Referrals and Prior Authorization*

At times you may require specialty care. Your plan gives you the flexibility to receive specialty care in network or out of network. But, if you want to lower your out-of-pocket expense:

1. Obtain a referral form from your PCP to have your specialty care covered at the in-network level.
2. Receive care from a participating specialist. If you go directly to a specialist without a referral, your care will be considered out of network and you will pay more for your care.

Referral Forms

Our referral process:

• Is easy to use.
• Can help you save money.
• Keeps your PCP informed about the medical care you are receiving.

Your PCP will give you a Horizon BCBSNJ Referral Form or referral receipt if he/she determines that you need specialty care or services.

Please take your referral and your Horizon POS ID card to the specialty care provider at the time of service. Be sure to keep a copy of it for your records.

What you need to know about referrals

When obtaining a referral from your PCP, please remember the following:

• Generally, your PCP can refer you for as many as 12 visits to a specialty provider within 180 days, if it is medically necessary and appropriate.
• If you have a serious chronic condition, your PCP may give you a referral form for an extended period of time.
• To receive specialty care at the in-network level and save on medical costs, you must obtain a referral form from your PCP beforehand.
• Your PCP cannot issue a valid referral form for specialty services you’ve already received. In addition, we cannot guarantee in-network payment for specialty services received without a referral form.
• You do not need a referral for routine, nonsurgical obstetrical or gynecological-related visits to participating Ob/Gyns.

*For more details about what services need referral forms, or for a list of services that require prior authorization, please refer to your Benefit Certificate/Booklet or call Member Services.

Prior Authorization

Prior authorization is the approval we give you and your doctor prior to you receiving certain specialty services. With the proper prior authorization (and referral form, if necessary), your eligible specialty services will be covered.

What you need to know about prior authorization

Some hospital-related care and services, including inpatient hospital care and some office procedures, require prior authorization. As such:

If services that require prior authorization are not approved by us, your care may be covered at the out-of-network level and you may have a greater out-of-pocket expense.

Please note: We are not responsible for payment of services not included in your group contract or those specifically excluded by your group contract. If you have questions about your covered benefits, please call Member Services or refer to your Benefit Certificate/Booklet.

Radiology Imaging Services

If your doctor refers you for radiology or imaging services, please call CareCore National’s (CCN) convenient scheduling line at 1-866-496-6200. A Member Services Representative will help you locate a participating radiology/imaging facility that most closely matches your health needs. You or your referring physician will receive a confirmation number from the scheduling line. The confirmation number will take the place of a referral.

Please note: Some radiology/imaging services (MRI, MRA, PET etc.) may need prior authorization from CCN. Your referring physician will call CCN at the number above on your behalf.

Specialty Copayments

When you are referred for specialty care, you are responsible for your copayment, which is due at the time you receive services. You can find your copayment amount on your Horizon POS ID card.