Horizon contracts with a variety of specialized business partners, or vendors, that manage certain programs on our behalf. Through these programs, these business partners make decisions about the administration of plan benefits for services requested for eligible members that participate in those programs.
Not all members participate in all the programs noted below.
Information about the clinical guidelines used by these vendors in making decisions about the administration of plan benefits is provided below.
For members that do not participate in a particular program, Horizon’s clinical guidelines would be used to understand how we make decisions about the administration of plan benefits.
Please contact the Member Services phone number on the back of your member ID card if you have questions about your participation in any of the programs noted below.
Horizon Care@Home Program
As part of the Horizon Care@Home Program, CareCentrix, Inc. reviews in-network requests for: Durable Medical Equipment (including Medical Foods, and Diabetic and Other Medical Supplies); Orthotics and Prosthetics and Home Infusion Therapy Services, including hemophilia.
Horizon reviews requests for: home health services such as in-home nursing services, physical therapy, occupational therapy and speech therapy.
Member Participation in this Program
Members enrolled in the following plans/programs are participating in this program:- Horizon commercial and level-funding plans/products
- Braven Health Medicare Advantage (MA) plans
- Certain Administrative Services Only (ASO) employer group accounts that have opted in to this program
- State Health Benefits Program (SHBP)/School Employees’ Health Benefits Program (SEHBP)
- Federal Employee Program® (FEP®) plans/products
Clinical Guidelines
CareCentrix uses Horizon’s clinical guidelines in support of their review processes.Horizon contracts with CareCentrix, Inc., a Delaware corporation and its subsidiary, CareCentrix of New Jersey, Inc., a New Jersey Corporation licensed by the NJ Department of Banking and Insurance as an Organized Delivery System to administer certain services for the Horizon Care@Home program. The Blue Cross® and Blue Shield® words and symbols, Federal Employee Program® and FEP® are all trademarks owned by the Blue Cross Blue Shield Association.
Horizon Supportive Care and Readmission Program
Through this program, we work with CareCentrix, Inc. to manage member access to care in the post-acute care setting and to provide support to our members requiring palliative care.
Member Participation in this Program
CareCentrix provides utilization management and member support in the post-acute care setting as well as a community-based palliative care program for patients enrolled in:- Horizon fully insured commercial plans
- Braven Health℠ Medicare Advantage plans
Clinical Guidelines
CareCentrix uses Horizon’s clinical guidelines in the administration of this program.CareCentrix, Inc. and CareCentrix of New Jersey, Inc. are independent companies that provide utilization and other management services in the areas of durable medical equipment, home infusion, post-acute and palliative care to Horizon Blue Cross Blue Shield of New Jersey. CareCentrix, Inc. and CareCentrix of New Jersey, Inc. are independent from, and not affiliated with, Horizon Blue Cross Blue Shield of New Jersey or the Blue Cross Blue Shield Association.
Surgical and Implantable Device Management Program
Horizon contracts with TurningPoint Healthcare Solutions, LLC (TurningPoint) for our Surgical and Implantable Device Management Program.
TurningPoint reviews requests for certain Cardiac Services, Orthopedic services, Spine Services and other related services, requested by in-network and out-of-network physicians. The requests are reviewed to make sure the service is medically necessary and appropriate.
Member Participation in these Programs
For Cardiac Services
- Horizon fully insured or level-funded plans/products including those members enrolled in plans that include BlueCard® benefits for care received outside of our local service area.
- State Health Benefits Program (SHBP)/School Employees’ Health Benefits Program (SEHBP) plans.
- Blue Cross and Blue Shield Federal Employee Program® (FEP®) plans/products.
- Horizon NJ Health NJ FamilyCare plans.
- Horizon NJ Health Horizon NJ TotalCare (HMO D-SNP) plans.
For Orthopedic Services
- Horizon fully insured or level-funded plans/products including those members enrolled in plans that have BlueCard® benefits for care received outside of our local service area.
- Braven Health Medicare Advantage (MA) plans.
- State Health Benefits Program (SHBP)/School Employees’ Health Benefits Program (SEHBP) plans.
- FEP® plans/products.
- Horizon NJ Health NJ FamilyCare plans.
- Horizon NJ Health Horizon NJ TotalCare (HMO D-SNP) plans.
For Spine Services
- Horizon fully insured or level-funded plans/products including those members enrolled in plans that include BlueCard® benefits for care received outside of our local service area.
- Certain Administrative Services Only (ASO) employer groups that have opted in to participation in this specific program.
- Braven Health Medicare Advantage (MA) plans.
