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How We Make Coverage Decisions
Effective date
Not stated in the notice
Identified
Oct 3, 2026
Summary
This policy clarifies Horizon Blue's framework for making coverage decisions, emphasizing medical necessity, appropriateness, and cost-effectiveness while prohibiting financial incentives to deny coverage. The policy mandates balanced utilization management to prevent both underutilization (necessary care denied) and overutilization (unnecessary treatments provided). Billing teams must ensure all claim submissions align with these coverage decision principles.
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What to do
Action · 7 steps
01Billing team must review current claim denial patterns and appeal procedures to ensure compliance with this policy framework.
02Audit recent denials to identify any that may have been based on incentivized denials rather than medical necessity—escalate questionable denials to compliance.
03Update claim submission guidance to emphasize that all submitted services must meet 'medically necessary and appropriate' standards per member benefit guidelines.
04Train billing staff to document the medical necessity rationale when submitting claims, particularly for services that may face scrutiny.
05Establish a process to flag and investigate potential underutilization (members not receiving needed care) and overutilization (unnecessary services) patterns.
06Communicate to providers that Horizon Blue's coverage decisions will prioritize appropriate, cost-effective care delivery.
07No specific effective date is stated; treat this as guidance effective upon publication (September 2022 archive).
If missed: Failure to align with these principles may result in increased claim denials or compliance audits.
Original notice
How We Make Coverage Decisions
horizonblue.com · Always check the source before changing claims.