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Utilization Management

Precertification Reference List
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Precertification Reference List

In general, prior authorization is required for all services (test or procedure) scheduled at a participating hospital. Elective or non-emergent admissions, including transfers to another facility, require a prior authorization.

Procedures performed at a freestanding Ambulatory Surgical Center (ASC) - Place of Service (POS) 24 or doctor’s office - POS 11 in the Horizon NJ Health network by a participating provider do not require prior authorization with the exception of the following, which require authorization:

  • Cosmetic Surgery
  • Gastric Banding Adjustments
  • Pain Management Injections
  • Sclerotherapy for Varicose Veins
  • As noted in table below
  • If not otherwise noted on this webpage, any procedure considered “investigational” or “not medically necessary” as per Horizon NJ Health or Horizon BCBSNJ policy.

All services performed by or at a non-participating provider require prior authorization.

All services are subject to member individual benefit provisions.

Key:

Referral from PCP:  A referral from the PCP to the rendering provider is the only requirement. Referral submissions and inquiries can be processed on NaviNet.

Prior Authorization:  An authorization is needed.  Call Horizon NJ Health at 1-800-682-9094. The request may need clinical information faxed with medical review. The prior authorization should be requested no later than five business days prior to rendering services.

Alternately, authorization requests can be submitted easily and securely online through Care Affiliate. Simply access Horizon NJ Health Plan Central from NaviNet. Select Utilization Management Requests and use the online submission form to complete the authorization request. Care Affiliate can also be used to check the status of a request.

 

NIA:  National Imaging Association is a radiology utilization management company. NIA performs prior authorization for  the following:  CT Scans, MRI/MRAs, Pet Scans, MUGA Scans, Virtual Colonoscopies, Angiography, Non-OB Ultrasound, Stress Echocardiography, Echocardiography, Cardiac Computed Tomography Angiography (CCTA), Cardiac Catheterization, Radiation Oncology Management for Radiation Therapy, Cardiac Implantable Devices including Implantable Cardioverter Defibrillator (ICD), Pacemaker, Cardiac Resychronization Therapy (CRT) Pacemaker and Nuclear Cardiology tests. 

*****  Primary radiology, with the exception of non-OB ultrasound, does not require authorization at ALL places of services. ******

NIA Call Center is open Monday to Friday, 8 a.m. to 8 p.m.