- FEP® plans/products.
- Horizon NJ Health NJ FamilyCare plans.
- Horizon NJ Health Horizon NJ TotalCare (HMO D-SNP) plans.
Clinical Guidelines
Visit TurningPoint’s Clinical Guidelines & Policies webpage to review the clinical guidelines used in the administration of this program.TurningPoint Healthcare Solutions, LLC supports Horizon Blue Cross Blue Shield of New Jersey in the administration and utilization management review of certain orthopedic, spine and cardiac services for coverage. TurningPoint Healthcare Solutions, LLC is independent from, and not affiliated with Horizon Blue Cross Blue Shield of New Jersey or the Blue Cross Blue Shield Association. The Blue Cross® and Blue Shield® words and symbols, Federal Employee Program® and FEP® and BlueCard® are all trademarks owned by the Blue Cross Blue Shield Association.
Cardiology Imaging Program
eviCore healthcare (eviCore) reviews certain nonemergency radiology service requests to determine if they are necessary and appropriate for members. The services include:
- Echo Stress Test
- Diagnostic Left Heart Catheterization
- Echocardiogram
Member Participation in this Program
eviCore reviews requests for Cardiology Imaging services for members enrolled in the following plans/products.- Horizon commercial and level-funding plans/products
- Braven Health Medicare Advantage (MA) plans
- Certain Administrative Services Only (ASO) employer groups that have opted in to participation in this specific program
- State Health Benefits Program (SHBP)/School Employees’ Health Benefits Program (SEHBP) plans
- Horizon NJ Health NJ FamilyCare plans
- Horizon NJ Health Horizon NJ TotalCare (HMO D-SNP) plans
Clinical Guidelines
eviCore uses Horizon’s clinical guidelines in the administration of this program.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 services.
Radiology/Imaging Services
eviCore healthcare (eviCore) reviews requests for certain nonemergency radiology services to determine if they are necessary and appropriate for members. The services include:
- CT/CTA scans
- MRI/MRAs
- PET scans
- Nuclear medicine studies, including nuclear cardiology
Member Participation in this Program
eviCore reviews requests for radiology imaging services that are to be provided to members enrolled in the following plans/products.- Horizon commercial and level-funding plans/products
- Braven Health Medicare Advantage (MA) plans
- Certain Administrative Services Only (ASO) employer groups that have opted in to participation in this specific program
- State Health Benefits Program (SHBP)/School Employees’ Health Benefits Program (SEHBP) plans
- Horizon NJ Health NJ FamilyCare plans
- Horizon NJ Health Horizon NJ TotalCare (HMO D-SNP) plans
Clinical Guidelines
Visit eviCore’s Clinical Guidelines webpage and click Cardiovascular & Radiology to review the clinical guidelines that eviCore uses as part of this program.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 services.
Molecular and Genomic Testing Program
eviCore healthcare (eviCore) reviews requests to perform certain clinical laboratory testing services, including:
- Hereditary cancer screening
- Carrier screening tests
- Tumor marker/molecular profiling
- Hereditary cardiac disorders
- Cardiovascular disease and thrombosis risk variant testing
- Pharmacogenomic testing
- Neurologic disorders
- Mitochondrial disease testing
- Intellectual disability/developmental disorders
Member Participation in this Program
eviCore reviews requests for clinical laboratory testing services that are to be provided to members enrolled in the following plans/products.- Horizon commercial and level-funding plans/products
- Braven Health Medicare Advantage (MA) plans
- Certain Administrative Services Only (ASO) employer groups that have opted in to participation in this specific program
This program does not apply to members enrolled through:
- State Health Benefits Program (SHBP)/School Employees’ Health Benefits Program (SEHBP) plans.
- Blue Cross and Blue Shield Federal Employee Program® (FEP®) plans/products.
- Horizon NJ Health NJ FamilyCare plans.
- Horizon NJ Health Horizon NJ TotalCare (HMO D-SNP) plans.
Clinical Guidelines
eviCore uses Horizon’s clinical guidelines in the administration of this program.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 services. The Blue Cross® and Blue Shield® words and symbols, Federal Employee Program® and FEP® are all trademarks owned by the Blue Cross Blue Shield Association.
Musculoskeletal Program for Pain Management Services
eviCore healthcare (eviCore) reviews requests for certain pain management services to determine if they are necessary and appropriate for members.
