Medical Necessity Criteria
In 2020, Horizon BCBSNJ will begin using the care guidelines from MCG Health, LLC (MCG) to make behavioral health care utilization management determinations. We will no longer apply Beacon’s medical necessity criteria.
As noted below, the effective dates of our transition to MCG Behavioral Health Care Guidelines will coincide with our overall transition plan:
- Effective January 1 2020, MCG will be used to make behavioral health care coverage determinations for members enrolled in Horizon BCBSNJ Medicare Advantage plans.
- Effective April 1, 2020, MCG will be used to make behavioral health care coverage determinations for members enrolled in all other Horizon BCBSNJ plans including fully insured plans/products, self-insured(Administrative Services Only [ASO]) employer group plans including the State Health Benefits Program (SHBP) and the School Employees’ Health Benefits Program (SEHBP) and the Federal Employee Program® (FEP®).
Horizon BCBSNJ will continue to use American Society of Addiction Medicine (ASAM) criteria when making coverage determinations for services related Substance Use Disorders.
For more information, review our Frequently Asked Questions.
New to Horizon BCBSNJ?
Access the Quick Reference Guide for Horizon Behavioral Health Providers for important information about working with us.