SHBP/SEHBP

  • Horizon Medicare Advantage NJDIRECT (PPO)
  • NJ DIRECT
  • NJDIRECT HDHP
  • SHBP/SEHBP HMO
  • SHBP OMNIA℠ Health Plan

Services Requiring Prior Authorization

Accidental dental injuries (not required for SHBP/SEHBP HMO)

Acute care confinements (all), exclusive of maternities, including:

  1. Surgical admissions
  2. Medical admissions
  3. Hospice admission
  4. All Skilled Nursing Facility (SNF) confinements

Air ambulance

Applied Behavioral Analysis (ABA)

Bone stimulators

Cancer clinical trials

Cardiac procedures

Cochlear implants

Defibrillators, external

Diagnostic left heart catheterization

Durable medical equipment (DME), (only required for SHBP/SEHBP HMO if over $500)

Echo stress tests

Electric beds/Clinitron/powered hospital beds/air mattresses/powered accessories

Electric, customized or motorized wheelchairs and scooters, and powered accessories

Enteral formula

Home health care services

Home hospice services

Home infusion (IV) therapy

Hyperbaric oxygen therapy

Infertility services, including gamete intrafallopian transfer, invitro fertilization, zygote intrafallopian transfer, artificial insemination, hysterosalpingography

Inpatient admissions

Limb and torso prosthetics

Lyme disease intravenous antibiotic therapy

Lymphadema pumps

Mental health confinements (including residential, partial hospitalizations and intensive outpatient admissions)

Mental health outpatient services

Neurostimulators

Orthotics (only required for SHBP/SEHBP HMO if over $500)

Pain management

Private duty nursing in the Home (Inpatient PDN is ineligible)

Prosthetics (only required for SHBP/SEHBP HMO if over $500)

Radiology services including CT/CTA scans, MRI/MRA, nuclear medicine/nuclear cardiology, PET and PET/CT scans (review performed by eviCore)

Reconstructive procedures that may be considered cosmetic: blepharoplasty/canthopexy/canthoplasty, excision of excessive skin due to weight loss, rhinoplasty/rhytidectomy, pectus excavatum repair, breast reconstruction/enlargement, breast reduction/mammoplasty, lipectomy or excess fat removal, sclerotherapy or surgery for varicose veins, facial reconstruction or repair including: orthognathic surgery, bone graft, osteotomies, surgical management of temporomandibular joint (TMJ), and any other potentially cosmetic procedure

Rehabilitation facility confinements

Rentals (all)

Specialty pharmaceuticals

Specific medications administered in a physician's office or dialysis center (review performed by eviCore) including but not limited to Aranesp, Epogen, Procrit

Spinal disc surgeries (including but not limited to) nucleoplasty, percutaneous laser discectomy, spinal fusion

Sub-acute confinements

Substance use disorders confinements (including residential, partial hospitalizations and intensive outpatient admissions)

Substance use disorder outpatient services

Surgery for morbid obesity (including but not limited to): bariatric procedures, gastric bypass, gastroplasty

Therapy services: cognitive therapy, occupational therapy, physical therapy, speech therapy

Transplants: autologous bone marrow, autologous condrocyte transplants, cornea, heart, kidney, liver, lung, pancreas

Uvulopalatopharyngoplasty (UPPP)

Voice prosthetic devices

Weight loss programs, hospital-based