Member Participation in this Program
As part of this program, eviCore reviews requests for pain management services requests that are to be provided within New Jersey to members enrolled in the following plans/products.- Horizon commercial and level-funding plans/products
- Braven Health Medicare Advantage (MA) plans
- State Health Benefits Program (SHBP)/School Employees’ Health Benefits Program (SEHBP) plans
- Certain Administrative Services Only (ASO) employer groups that have opted in to participation in this specific program
This program does not apply to members enrolled through:
- Blue Cross and Blue Shield Federal Employee Programs (FEP®) plans/products.
- Horizon NJ Health NJ FamilyCare plans.
- Horizon NJ Health Horizon NJ TotalCare (HMO D-SNP) plans.
Clinical Guidelines
eviCore uses Horizon’s clinical guidelines in the administration of this program.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 services. The Blue Cross® and Blue Shield® words and symbols, Federal Employee Program® and FEP® are all trademarks owned by the Blue Cross Blue Shield Association.
Radiation Therapy Program
eviCore helps us ensure that the radiation therapy services provided to our members are consistent with nationally recognized clinical standards.
eviCore reviews requests for radiation therapy services for all cancers as well as for non-cancerous conditions that require radiation treatment including, but not limited to, the following:
- Adrenal Cancer
- Anal Cancer
- Bile Duct Cancer
- Bladder Cancer
- Bone Metastases
- Brain Metastases
- Breast Cancer
- Cervical Cancer
- Endometrial Cancer
- Esophagus Cancer
- Extracranial Oligometastases
- Gallbladder Cancer
- Gastric Cancer
- Head/Neck Cancer
- Hepatobiliary Cancer
- Hodgkin's Lymphoma
- Kidney Cancer
- Liver Cancer
- Multiple Myeloma
- Non-Cancerous Diagnosis
- Non-Hodgkin's Lymphoma
- Non-Small Cell Lung Cancer
- Other Metastases (Non-Bone/Brain)
- Pancreatic Cancer
- Primary Central Nervous System Lymphoma
- Primary Central Nervous System Neoplasms
- Prostate Cancer
- Rectal Cancer
- Skin Cancer
- Small Cell Lung Cancer
- Soft Tissue Sarcoma
- Testicular Cancer
- Urethral Cancer
- Vulva Cancer
Members Participation in this Program
Member’s enrolled in the following plans/products participate in this program.
- Horizon commercial and level-funding plans/products including those members enrolled in plans that have BlueCard® benefits for care received outside of our local service area.
- Braven Health Medicare Advantage (MA) plans.
- Certain Administrative Services Only (ASO) employer groups that have opted in to participation in this specific program.
- Horizon NJ Health NJ FamilyCare plans.
- Horizon NJ Health Horizon NJ TotalCare (HMO D-SNP) plans.
This program does not apply to members enrolled through:
- Blue Cross and Blue Shield Federal Employee Program® (FEP®) plans/products.
- State Health Benefits Program (SHBP)/School Employees’ Health Benefits Program (SEHBP).
Clinical Guidelines
eviCore uses Horizon’s clinical guidelines in the administration of this program.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 services. The Blue Cross® and Blue Shield® words and symbols, Federal Employee Program® and FEP® and BlueCard® are all trademarks owned by the Blue Cross Blue Shield Association.
Medical Injectables Program
Magellan Rx Management (Magellan Rx) reviews requests to provide specific injectable medications to determine if they are necessary and appropriate treatments for members.
Member Participation in this Program
Member’s enrolled in the following plans/products participate in this program.- Horizon commercial and level-funding plans/products including those members enrolled in plans that include BlueCard® benefits for care received outside of our local service area.
- Braven Health Medicare Advantage (MA) plans.
- State Health Benefits Program (SHBP)/School Employees’ Health Benefits Program (SEHBP).
- Certain Administrative Services Only (ASO) employer groups that have opted in to participation in this specific program.
Clinical Guidelines
Magellan Rx uses Horizon’s clinical guidelines in the administration of this program.Magellan Rx Management is an independent company that has contracted with Horizon Blue Cross Blue Shield of New Jersey in the administration of medical necessity and appropriateness review (MNAR) for certain medical injectable drugs. Magellan Rx Management is independent from and not associated with Horizon Blue Cross Blue Shield of New Jersey. BlueCard® is a registered mark of the Blue Cross Blue Shield Association.
The information provided here does not replace or modify the terms, conditions, limitations and exclusions contained within health benefit plans issued or administered by Horizon. In the event a conflict between the information provided here and member plan documents, member plan documents shall prevail. The information provided here is not a guarantee of payment. Claim processing is subject to member eligibility and all member and group benefit limitations, conditions and exclusions. Your doctor handles most of the interaction/communication with these business partners.
