Musculoskeletal Program

Horizon Blue Cross Blue Shield of New Jersey is committed to providing your patients, our members, with access to high-quality health care services that are consistent with nationally recognized clinical criteria and guidelines.

As part of that commitment, Horizon BCBSNJ collaborates with eviCore healthcare (eviCore) to administer our Musculoskeletal Program. eviCore conducts Prior Authorization and/or Medical Necessity Determination (PA/MND) reviews of certain musculoskeletal pain management and spine surgery services.

To obtain PA/MND from eviCore for musculoskeletal pain management or spine surgery services, please:

  • Submit a request online through eviCore.com
  • Call 1-866-241-6603, between 7 a.m. and 7 p.m., Eastern Time

Claim processing will be delayed and services may be denied if a PA/MND is not obtained prior to services being rendered.

Participating providers, based on their Agreements/Contracts with us, may not seek payment from members for denied claims/services because a PA/MND was not obtained prior to the performance of services or because medical documentation was requested from the referring or rendering provider.

If you have questions, please call eviCore at 1-866-241-6603.

Horizon Blue Cross Blue Shield of New Jersey collaborates with eviCore healthcare (eviCore) to administer a Prior Authorization and/or Medical Necessity Determination (PA/MND) review program for certain musculoskeletal pain management services.

Policies

The Horizon BCBSNJ Medical Policies on pain management were developed using recognized evidence-based guidelines and incorporate criteria derived from published materials that are supported by nationally-recognized agencies such as the American Society of Interventional Pain Physicians, the American Pain Society, the American Academy of Pain Management and the National Institutes of Health.

Medical Policy ManualPolicy
Access the Horizon BCBSNJ Medical Policy Manual to view clinical criteria and guidelines related to musculoskeletal pain management services.

Archive

Horizon Blue Cross Blue Shield of New Jersey collaborates with eviCore healthcare (eviCore) to conduct Prior Authorization and Medical Necessity Determination (PA/MND) reviews for certain Spine Surgery services for members enrolled in Horizon BCBSNJ fully insured products as well as ASO accounts that have elected the Musculoskeletal Program.

No reimbursement will be made for Spine Surgery services provided by a nonparticipating professional/facility unless PA/MND is obtained.

If an out-of-network co-surgeon will be used in the Spine Surgery, the referring/rendering health care professional is responsible for:

  • Notifying eviCore, AND
  • Informing the patient that he/she will be responsible for the higher out-of-pocket costs associated with using a nonparticipating co-surgeon.

Policies
Horizon BCBSNJ has adopted the eviCore guidelines for Spine Surgery services for use with members who are enrolled in plans that participate in the Musculoskeletal Program administered by eviCore.

Visit www.eviCore.com/HorizonSpineSurgery to access the Spine Surgery guidelines that apply to members enrolled in plans that have elected to participate in the Musculoskeletal Program administered by eviCore.

The eviCore guidelines were developed using recognized evidence-based guidelines and incorporate criteria derived from published materials that are supported by nationally-recognized agencies such as the American Society of Interventional Pain Physicians, the American Pain Society, the American Academy of Pain Management and the National Institutes of Health.

Please note that the Spine Surgery guidelines maintained on eviCore’s website pertain only to members who are enrolled in Horizon BCBSNJ plans that participate in the Musculoskeletal Program for Spine Surgery administered by eviCore.

Resources

Musculoskeletal Program for Spine Surgery Services Quick Reference Guide

Horizon BCBSNJ announcement of the Musculoskeletal Program for Spine Surgery Services

Spine Surgery Program Q&A