NIA website: www.radmd.com
NIA: 1-800-642-7299

Horizon NJ Health Pre-Authorization Codes Managed by NIA

Procedure/Treatment Par Provider/Par Facility Referral From PCP (Excluding Hospital) Authorization Required (Excluding Hospital) Authorization Required (Hospital) Comments
Abdominal Pregnancy   X X  
ABR (Auditory Brainstem Response/ Hearing Test) X   X  
Acid Reflux Test X   X  
ACL Reconstructions   X X  
Acupuncture   X X  
Allergy Injections X   X  
Amniocentesis   X X  
Anascopy X   X  
Angiogram X   X    
Angiography X All Other CPT Codes X CPT Codes 36251, 36252, 36253, 38790,38792,70496, 70498, 71275, 72191, 73206, 73706, 74175 and 75635 X    
Aortography X CPT Codes 75600,  75605, 75625 and 75630 X All Other CPT Codes   X    
Application of Blood Patch X    X  
Arthrodesis X   X  
Arthrography X CPT Code 27093 X  CPT Codes 23350 and 27095 X  
Arthroscopy X   X  
Barium Swallow Request through NIA at 1-800-642-7299 or see NIA grid
Biopsy (All) X CPT Codes 56606 and 77002 X CPT Codes 27323, 27324, 39400, 43202, 47001, 93505, 24101, 27050, 27052, 28052,32602, 37200, 39400, 43202, 47001, 49321, 52250, 32096-32098 and 32607-32609  X  
Blood Transfusion X   X  
Blood Work X LabCorp X (If not available through LabCorp)  X*  *STAT/ PAT blood work if LabCorp unavailable and unable to perform may be done at par hospital
Bone Scan Request through NIA at 1-800-642-7299 or see NIA grid
Botox Injections   X X  
  Bronchoscopy X CPT Codes 31622 and 31646 X All Other CPT Codes X    
Bunionectomy   X X  
Cardiac Catheterizations (All, Including Injections)   X X Request through NIA at 1-800-642-7299
Carpal Tunnel X
CPT Codes 20526, 64721		 X All Other CPT Codes X  
Casting (Application, Removal, Windowing or Wedging) X CPT Codes 29058, 29355 and 29550 X
All Other CPT Codes		 X    
Cataract Surgery X CPT Code 66984 X All Other CPT Codes X    
Cervical Cerclage   X X  
Chemodenervation of Extremity   X X  
Chemotherapy   X X  
Chiropractic Services X X X  
Cholangiogram X   X  
Cholecystectomy (Any Method) X   X  
Circumcision (Initial) X   X  
Colonoscopy (Except Virtual Colonoscopy) X   X  
Colonoscopy Virtual   X X Request through NIA at 1-800-642-7299
Colporrhaphy   X X  
Colposcopy X   X  
Corbin Urea (Breath Test) X   X  
Cosmetic Surgery   X X  
CT Scans   X X Request through NIA at 1-800-642-7299
Cystectomy X All Other CPT Codes X  CPT Code 68500 X  
Cystoscopy X All Other CPT Codes X  CPT Code 50385 X  
Cystometrogram with Urodynamics X   X  
Cystourethroscopy X All Other CPT Codes X CPT Code 52327 X    
Debridement X   X    
Dilation of Esophageal Stricture X      X  
Discography X   X  
Dilation and Curettage X CPT Codes 57558, 58120 and 77800 X All Other CPT Codes X    
Dilation and Evacuation (D&E)   X X  
DME (Durable Medical Equipment)     X Call 1-800-682-9094, extension 81017
Doppler Study Request through NIA at 1-800-642-7299 or see NIA grid
Echocardiography Request through NIA at 1-800-642-7299 or see NIA grid
Electroencephalography (EEG) Except with Video Monitoring X   X  
Electroencephalography (EEG) with Video Monitoring   X X  
Electromyography (EMG) X All Other CPT Codes X CPT Code 96004  X  
Endoscopic Retrograde Cholangiopancreatgraphy (ERCP) X All Other CPT Codes X CPT Code 43273  X  
Endoscopy, Except Wireless Endoscopy X   X    
Endoscopy, Wireless   X CPT Codes 91110 and 91111 X    
Excision of Chalazion X   X    
Excision of Cyst X CPT Codes 30124 and 30125 X All Other CPT Codes X  
Excision of Keloids/Lesions   X X  
Excision of Mass X (If not considered cosmetic)    X  
Excision of Tendon Sheath   X X  
Exostectomy   X X  
Fasiectomy   X X  
Frenulectomy/ Frenuloplasty X   X  
Gastric Banding Adjustment   X X  
Gastric Bypass Surgery   X X  
Graft Insertions   X X  
Growth Stimulation Test X  (If labs cannot be done at LabCorp)   X  
Holter Monitor X   X  
Hammer Toe Correction X   X  
Hemodialysis   X X  
Hemorroidectomy X   X    
Hernia Repair X   X  
Home Health   X X  
Hyaluronic Acid Injection   X X  
Hydrocele Aspiration, Excision or Repair X   X  
Hypospadias X CPT Codes 54300 and 54352 X All Other CPT Codes X    
Hysterosalpingography X   X  
Hysteroscopy X All Other CPT Codes X CPT Codes 58561, 58565, 58578 and 58579 X  
I and D (Incision and Drainage) X     X  
Intravenous Pyelogram (IVP/Urography) Request through NIA at 1-800-642-7299 or see NIA grid
Kidney Function Study X   X    
Laparoscopy X   X  
Laryngoscopy X   X  
LEEP, Loop Electrosurgical Excision Procedure   X X  
Lithotripsy X    X  
Mammogram

