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:

Medical policy

Use this online searchable database to read AmeriHealth New Jersey medical and claim payment policies.

Pharmacy policy

Use this online database to read AmeriHealth New Jersey pharmacy policies.

Perinatal guideline

Download guideline outlining perinatal care.

Clinical practice guidelines summary

Download guideline outlining clinical practices.

Preapproval/precertification for services and member cost-sharing

Certain services require preapproval/precertification from AmeriHealth New Jersey prior to being performed.

Precertification lists:

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.

Dosage and Frequency Program

Learn how AmeriHealth New Jersey reviews treatment regimens for certain specialty drugs to ensure they adhere to safe prescribing limits.

Drug Formularies

Value formulary

Select formulary

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.