What does my policy cover? How does a health insurer make coverage decisions? If my doctor says I should have a test, procedure or prescription, isn’t that all that matters?

Many consumers incorrectly assume that a faceless bookkeeper with a sharp pencil and a cold heart decides what is covered and what is not with no regard to medical science. Medicine is complicated because humans, injuries, and diseases are complex. But, doctors – and health insurers – don’t have to figure it all out themselves. There is a huge body of scientific research that serves as the basis of how, when, and why to use a certain drug, procedure or test is recommended for a patient.

Evidence-based research and best practices are the building blocks of Horizon’s medical policy.

As a result, members rarely encounter an instance when Horizon’s medical policy differs from a doctor’s recommendation. But, it does happen (remember, this is complex stuff!). But it’s rare. Only 8,438 of the 60 million member claims Horizon BCBSNJ processed in 2018 wound up under appeal,  though not all of those appeals were due to medical policy.

To better understand how Horizon BCBSNJ makes determinations about what is covered and what is not, here are seven things you should know about the development and use of medical policies:

1. Evidence rules. We start with all the relevant information from scientific and peer-reviewed clinical literature, guidelines and recommendations from national and local medical professionals and professional medical and disease-focused organizations (think American Cancer Society or American College of Obstetricians and Gynecologists) to provide the evidence and scientific basis for our medical policies.

2. Things change. As of July 2019, Horizon had in excess of 720 medical policies. Every month, we update and, if necessary, add to them based on the best and most current information and research available on medical procedures, drugs, medical devices and technologies. These policies are highly complex and detailed and are tailored specifically for medical professionals who treat our members. But anyone can access medical policies on Horizonblue.com.

3. New Jersey’s Doctors Have a Seat at the Table. Our Clinical Policy Committee – comprised of Horizon medical experts and independent physicians who see patients here in New Jersey -- meets monthly to consider changes and additions to our medical policies. They are part of a larger governance structure that ensures Horizon’s policies are aligned with the rules issued by regulatory authorities, such as the New Jersey Department of Banking and Insurance, and incorporate nationally recognized standards for care quality, such as those created by the National Committee for Quality Assurance (NCQA).

4. Safe and effective trumps experimental and investigational. Our top priority is the safety of our members and that’s why our medical policies ensure that medical services, technologies, drugs and procedures we cover are proven to be safe. But, we also want our members to get effective treatments: those that have proven to achieve the desired outcome. For this reason, coverage generally does not include drugs, procedures, therapies and other services that are unproven, do not have outcomes supported by accepted clinical evidence or that are not sanctioned for a particular use by government regulators or the external professional associations with the greatest expertise. Of course, there are always exceptions to the rule. Your doctor can have a peer-to-peer discussion with our doctors to discuss your case and the rationale for the treatment. And you can always file an appeal that engages an outside, independent medical professional with specific expertise who has the power to make a final determination.

5. Believe in the “Blue” Advantage. The Technology Evaluation Center (TEC) is a Blue Cross and Blue Shield Association program that locates and examines the best existing scientific evidence to determine the safety and efficacy of new medical technologies. Administered in partnership with Kaiser Permanente, the program has been called “one of the best established processes for evaluating scientific evidence for medical technologies” by leading journal Health Affairs. We also consult with pharmacy, lab and medical device communities and our OMNIA Health Alliance partners to vet or stay current on new advances and developments.

6. Taking part in trials. Horizon participates in clinical trials that create medical evidence needed to grow our medical policy. Examples include the WISDOM study, which is devoted to finding the most effective means of screening for breast cancer risks, and a research partnership with Rutgers University that includes 14 innovative projects to create medical breakthroughs.

7. About that faceless bookkeeper… Horizon medical policies are overseen by a medical policy team comprised of licensed physicians, nurses and other health care professionals. If they determine that drugs, devices, procedures or other services are outside of Horizon’s medical policies, they participate in any subsequent appeals with members’ doctors. This allows Horizon medical staff to incorporate any additional relevant evidence before a decision is finalized.

So, there’s the primer on medical policies – and no decoder ring necessary. For a deeper look, you can visit our medical policies page on Horizonblue.com.