Description of horizon blue cross blue shield prior authorization form
HORIZON NJ HEALTH Reset Form Date of Request: / / MM DD YYY DME Authorization Request Form Requirements: Clinical information and supportive documentation should consist of current physician order,
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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.
© 2022 Horizon Blue Cross Blue Shield of New Jersey, Three Penn Plaza East, Newark, New Jersey 07105.
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 The following behavioral health services require prior-authorization for both in network and out of network providers: Important ResourcesPrior Authorization
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.