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:
- Behavioral Health: certain services require prior authorization, please review the complete list
- 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 the Utilization Management Tool. Simply access Horizon NJ Health Plan Central from NaviNet. Select Utilization Management Requests and use the online submission form to complete the authorization request. The Utilization Management Tool can also be used to check the status of a request.
Procedure/Treatment Par Provider/Par Facility | Authorization Required (Excluding Hospital) | Authorization Required (Hospital) | Comments | |
Abdominal Pregnancy | X | X | ||
ABR (Auditory Brainstem Response/ Hearing Test) | X | |||
Acid Reflux Test | X | |||
ACL Reconstructions | X | X | ||
Acupuncture | X | X | ||
Allergy Injections | X | |||
Amniocentesis | X | X | ||
Anoscopy | X | |||
Angiogram | X | |||
Angiography | Request through eviCore at 1-866-496-6200 or see eviCore grid | |||
Aortography | Effective January 1, 2020 No authorization/No referral required | |||
Application of Blood Patch | X | |||
Arthrodesis | X | |||
Arthrography | X CPT Codes 23350 and 27095 | X | ||
Arthroscopy | X | |||
Barium Swallow | Effective January 1, 2020 No authorization/No referral required | |||
Biopsy (All) | 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 | |||
Blood Work | 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 eviCore at 1-866-496-6200 or see eviCore grid | |||
Botox Injections | X | X | ||
Bronchoscopy | X All Other CPT Codes | X | ||
Bunionectomy | X | X | ||
Cardiac Catheterizations (All, Including Injections) | X | X | Request through eviCore at 1-866-496-6200 |
|
Carpal Tunnel | CPT Codes 20526, 64721X All Other CPT Codes | X | ||
Casting (Application, Removal, Windowing or Wedging) | X All Other CPT Codes |
X | ||
Cataract Surgery | X All Other CPT Codes | X | ||
Cervical Cerclage | X | X | ||
Chemodenervation of Extremity | X | X | ||
Chemotherapy | X | X | ||
Chiropractic Services | X | X | ||
Cholangiogram | X | |||
Cholecystectomy (Any Method) | X | |||
Circumcision (Initial) | X | |||
Colonoscopy (Except Virtual Colonoscopy) | X | |||
Colonoscopy Virtual | X | X | Request through eviCore at 1-866-496-6200 |
|
Colporrhaphy | X | X | ||
Colposcopy | X | |||
Corbin Urea (Breath Test) | X | |||
Cosmetic Surgery | X | X | ||
CT Scans | X | X | Request through eviCore at 1-866-496-6200 |
|
Cystectomy | X CPT Code 68500 | X | ||
Cystoscopy | X CPT Code 50385 | X | ||
Cystometrogram with Urodynamics | X | |||
Cystourethroscopy | X CPT Code 52327 | X | ||
Debridement | X | |||
Dilation of Esophageal Stricture | X | |||
Discography | X | |||
Dilation and Curettage | X All Other CPT Codes | X | ||
Dilation and Evacuation (D&E) | X | X | ||
DME (Durable Medical Equipment) | X | Call 1-800-682-9094 x81017 |
||
Doppler Study | Effective January 1, 2020 No authorization/No referral required | |||
Echocardiography | Request through eviCore at 1-866-496-6200 or see eviCore grid | |||
Electroencephalography (EEG) Except with Video Monitoring | X | |||
Electroencephalography (EEG) with Video Monitoring | X | X | ||
Electromyography (EMG) | X CPT Code 96004 | X | ||
Endoscopic Retrograde Cholangiopancreatgraphy (ERCP) | X CPT Code 43273 | X | ||
Endoscopy, Except Wireless Endoscopy | X | |||
Endoscopy, Wireless | X CPT Codes 91110 and 91111 | X | ||
Excision of Chalazion | X | |||
Excision of Cyst | X All Other CPT Codes | X | ||
Excision of Keloids/Lesions | X | X | ||
Excision of Mass | X | |||
Excision of Tendon Sheath | X | X | ||
Exostectomy | X | X | ||
Fasiectomy | X | X | ||
Frenulectomy/ Frenuloplasty | X | |||
Gastric Banding Adjustment | X | X | ||
Gastric Bypass Surgery | X | X | ||
Graft Insertions | X | X | ||
Growth Stimulation Test | X | |||
