Guidelines existing at the time of the decision, and are not subject to later revision as the result of a change in MCG Care Guidelines.

For information about accessing the MCG Care Guidelines, please visit mcg.com, and click Care Guidelines.

If you are not already licensed to use MCG’s evidence-based tools, visit mcg.com and:

• Click Contact Us and click Sales Inquiry.
• Complete the requested information and click Submit.

If you have questions, please contact your Network Hospital Specialist, Ancillary Reimbursement Analyst or Ancillary Contracting Specialist.