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.