Policies and guidelines
Find out what you need to know when working with AmeriHealth New Jersey. The following databases and downloadable guidelines make our policies readily available to providers:
Use this online searchable database to read AmeriHealth New Jersey medical and claim payment policies.
Use this online database to read AmeriHealth New Jersey pharmacy policies.
Download guideline outlining perinatal care.
Download guideline outlining clinical practices.
Download guidelines outlining wellness care.
Preapproval/precertification for services and member cost-sharing
Certain services require preapproval/precertification from AmeriHealth New Jersey prior to being performed.
2019 Precertification lists:
- 2019 Precertification List (as of 6/1/2019)
- 2019 Precertification List with AIM Opt Out (as of 6/1/2019)
- 2019 Precertification List (as of 1/1/2019)
- 2019 Precertification List with AIM Opt Out (as of 1/1/2019)
Download the American Imaging Management Preauthorization Form.
Most Cost-Effective Setting Program
Find out about this program through which AmeriHealth New Jersey reviews the requested treatment settings for certain specialty drugs that are eligible for coverage under the medical benefit.
Prescription Drug Coverage
Medical necessity criteria
Our registered nurses (Case Management Coordinators) use McKesson’s InterQual criteria as their main source of decision support. AmeriHealth New Jersey began licensing the InterQual criteria for acute and subacute rehabilitation services in 2000. AmeriHealth New Jersey also uses the InterQual guidelines for acute and home-care settings.
The InterQual decision-support tools (criteria) are well recognized and have widespread acceptance within the provider and payer environments. The tools are developed in annual cycles using a rigorous methodology that has been refined over the course of 30 years. This includes an extensive review of the latest evidence-based medical literature with consensus building among clinical experts from a pool of more than 700 consultants representing a wide range of specialties and sub-specialties.
For information regarding the InterQual clinical decision support tools, please visit their website at www.mckesson.com. Information regarding a specific case guideline can also be obtained by calling 856-802-3109.