Horizon BCBSNJ has a comprehensive network of contracted ancillary providers throughout our region.
If a PCP determines a patient, who is enrolled in a Horizon BCBSNJ managed care plan that requires referrals, needs care from a specialist or facility, the PCP should refer the patient to a specialty care physician, other ancillary provider or facility participating in the Horizon Managed Care Network.
Referrals serve several purposes. They:
- Provide a mechanism to manage the appropriate use of specialty care services.
- Expedite communication between the PCP, specialist, facility and Horizon BCBSNJ, allowing for efficient and prompt reimbursement of services.
- Provide clinical information for data analysis and medical outcomes.
To help ensure that your patients receive the highest level of benefit coverage, it is important to make sure all referrals to a physician, ancillary provider or hospital are obtained prior to services being rendered.
- Horizon BCBSNJ requires that all referrals are created electronically through either NaviNet.net or our IVR system. We do not accept paper referrals.
- Referrals must be completed before the specialist’s services are rendered.
- Referrals are valid for 365 days from the date of issuance and must include the referring physician’s name, the name of the hospital and the approved number of visits.
- Generally, the maximum number of visits per referral is 12. However, referrals for dialysis treatment may be created for up to 160 visits.
- PCPs and Ob/Gyns in the Horizon Managed Care Network can submit initial referrals to specialists in the network. These are called Primary referrals. Ob/Gyns may issue Primary referrals for Ob/Gyn-related services only.
- Specialists in the Horizon Managed Care Network can submit secondary referrals to network radiology centers or to ambulatory surgery centers or hospital outpatient departments for same day surgery. These are called Refer-On referrals.
- Referrals are NOT required for members enrolled in any Horizon BCBSNJ Medicare Advantage HMO plans, including: Horizon Medicare Blue Value (HMO), Horizon Medicare Blue Value w/Rx (HMO), Horizon Medicare Blue Choice w/Rx (HMO) and Horizon Medicare Blue Advantage (HMO).
- Referrals are not required for members enrolled in Horizon HMO Access, Horizon Direct Access, NJ DIRECT10, NJ DIRECT15, NJ DIRECT1525, NJ DIRECT2030, Horizon Advantage EPO, OMNIA Health Plans, Horizon Medicare Blue Access Group (HMO-POS), Horizon Medicare Blue Access Group w/Rx (HMO POS), Horizon Medicare Blue (PPO), Horizon Medicare Blue Group, (PPO) or Horizon Medicare Blue Group w/Rx (PPO) plans when they use physicians, other health care professionals or facilities that participate in the Horizon Managed Care Network.
- Referrals are not valid for out-of-network services.
- Any referral to a non-participating physician or other health care professional for a member enrolled in a plan that does not include out-of-network benefits requires prior authorization from Horizon BCBSNJ.
- Referrals are required for members enrolled in Horizon POS plans to receive the in-network benefit level.
- Although referrals or approval from Horizon BCBSNJ are not required for members enrolled in managed care plans that include the option of receiving care from nonparticipating physicians, other health care professionals or facilities, these services are generally subject to higher out-of-pocket expense than in-network services. Participating referring physicians are required to follow the guidelines set forth in our Out-of-Network Consent Policy.
REFERRING TO A SPECIALIST
If a PCP determines a patient needs care from a specialist, the PCP should refer the patient to a specialty care physician or other health care professional participating in the Horizon Managed Care Network. Visit our Online Doctor & Hospital Finder, HorizonBlue.com/directory to confirm the participation status of specific physicians.
A patient’s PCP may obtain authorization from our Medical Management Department to allow the specialist to exercise authority and control care provided for a chronic condition (e.g., HIV, cancer, diabetes and transplants). This includes performing tests and treatment and referring to other specialists, hospitals and facilities, as necessary.
If the PCP determines the need to refer a member to a participating specialist for a chronic condition, the PCP must call Medical Management for authorization at 1-800-664-BLUE (2583).
REFERRING TO A FACILITY FOR CHEMOTHERAPY
Only chemotherapy services rendered at a facility require a referral.