No auth or referral needed
Mammoplasty (Breast Reduction)   X X  
Mastectomy   X X  
MRI /MRA Request through NIA at 1-800-642-7299 or see NIA grid
Myelography Request through NIA at 1-800-642-7299 or see NIA grid
Myocardial Perfusion Imaging Nuclear Cardiology and MUGA – Multiple Gated Acquisition Scan Request through NIA at 1-800-642-7299 or see NIA grid
Nasal Lacrimal Duct Probing X CPT Codes 68815, 68816, 68840, 68850 X All Other CPT Codes X    
Nipple Exploration X CPT Code 19110 X All Other CPT Codes X    
Open Reduction Internal Fixation (ORIF) of Fracture X CPT Codes 24635, 27524, 27823, 21325, 21335 X All Other CPT Codes X  
Opthalmological Examination and Evaluation Under General Anesthesia X CPT Code 92018   X    
Orchiopexy X CPT Code 54640 X All Other CPT Codes X  
Osteotomy X CPT Codes 27140, 27151, 27450, 27454, 27181 X All Other CPT Codes X  
Otolaryngologic Examination Under General Anesthesia X   X    
Out-of-Network Admissions or Procedures   X X  
Out-of-Network Office Visits   X X  
Pain Management Injections   X X  
Paracentesis X   X  
PET Scans (Positron Emission Tomography)   X X Request through NIA at 1-800-642-7299 or see NIA grid
Physical/Occupational Therapy   X X Does not include home
Physical Therapy Inpatient        
PICC Line or Port-a-Cath Insertion/Removal X   X  
Ptosis   X X  
Pulmonary Function Test X   X  
Pulse Oximetry X   X  
Radiation Therapy Request through NIA at 1-800-642-7299 or see NIA grid
Removal of Foreign Body X CPT Codes 10120, 31511, 31577, 31635, 43247, 43269, 44363, 44390, 45332, 45379, 46608, 52310, 69205 and 69990 when performed in MD Office X All Other CPT Codes X  
Retinopathy Treatment X   X    
Rhinoplasty/Septoplasty   X X  
Sclerotherapy   X X  
Sedation X   X    
Shunt Insertion/Removal X   X    
Sigmoidoscopy  X   X  
Skin Tag Removal   X X  
Sleep Study – Sleep Study Titration X             X  
Sling Operation   X X  
Spinal Tap (Lumbar Puncture) X   X  
Splints, Application X   X  
Stent Removal X   X    
Strabismus X CPT Codes 67312, 67314 and 67316 X All Other CPT Codes X    
Stress Test (Cardiovascular) Request through NIA at 1-800-642-7299 or see NIA grid
Stress Test ( Pulmonary) X   X  
Sweat Test (Choloride) X   X  
Synagis (Drug)   X  X Request through Pharmacy, call 1-800-682-9094, extension 81016
Hyaluronic Acid Injection   X X  
Tendon Lengthening   X X  
Thyroid Hormone Uptake X   X  
Tilt Test X   X  
Tonsillectomy & Adenoidectomy X   X    
Trabeculetomy X   X    
Transesophageal Echocardiography (TEE)  Request through NIA at 1-800-642-7299 or see NIA grid
Treatment of Missed Abortion X CPT Codes 59820 and 59821 X All Other CPT Codes X    
Trigger Point Injections   X X  
Tympanostomy X CPT Code 69436 X All Other CPT Codes X    
Ultrasounds (Non-OB)  Request through NIA at 1-800-642-7299 or see NIA grid

Exception includes:

CPT 76641 & 76642 No authorization/No referral

CPT 76830 Non-OB Ultrasound Transvaginal – Referral only all places of service

CPT 76942 Ultrasonic Guidance for Needle Placement – Referral only all places of service
OB ultrasound   X   X   Authorization is required for all OB/US after the 3 OB/US are utilized from the GEMS2 and GEMS 3 authorization.
Upper GI Swallow Request through NIA at 1-800-642-7299 or see NIA grid
VCUG (Voiding Cystourethrogram) X   X  
Venography

Request through NIA at 1-800-642-7299 or see NIA grid
Vitrectomy X   X    
X-Rays (All Primary Radiology) Request through NIA at 1-800-642-7299 or see NIA grid
YAG Laser Surgery X CPT Code 66821 X All Other CPT Codes X