Authorizations

 Authorization Form - Spending-Savings Accounts - Flexible Spending Account - Direct Deposit

This form authorizes Horizon BCBSNJ to make a bank account deposit for a Flexible Spending Account (FSA). ID: 8314

 Authorization Form - VeriPoint Application Verification

This form authorizes Horizon BCBSNJ to collect information supplied by a provider on their application. ID: 1090

 Clinical Information Cover Sheet – Authorization Request

Use this cover sheet when uploading clinical/medical record information through Horizon BCBSNJ’s online utilization management tool to support an Authorization request. ID: 32039

 Clinical Information Cover Sheet – Medical Necessity Determination Request

Use this cover sheet when uploading clinical/medical record information through Horizon BCBSNJ’s online utilization management tool to support a Medical Necessity Determination request. ID: 32038

 NJ State Police Annual Medical History

Please use this form for NJ State Police Annual Medical History. ID: sp117

 Orthodontic Referral Authorization

Dental providers use this form as a referral for specialty service authorizations. ID: 8083

 Periodontal Specialty Referral Authorization

Dental providers use this form as a referral for specialty periodontal authorizations. ID: 1649

 Request Form - Authorization for EPOETIN ALPHA (Epogen/Procrit) DARBEPOETIN ALPHA (Aranesp)

Use this form to request authorization of the medical necessity of EPOETIN ALPHA (Epogen/Procrit) DARBEPOETIN ALPHA (Aranesp). ID: 9395

 Request Form - Authorization for Post-Acute Facility Admission

Use this form to request authorization for admission to a post-acute (Acute Rehab, Subacute, SNF or LTAC) facility. ID: 4155

 Request Form - Authorization for Post-Acute Facility Continued Stay

Use this form to request an extension for a member's stay in a post-acute facility. ID: 6637

 Specialty Service Referral Authorization

Dental providers use this form as a referral for specialty service authorizations. ID: 8083