Precertification Reference List
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.
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.
eviCore - eviCore will provide Utilization Management programs for Radiation Therapy and Radiology/Cardiology for Horizon NJ Health and Horizon NJ Total Care (HMO D-SNP) members effective January 1, 2020. However, eviCore will begin accepting authorization requests on December 16, 2019 for dates of service beginning January 1, 2020. Horizon BCBSNJ is partnered with eviCore healthcare to manage Advanced Imaging Services for our members through Prior Authorizations/Medical Necessity Determinations (PA/MND) with physicians. eviCore healthcare helps to ensure our members receive appropriate radiology/imaging services, provides clinical consultation to our participating healthcare professionals and assists in the scheduling of radiology/imaging services. The Advanced Imaging Services included in this program are CT/CTA, MRI/MRA, PET and Nuclear Medicine studies (including Nuclear Cardiology).
Please note that eligibility and participation may vary based on line of business therefore, all providers should check eligibility and benefits prior to performing any services related to this program. In addition, actual benefit determinations cannot be made until a claim is received and is subject to the provisions of the patient’s present contract including any applicable deductible, coinsurance and/or coordination of benefits.
Prior authorization through eviCore does not apply to services that are performed in:
- Emergency room
- 23-hour observation
Prior authorization applies to services that are:
- Elective / Non-emergent
Authorization is required for Horizon BCBSNJ members enrolled in the following programs:
- Medicaid Managed Care
- NJ FamilyCare
- Horizon NJ TotalCare (HMO D-SNP)
- Managed Long Term Services & Supports (MLTSS)
Providers and/or staff can request prior authorization in one of the following ways:
The eviCore portal is the quickest, most efficient way to request prior authorization and is available 24/7. Providers can request Authorization at eviCore.com.
eviCore’s call center is open from 7 a.m. to 7 p.m. local time. Providers and/or staff can request prior authorization and make revisions to existing cases by calling 1-866-496-6200.
eviCore's call center will be closed in observance of New Year’s Day, Memorial Day, Independence Day, Labor Day, Thanksgiving and the day after, and Christmas Day. The eviCore web portal is available 24/7, 365 days a year.