Why was my claim denied for not having an authorization or referral?
Your Horizon BCBSNJ plan requires you to receive prior authorization or a referral for certain services or treatments. The Explanation of Benefits (EOB) statement includes information in the Message Codes section about why your claim was denied. Under the Detail Information field on the EOB, you will see a column listing the Message Codes that apply to the processing of your claim. There will be a full description of your Message Codes explaining why your claim was either paid, pending or denied. The Message Code M737 means that your claim has been denied because there was no prior authorization or referral on file for this visit.
If you used an in-network doctor, other health care professional or facility, the provider should have submitted the request for prior authorization or given you a referral.
Prior authorization (sometimes called pre-authorization, prior approval or pre-certification) is the written approval by Horizon BCBSNJ, prior to the date of service, for a doctor or other health care professional or facility to provide specific services or supplies. Your Horizon BCBSNJ plan may require prior authorization for certain services before you receive them, except in an emergency. Prior authorization isn’t a promise your health insurance plan will cover the cost for services. Your participating doctor will work with Horizon BCBSNJ to obtain required prior authorization.
A referral is a written recommendation from your Primary Care Physician (PCP) or participating physician for you to receive specific care from a participating doctor or facility. Your Horizon BCBSNJ plan will determine if you need a referral. Please call your PCP or participating physician to submit a request for a referral for specialty care or services. A referral is not a guarantee of coverage.