Ultrasound Services Program
The implementation of our Ultrasound Services Program is being delayed until further notice.
We are reviewing current program guidelines and criteria in preparation for our implementation at a future date. We will advise you of further program updates on HorizonBlue.com/providernews.
Horizon BCBSNJ will partner with eviCore healthcare (eviCore) to administer our Ultrasound Services Program.
As part of this program, eviCore will perform Medical Necessity Determination (MND) reviews of certain obstetrical and non-obstetrical ultrasound procedures based on Horizon BCBSNJ’s Medical Policy guidelines and criteria for services to be provided to members enrolled in Horizon BCBSNJ fully insured and Medicare Advantage products/plans.¹ (Ultrasound services rendered in an Inpatient setting, Observation setting or in an Emergency Room (ER) are not subject to MND review as part of this program).
This program introduces medical necessity determination, as appropriate, for ultrasound services. This program does NOT add a prior authorization requirement.
Ultrasound services submitted on professional and facility claims that are reviewed by eviCore on a post-service basis and deemed not medically necessary may not be eligible for coverage or payment by Horizon BCBSNJ.
eviCore will not perform member scheduling for ultrasound services as part of this program.
Please note that eligibility and participation may vary based on line of business therefore, all providers should check eligibility and benefits prior to performing any services related to this program. In addition, actual benefit determinations cannot be made until a claim is received and is subject to the provisions of the patient’s present contract including any applicable deductible, coinsurance and/or coordination of benefits. Payment is dependent on the patient being an eligible Horizon BCBSNJ member at the time the services are rendered. Authorizations will be affected should the claim submitted differ from the information provided at the time of a request.
- Review our Ultrasound Services Program FAQs for details about this program, including instructions on how to request and validate MNDs for obstetrical and non-obstetrical services
- Ultrasound services subject to MND as part of this program
- Code Bundling Rules
- Code Pair Rules Bank
- Maternal Fetal Medicine Evaluation Coding
- Access our Medical Policy Manual to review clinical criteria and guidelines related to ultrasound services as well as our Standards for Diagnostic Radiology/Imaging Facilities/Freestanding-Office including Surgi-Centers and Diagnostic Dental - Radiographic Imaging
- Review our Diagnostic Imaging Privileging Policy to identify the accreditation required for practitioners and facilities to render and receive MND approvals for ultrasound services
eviCore healthcare is an independent company that supports Horizon Blue Cross Blue Shield of New Jersey in the provision of Prior Authorization and/or Medical Necessity Review (PA/MND) of certain nonemergency radiology services.
¹Members enrolled in Self-Insured ASO (Administrative Services Only) employer groups, the State Health Benefits Program (SHBP) and School Employees’ Health Benefits Program (SEHBP), the Federal Employee Program® (FEP®), Horizon NJ Health or Horizon NJ TotalCare (HMO SNP) are not included in this new program expansion.