Utilization Management
Utilization Management Request Tool
Use our online Utilization Management Request Tool, available 24/7, to easily and securely submit authorization and referral requests to us for your Horizon NJ Health and Horizon NJ TotalCare (HMO D-SNP) patients. The Utilization Management Request Tool can also be used to check the status of your requests. To access this tool, simply sign in to NaviNet and from the Horizon NJ Health plan central page, select Utilization Management Requests.
Prior Authorization Procedure Search Tool
Use our Prior Authorization Procedure Search Tool, available 24/7, to determine if you need to get prior authorization (PA) before providing services to your Horizon NJ Health and Horizon NJ TotalCare (HMO D-SNP) patients.
We collaborate with certain business partners to manage PA reviews on our behalf. The tool will let you know when requests need to be submitted directly to these business partners.
UM Decisions for Appropriate Care and Services
It’s important to your patients, our members, that they get the care they need when they need it. That’s why we maintain standards — a key part of UM — to help ensure that our members get care that’s necessary, effective and appropriate.
We make UM decisions based on a member’s health care needs and Horizon NJ Health/Horizon NJ TotalCare (HMO D-SNP) benefits. Our Medical Management Program follows ethical business practices and values. We do not offer rewards or incentives to health care professionals for UM decisions.
Our UM team manages authorizations for medical services using:
You may request free copies of benefit provisions or the guidelines on which decisions are based by calling 1-800-682-9094, x89469 or by writing to:
Horizon NJ Health
Medical Director
1700 American Boulevard
Pennington, NJ 08534
Requesting UM Determinations
You can use our Utilization Management Request Tool to submit authorization requests 24/7 via NaviNet, or call our staff weekdays from 8 a.m. to 5 p.m., Eastern Time, at these numbers:
- Behavioral Health requests: 1-800-682-9094, x81320
- Elective Medical and Surgical requests: 1-800-682-9094, x81023
- Medical Day Care/PCA authorization: 1-800-682-9094, x81364 (fax: 1-609-583-3048)
- Outpatient PT/OT requests: 1-800-682-9094, x81623
- Personal Preference Program (PPP) requests: 1-855-465-4777
- Post-Acute Rehabilitation or Custodial Care requests: 1-800-682-9094, x89104