Prior authorization review by eviCore Healthcare when you use an out-of-network facility or provider for advanced imaging services

As a Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ) member, you have access to our vast network of doctors, specialists, hospitals and facilities to help you get the care you need, when you need it.

When you receive certain advanced imaging services, your doctor will get prior authorization (PA) to ensure the services are approved as medically necessary, and are safe and appropriate for your care. Advanced imaging services in our Radiology/Cardiology Imaging Services program include:

Prior authorization requests are submitted by your doctor or facility to eviCore Healthcare (eviCore), our Radiology/Cardiology Imaging Services program administrator, who manages PA review and approval on behalf of Horizon BCBSNJ. Members that don’t have out-of-network benefits need to receive advanced imaging services at participating facilities within Horizon BCBSNJ’s network.

Prior authorization requirements for health plans with out-of-network benefits

Beginning April 1, 2021, if your health plan includes out-of-network benefits, and you choose to use them for advanced imaging services, you or the nonparticipating facility or provider will be required to request prior authorization/medical necessity review through eviCore before you receive services. This will allow eviCore and Horizon BCBSNJ to ensure that our standards of medical necessity and safety are applied to your care, regardless of where services are received. If a PA request is not approved, and you receive advanced imaging services, you will have to pay the entire cost of the services provided. Members are therefore advised to be sure that their physician has obtained eviCore’s prior authorization approval prior to receiving any of the above advanced imaging services.

This requirement applies to advanced imaging services provided at nonparticipating facilities located within Horizon BCBSNJ’s local service area¹ for members enrolled in fully insured commercial plans, as well as Administrative Services Only (ASO) group plans that have opted-in to the eviCore Radiology/Cardiology Imaging Services program that include out-of-network benefits. If you’re not sure this requirement applies to you, please check with your company’s benefits administrator.

Using your out-of-network benefits

If your Horizon BCBSNJ plan includes out-of-network benefits, your doctor must first talk to you about using a nonparticipating facility or provider and ask you to sign a completed copy of our Consent for Referral to an Out-of-Network Provider form.

Remember, you can keep your out-of-pocket costs low by using an in-network doctor and facility. If you have questions about the prior authorization requirement for advanced imaging services, or need help finding an in-network doctor or facility, please contact Member Services.

¹Horizon BCBSNJ’s local service area includes all counties in New Jersey; Kent, New Castle and Sussex counties in Delaware; Bronx, Kings, New York, Orange, Richmond, Rockland and Westchester counties in New York; Bucks, Delaware, Lehigh, Monroe, Northampton, Philadelphia and Pike counties in Pennsylvania.