Holter Monitor | X | |||
Hammer Toe Correction | X | |||
Hemodialysis | X | X | ||
Hemorroidectomy | X | |||
Hernia Repair | X | |||
Home Health | X | X | ||
Hyaluronic Acid Injection | X | X | ||
Hydrocele Aspiration, Excision or Repair | X | |||
Hypospadias | X All Other CPT Codes | X | ||
Hysterosalpingography | X | |||
Hysteroscopy | X CPT Codes 58561, 58565, 58578 and 58579 | X | ||
I and D (Incision and Drainage) | X | |||
Intravenous Pyelogram (IVP/Urography) | Effective January 1, 2020 No authorization/No referral required | |||
Kidney Function Study | X | |||
Laparoscopy | X | |||
Laryngoscopy | X | |||
LEEP, Loop Electrosurgical Excision Procedure | X | X | ||
Lithotripsy | X | |||
Mammogram | No auth or referral needed | |||
Mammoplasty (Breast Reduction) | X | X | ||
Mastectomy | X | X | ||
MRI /MRA | Request through eviCore at 1-866-496-6200 or see eviCore grid | |||
Myelography | Effective January 1, 2020 No authorization/No referral required | |||
Myocardial Perfusion Imaging Nuclear Cardiology and MUGA – Multiple Gated Acquisition Scan | Request through eviCore at 1-866-496-6200 or see eviCore grid | |||
Nasal Lacrimal Duct Probing | X All Other CPT Codes | X | ||
Nipple Exploration | X All Other CPT Codes | X | ||
Open Reduction Internal Fixation (ORIF) of Fracture | X All Other CPT Codes | X | ||
Ophthalmological Examination and Evaluation Under General Anesthesia | X | |||
Orchiopexy | X All Other CPT Codes | X | ||
Osteotomy | X All Other CPT Codes | X | ||
Otolaryngologic Examination Under General Anesthesia | X | |||
Out-of-Network Admissions or Procedures | X | X | ||
Out-of-Network Office Visits | X | X | ||
Pain Management Injections | X | X | ||
Paracentesis | X | |||
PET Scans (Positron Emission Tomography) | X | X | Request through eviCore at 1-866-496-6200 or see eviCore grid |
|
Physical/Occupational Therapy | X | X | Does not include home | |
Physical Therapy Inpatient | ||||
PICC Line or Port-a-Cath Insertion/Removal | X | |||
Ptosis | X | X | ||
Pulmonary Function Test | X | |||
Pulse Oximetry | X | |||
Radiation Therapy | Request through eviCore at 1-866-496-6200 or see eviCore grid | |||
Removal of Foreign Body | X All Other CPT Codes | X | ||
Retinopathy Treatment | X | |||
Rhinoplasty/Septoplasty | X | X | ||
Sclerotherapy | X | X | ||
Sedation | X | |||
Shunt Insertion/Removal | X | |||
Sigmoidoscopy | X | |||
Skin Tag Removal | X | X | ||
Sleep Study – Sleep Study Titration | X | |||
Sling Operation | X | X | ||
Spinal Tap (Lumbar Puncture) | X | |||
Splints, Application | X | |||
Stent Removal | X | |||
Strabismus | X All Other CPT Codes | X | ||
Stress Test (Cardiovascular) | Request through eviCore at 1-866-496-6200 or see eviCore grid | |||
Stress Test ( Pulmonary) | X | |||
Sweat Test (Choloride) | X | |||
Synagis (Drug) | X | X | Request through Pharmacy, call 1-800-682-9094 x81016 |
|
Hyaluronic Acid Injection | X | X | ||
Tendon Lengthening | X | X | ||
Thyroid Hormone Uptake | X | |||
Tilt Test | X | |||
Tonsillectomy & Adenoidectomy | X | |||
Trabeculetomy | X | |||
Transesophageal Echocardiography (TEE) | Request through eviCore at 1-866-496-6200 or see eviCore grid | |||
Treatment of Missed Abortion | X All Other CPT Codes | X | ||
Trigger Point Injections | X | X | ||
Tympanostomy | X All Other CPT Codes | X | ||
Ultrasounds (Non-OB) | Effective January 1, 2020 No authorization/No referral required | |||
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 | Effective January 1, 2020 No authorization/No referral required | |||
VCUG (Voiding Cystourethrogram) | X | |||
Venography | Effective January 1, 2020 No authorization/No referral required | |||
Vitrectomy | X | |||
X-Rays (All Primary Radiology) | Effective January 1, 2020 No authorization/No referral required | |||
YAG Laser Surgery | X All Other CPT Codes | X |