The Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ) Utilization Management (UM) Program is based on the premise that quality medical care is the single-most-important element in delivering health care services. It is a coordinated and comprehensive program designed to monitor access to health care services to members/covered persons. The UM Program promotes the continuing education of Horizon BCBSNJ employees, members/covered persons, and employers, and is available to Horizon BCBSNJ's health insurance lines of business.*

The Horizon BCBSNJ UM Program is based on the following principles:

Utilization Management decisions made by Horizon BCBSNJ are based solely on the necessity and appropriateness of care and service within the parameters of each member's/covered person's benefits package.

• Horizon BCBSNJ does not compensate those responsible for making UM decisions in a manner that permits them to deny coverage for medically necessary and appropriate covered services.
• Horizon BCBSNJ does not offer our employees or delegates performing UM reviews incentives to encourage denials of coverage or service, and does not provide financial incentives to providers to withhold covered health care services that are medically necessary and appropriate.
• Horizon BCBSNJ emphasizes the provision of medically necessary and cost-effective delivery of health care services to members/covered persons and encourages the reporting, investigation, and elimination of underutilization.

* Program components differ among the product lines and coverage contract.