ELECTRONIC REFERRAL REQUIREMENT
Horizon BCBSNJ requires that all referrals are created electronically through either NaviNet.net or our IVR system. We do not accept paper referrals.
Submitting Referrals through NaviNet
Registered users of NaviNet may create, submit and review referrals with just a few clicks of the mouse.
Here are a few tips to help make using online referral submissions even easier:
- After entering the subscriber ID number, select the name of the patient being referred. The subscriber information, along with the patient information will prepopulate the referral.
- Search for the ETIN number, which will prepopulate the referred-to physician information.
- You can create multiple consecutive referrals for the same patient without having to re-enter the patient’s information.
- The system speeds up online referral submissions by saving the following frequently used information as favorites:
- - ETIN or tax ID numbers.
- - Number of visits.
- Download/print a Referral Confirmation at any time.
Learn about creating online referral submissions by viewing the NaviNet tutorial:
- Log in to NaviNet.net.
- Select Provider Reference Materials and mouse over Resources.
- Select Training, then Education.
- Select NaviNet Information Demo.
Submitting Referrals through the IVR System
Referrals may be submitted via our IVR system. To access our easy-to-use IVR system, please call 1-800-624-1110.
After submitting a referral through our IVR system, you can request a fax copy of that referral through the IVR. Or, if you are a registered user of NaviNet, you can view and/or print the applicable Referral Confirmation Receipt(s) through NaviNet.net.
Before you submit a referral using IVR, you will need:
- Either your provider ID number, tax identification number (TIN) or National Provider Identifier (NPI).
- The ID number or Social Security Number of the patient being referred.
- The birth date (month, day and year) of the patient being referred.
- The electronic tax identification number (ETIN), TIN, NPI or Medicare ID of the specialist or facility the patient is being referred to.
- Your fax number to receive a fax copy of the referral (optional).
Submitting a primary referral
- From the IVR main menu, say referrals or press 4.
- From the Referrals menu, say submit or press 1.
- Say primary or press 1.
- Say or enter the patient’s ID number or Social Security Number.
- Say or enter the patient’s eight-digit date of birth (mm/dd/yyyy).
- Say or enter the ETIN, TIN, NPI or Medicare ID of the specialist who you are referring the patient to.
- Say or enter the number of visits. (The maximum number of visits, per referral, is 12. The maximum number of dialysis visits, per referral, is 160.)
- Confirm the information you have entered, when prompted.
- Say or enter your fax number, when prompted.
- Listen for and make note of the referral number.
Submitting a Secondary Referral
- From the IVR Main menu, say referrals or press 4.
- From the Referrals menu, say submit or press 1.
- Say secondary or press 2.
- Say the Referral Number for the applicable primary referral. You may enter it via touch-tone if it is all numeric digits.
- Say or enter the ETIN, TIN, NPI or Medicare ID of the hospitals, radiology centers, or ambulatory surgical centers that you are referring to.
- Follow steps 7 through 10 under Submitting a Primary Referral.
Checking Referral Status on the IVR
- From the IVR main menu, say Referrals or press 4.
- From the Referrals menu, say Status or press 2.
- Enter the patient’s ID number or Social Security Number.
- Enter the patient’s eight-digit date of birth (mm/dd/yyyy).
- Listen for a list of referral status records.
- Listen for your opportunity to provide your fax number to request a fax copy of the referral.
IVR System Tips
Here are a few tips to make it easier to submit referrals through the IVR:
- Listen carefully to the prompts and speak your response in a clear voice.
- Information containing letters should be spoken.
- If you think you made a mistake in entering information, simply wait.
- To return to the main menu at any time, say main menu.
To review other best practice hints for creatin referrals through the IVR, visit HorizonBlue.com/ivr.
Viewing Referral Confirmations Online
After submitting a referral through our IVR system, you can view and/or print the applicable Referral Confirmation Receipt(s) through NaviNet.net.
- A few minutes after submitting a referral through the IVR, log in to NaviNet.net.
- Mouse over Referrals and Authorization and click Referral/Authorization Inquiry.
- Search submitted referrals in the appropriate date range.
- Click the appropriate referral confirmation number to see the details.