UNITE HERE HEALTH
The procedures/services outlined here require prior authorization.
Please note that UNITE HERE HEALTH (Local 54) uses eviCore healthcare to perform prior authorization reviews for advanced radiology/imaging/cardiology services (including echocardiograms) and for radiation therapy. Additional information about eviCore healthcare and the services that require prior authorization through eviCore healthcare may be obtained online.
The Medical Injectables Program is administered through Magellan Rx Management. Additional information about Magellan Rx Management and the list of injectable medications under the program may be obtained online or call 1-800-424-4508, Monday through Friday, between 8 a.m. and 5 p.m., ET.
- All Inpatient Admissions
All elective acute care, exclusive of maternities (routine maternity admissions are excluded from prior authorization), including:- Elective surgical admissions
- Elective medical admissions
- Elective C-section admissions under 38 weeks gestation.
- Hospice admissions
- All rehabilitation facility admissions including acute rehab, skilled nursing facility (SNF) and sub-acute admissions
- Mental health and substance abuse admissions. Prior authorization performed by Optum; call 1-866-248-4094
**Routine maternity admissions are excluded from prior authorization requirement; NOA required**
**NonElective Admission including ER Admissions require Notification of Admission (NOA)**
- ABA Therapy (Call UNITE HERE HEALTH at 1-888-437-3480)
- Ambulance transportation – non-emergent – ground or air
- Arthroscopy, regardless of setting
- Bariatric services including gastric bypass and banding procedures
- Blepharoplasty
- Cardiac radiology services (non emergent) (prior authorization performed by eviCore healthcare)
Including Non-emergent diagnostic cardiac catheterization/echo stress test - Carpal tunnel release
- Clinical Trials – all
- Cochlear implants
- Durable medical equipment (DME) exceeding $500 (Where the total anticipated cost or rental charge exceeds $500)
- Echocardiograms (prior authorization performed by eviCore healthcare)
- Electromyogram (EMG)
- Excision of excessive skin – e.g. due to weight loss
- Genetic testing
- Gynecomastia – surgical treatment
- Habilitative therapy for children with autism spectrum disorder (ABA therapy)
(Call UNITE HERE HEALTH at 1-888-437-3480) - Hip replacement
- Home health care services – all skilled visits in the home
- Home IV infusion therapy/services
- Hospice care services
- Hyperbaric oxygen therapy
- Knee replacement
- Laminectomy
- Lipectomy or removal of excessive fat/tissue
- Mammoplasty (breast reduction)
- Medical foods for inborn errors of metabolism
- Meniscectomy
- Myelogram
- Occupational therapy
- Orthognathic jaw surgery including treatment for temporomandibular joint disorder (TMJ) and other craniofacial disorders
- Orthotics (including podiatric orthotics) over $500
- Out-of-network requests for consideration of in-network level of benefit when network deficiency exists (Notify UNITE HERE HEALTH of all such requests)
- Outpatient surgery performed in a hospital-based site of service
- Percutaneous discectomy reduction
- Physical therapy – outpatient services and home health visits
- 202 only: podiatric services (All non-routine services)
- Prosthetics over $500
- Radiation Therapy (prior authorization performed by eviCore healthcare)
- Radiology (prior authorization performed by eviCore healthcare)
- Cardiac CT scans
- CT and CTA scans
- Echocardiogram
- MRI
- MRA
- Nuclear medicine/nuclear cardiology
- PET and PET/CT scans
- Rhinoplasty/septoplasty
- Sclerotherapy or surgery for varicose veins
- Sleep studies
- Speech therapy
- Submucous resection
- Transplant services
- Travel and lodging benefits (Call UNITE HERE HEALTH at 1-888-437-3480)
- Uvulopalatopharyngoplasty (UPPP)
THERE IS NO PRIVATE DUTY NURSING BENEFIT
Horizon BCBSNJ has a number of specialized service areas that provide more specific information and assistance with authorizations and pre-certification. In order for these specialized service areas to perform their functions efficiently and effectively, please seek basic benefits, enrollment and eligibility information prior to contacting our Prior Authorization Department for an authorization request. If you require documentation that a service does not require pre-certification, a Physician Services Representative can provide both the information you need and a service reference number that documents the information you were provided.
- BlueCard®/Out-of-state authorizations
1-888-621-5894 - BlueCard®/Out-of-state members (eligibility and benefits)
1-800-676-BLUE(2583) - eviCore healthcare (prior authorization/medical necessity determinations)
Phone: 1-866-496-6200
Fax: 1-800-637-5204 (radiology services); 1-888-785-2480 (cardiology services) - Home care and/or Home IV infusion
1-800-492-2580 (fax) - Notices of admission for out-of-state and non-network facilities
1-888-621-5894 - Optum (Mental health and substance abuse admissions and non-routine outpatient care, including: intensive outpatient programs, partial hospitalization programs, electro-convulsive treatment, psychological testing, methadone maintenance, extended outpatient visits greater than 53 minutes, and transcranial magnetic stimulation) 1-866-248-4094
- Physical Therapy Unit: Prior authorization can be obtained online. Simply log into NaviNet.net, access our Plan Central page and select Physical and Occupational Therapy Authorizations. The first 12 visits are usually authorized after a claim is received. You can also fax the Physical Therapy Authorization Form to 1-800-723-5188.
- Prior-authorization requests: Most PAs can be requested online. Simply log into NaviNet.net, access our Plan Central page and select Referrals and Authorization, then Utilization Management Requests. You may also call 1-800-664-2583 or fax a request to 1-877-798-5903.
