Horizon blue cross blue shield prior authorization form

Prior Authorization

Members do not need a referral from their Primary Care Provider (PCP) to see a behavioral health provider. We encourage all providers to call us in advance of providing services to confirm the member’s eligibility, the in-network status of the facility and to verify benefits.

To verify member’s eligibility, the in-network status of the facility, verify benefits and for prior-authorization requests and other related clinical questions, please call 1-800-682-9094. For authorization requests, please call within 24 hours of the admission and provide the reason for the admission, diagnosis, medication, treatment plan, discharge plan and any other pertinent information we would need for medical necessity review.

Authorization is available 24 hours a day, seven days a week. Non-emergent behavioral health services are available Monday to Friday from 8 a.m. to 5 p.m., Eastern Time.

For substance use disorder services for individuals who are not MLTSS, DDD or FIDE-SNP members, contact IME Addiction Access Center at 1-844-276-2777, 24 hours a day, seven days a week.

Outpatient Services
Prior authorization is not required for outpatient services for in-network providers. Prior authorization and a single case agreement are required for out-of-network providers. Criteria for single case agreement will be discussed during the review for authorization.

The following behavioral health services require prior-authorization for both in network and out of network providers:

Inpatient Psychiatric Treatment
Residential Mental Health
Partial Hospitalization (PHP)
Partial Care
Intensive Outpatient (IOP)
Adult Mental Health Rehabilitation (AMHR) Group Homes and Apartments
Psychological Testing
Repetitive Transcranial Magnetic Stimulation (rTMS)
Electroconvulsive Therapy (ECT)
Medically Managed Detox (ASAM 4.0)
Medically Monitored Detox (SUD ASAM 3.7D)
Inpatient SUD Rehab (ASAM 3.7)
Residential SUD (ASAM 3.5)
Partial SUD (ASAM 2.5)
IOP SUD (ASAM 2.1)
Applied Behavior Analysis (ABA)
Developmental, Individual-differences and Relationship-based Model (DIR)
All out-of-network providers will require an authorization for any level of care including outpatient levels of care.

Important Resources

Horizon NJ Health Quick Contact Guide
FIDE-SNP Provider Quick Reference Guide
Provider Administrative Manual
Quick Reference Guide to the Provider Administrative Manual
Presentation: Changes to the Management of the Horizon Behavioral Health Program

Products and services are provided by Horizon Blue Cross Blue Shield of New Jersey, Horizon Insurance Company, Horizon Healthcare of New Jersey, and/or Horizon Healthcare Dental, Inc., each an independent licensee of the Blue Cross Blue Shield Association. Communications may be issued by Horizon Blue Cross Blue Shield of New Jersey in its capacity as administrator of programs and provider relations for all its companies. The Blue Cross® and Blue Shield® names and symbols are registered marks of the Blue Cross Blue Shield Association. The Horizon® name and symbols are registered marks of Horizon Blue Cross Blue Shield of New Jersey.

CareCentrix is responsible for ensuring certain Horizon Care@Home services are medically necessary and appropriate through its utilization management activities, including:

Durable medical equipment (including medical foods [enteral], and diabetic and other medical supplies)
Orthotics and prosthetics
Home infusion therapy
Diabetic and other medical supplies

For home health services (including in-home nursing services, physical therapy, occupational therapy and speech therapy), you must obtain prior authorization using Horizon BCBSNJ's online utilization management request tool via NaviNet.

Rendering Providers

Participating Horizon Care@Home ancillary services providers of home care services are required to complete a pre-service registration for certain services, including:

Durable medical equipment (including medical foods [enteral], and diabetic and other medical supplies)
Orthotics and prosthetics
Home infusion therapy
Diabetic and other medical supplies

Registrations can easily be submitted by calling CareCentrix at 1-855-243-3324 between 8 a.m. and 6 p.m., Eastern Time. When you refer a patient to a participating Horizon Care@Home ancillary services provider, that rendering provider will work with CareCentrix to ensure that the appropriate prior authorization/pre-service registration is performed.

Referring/Ordering Providers

Physicians, other health care professionals, hospital discharge planners and case managers may initiate a prior authorization/pre-service registration by calling CareCentrix at 1-855-243-3321 between 8 a.m. and 6 p.m. (ET) for:

Durable medical equipment (including medical foods [enteral], and diabetic and other medical supplies)
Orthotics and prosthetics
Home infusion therapy
Diabetic and other medical supplies

You may also call CareCentrix at 1-855-243-3321 to find a Horizon Care@Home participating ancillary services provider.

As part of the review of a request for home care services to be provided, Horizon BCBSNJ or CareCentrix may contact your office for information required to conduct/complete their review.

Members with BlueCard® Coverage

As a reminder, you have the ability through NaviNet to access the online prior authorization tools of other Blue Plans to review/initiate prior authorizations online for BlueCard® members.
Members with BlueCard® coverage who are enrolled through another Blue Cross and/or Blue Shield Plan and are receiving care in New Jersey would access in-network home care services through a participating Horizon Care@Home provider; however, prior authorization requirements may vary based on the member's benefits.
Simply log in to NaviNet.net and:

Mouse over Referrals and Authorization.
Select Pre-Service Review for Out-of-Area Members.

After entering the member's alpha prefix, you'll be routed to the member's Home Plan. You can then follow the prompts to review a member's pre-service authorization requirements as well as submit a prior authorization request, if necessary.

horizon blue cross blue shield prior authorization form