Horizon BCBSNJ Prior Authorization Form: Filing, Timing, and Appeals

The Horizon BCBSNJ prior authorization form is submitted by the treating provider, not the patient, and goes to Horizon either through the CareAffiliate-powered Utilization Management Request Tool or by fax to the Prior Authorization Department. Horizon uses two separate forms: one for medical, surgical, and diagnostic services, and a different Coverage Exception form for prescription drugs. Which form you use, what you attach to it, and how quickly Horizon must respond all follow rules set in New Jersey administrative code and Horizon’s own medical policy manual.

Check Whether the Service Needs Authorization First

Not every service requires approval, and the list depends on the member’s plan. Horizon publishes a Prior Authorization Procedure Search Tool that accepts a CPT or HCPCS code and returns whether that code needs authorization for the member in front of you.¹ It covers Commercial Fully Insured, State Health Benefits Program, School Employees’ Health Benefits Program, Braven Health, Medicaid, and DSNP plans. Self-funded (ASO) accounts are excluded, other than SHBP and SEHBP.

Services that routinely require authorization include elective inpatient admissions, advanced imaging such as MRIs and CT scans, durable medical equipment like power wheelchairs, and high-cost or complex specialty medications. The search tool is a starting point; Horizon’s disclaimer states that the member’s plan documents control if there is any conflict.

What the Medical Prior Authorization Form Requires

For a medical, surgical, or diagnostic request, gather the following before you open the form:

Member’s Horizon ID number, from the front of the insurance card.
Group number, also on the card.
National Provider Identifier (NPI) for the requesting provider or facility.
ICD-10 diagnosis codes describing the patient’s condition.
CPT or HCPCS procedure codes for the exact service, test, or equipment requested.¹
Supporting clinical documentation: physician notes, lab results, imaging reports, and prior treatment history that show why the requested service is appropriate.

Horizon reviews each request against the criteria in its medical policy manual, which defines when a given service qualifies as medically necessary.² Thorough clinical documentation on the first submission is the single best way to avoid a denial or a request for additional information that resets the clock.

What the Pharmacy Form Requires Instead

Prescription drug requests use a different form entirely: the Coverage Exception Prior Authorization / Medical Necessity Determination form. Instead of CPT codes, it asks for the medication name, strength, dosing schedule, and quantity per month.³ The prescriber still supplies the patient’s ICD diagnosis code and their own NPI, but the pharmacy form has no field for a Tax Identification Number or facility procedure codes. Sending the wrong form usually triggers a rejection before any clinical review begins.

How to Submit the Form

Horizon’s preferred channel is the Utilization Management Request Tool, an online portal available around the clock through Horizon’s provider self-service tools.⁴ Electronic submission is faster and generates an immediate confirmation of receipt.

Fax remains an option. Medical prior authorization requests go to Horizon BCBSNJ’s Prior Authorization Department at 1-973-274-2263.⁵ Pharmacy forms fax to the number printed on the form itself, which routes to Horizon’s pharmacy benefit manager. Either way, keep a copy of the submission confirmation. You’ll need it if the request goes missing or a deadline is approaching without a response.

How Long Horizon Has to Decide

New Jersey administrative code sets hard deadlines for utilization management decisions under N.J.A.C. 11:24-8.3:

Urgent requests: a decision within 72 hours of receipt, when the attending provider determines that delay could seriously jeopardize the patient’s health.⁶
Non-urgent pre-service requests: a decision within 15 calendar days of receipt.⁶
Post-service claims: a decision within 30 calendar days of receipt.

These are ceilings, not targets. Many requests submitted through the electronic portal are decided well inside those windows. If a deadline is approaching without a response, contact the Prior Authorization Department directly rather than waiting.

Approved requests come with an authorization number that must appear on the corresponding claim. Without it, the claim is processed as though no authorization exists. Attach the number to the patient’s file and forward it to billing.

If the Request Is Denied

Denials come with an explanation of the clinical reasoning. Members who receive a denial should first check whether their in-network provider has already filed an appeal, because provider offices often handle the first round without waiting for the patient to act.

Internal Appeal to Horizon

The internal appeal is written and must include the member’s name, ID number, dates of service, the claim number, and the reason for the appeal.⁷ Members have up to one year from the date of the Explanation of Benefits to file. Horizon must decide pre-service appeals within 15 days of receipt and post-service appeals within 30 days.⁸

A provider can appeal on the member’s behalf. New Jersey law requires the provider to notify the patient at each stage when they initiate or continue an appeal.⁹

External Review Through the State

If the internal appeal fails, the next step is New Jersey’s Independent Health Care Appeals Program, administered by the Department of Banking and Insurance. An Independent Utilization Review Organization (currently Maximus Federal Services) conducts the review.¹⁰

External review is limited to denials that turned on medical necessity, an experimental or investigational finding, or a cosmetic classification. The internal appeal generally must be completed first, though exceptions apply when the carrier missed its own internal deadlines or when expedited external and internal reviews are requested together.¹⁰

The application is due within 60 days of Horizon’s final internal decision⁹ and must include Horizon’s denial letter and a signed medical records release. Once the review organization accepts the case, the member or provider has five business days to submit additional written information.¹⁰ External review is not available for self-funded plans, Medicare, or Medicare Advantage; those use separate federal processes.

Emergency Care and Retrospective Requests

Federal law removes prior authorization from emergency care. Under the No Surprises Act, a health plan cannot require prior authorization for emergency services or deny coverage because a member went to the ER without pre-approval, and the protection extends to pre- and post-stabilization services whether or not the facility is in-network.¹¹

When authorization wasn’t feasible before the service, providers can submit a retrospective request. The window depends on coverage. Horizon NJ Health Medicaid outpatient services must be submitted within six business days after the service, and missing that deadline results in an administrative denial. Medicaid inpatient admissions require a Notice of Admission within three calendar days of discharge. Medicare members have up to 365 days from the date of service to request a retrospective medical necessity review.¹²

If a service that required prior authorization was performed without it and the provider is in-network, the provider carries the responsibility, and the member should not be held financially liable for the resulting denial.¹³ Out-of-network situations offer less protection, and the financial exposure to the member can be substantial.

1
Horizon Blue Cross Blue Shield of New Jersey. Prior Authorization Procedure Search
2
Horizon Blue Cross Blue Shield of New Jersey. Medical Policy Manual
3
Prime Therapeutics. Horizon BCBSNJ Coverage Exception Prior Authorization Medical Necessity Determination Prescriber Fax Form
4
Horizon Blue Cross Blue Shield of New Jersey. Utilization Management Request Tool
5
Horizon Blue Cross Blue Shield of New Jersey. Horizon Hospital Network Manual – Service
6
Cornell Law School. N.J. Admin. Code 11:24-8.3 – Utilization Management Determinations
7
Horizon Blue Cross Blue Shield. How Do I File an Appeal?
8
Horizon Blue Cross Blue Shield of New Jersey. Inquiries, Complaints and Appeals
9
Justia Law. New Jersey Code 26:2S-11
10
New Jersey Department of Banking and Insurance. Independent Health Care Appeals Program
11
U.S. Department of Labor. Avoid Surprise Healthcare Expenses: How the No Surprises Act Can Protect You
12
Horizon NJ Health. Retrospective Review of Medical Services
13
Horizon Blue Cross Blue Shield of New Jersey. Claims Requiring Additional Documentation