Prior Authorization - Information for Patients
Prior Authorization (also referred to as utilization management) is a process by which insurance companies review procedures and medications to determine whether they will provide coverage, before the service is rendered. Not all medical procedures and medications are subject to prior authorization, but many are. Below please find links to prior authorization policies, listed by insurance company, that are available online. Prior authorization is generally obtained by the physician office. However, it is important for patients to be aware of their rights regarding services that are denied prior authorization. For more information regarding coverage under your plan, please call the phone number on the back of your insurance identification card.
What’s getting in the way of you receiving the care your physician prescribes?
Learn more at:
New Jersey Department of Banking & Insurance Resources
The NJ Department of Banking & Insurance is the regulating body for insurance companies in the state.
The Department's Independent Health Care Appeals Program establishes a three stage complaint mechanism for patients (and their healthcare providers) to appeal prior authorization denials.
Call DOBI at 1-888-393-1062, extension 50998 or (609) 777-9470, ext. 50998 for help.
Visit the Department's website for more information on filing insurance complaints that are not related to prior authorization/ utilization management.
Below are links to payer prior authorization policies available online. This is not a comprehensive list, as many policies were only available through payer portals and payer policies change frequently. These links will be updated periodically; however, we cannot guarantee the accuracy or timeliness of the information provided. Before receiving care, it is recommended that you contact your health insurance company and/or your healthcare provider to determine whether prior authorization is required.
Aetna Better Health of NJ (Medicaid Managed Care Organization)
Aetna Medicare Advantage
Amerigroup (Medicaid Managed Care Organization)
Clover Health (Medicare Advantage)
Horizon Blue Cross Blue Shied of NJ
Horizon Medicare Advantage
Horizon NJ Health (Medicaid Managed Care Organization)
United Healthcare Community Plan (Medicaid Managed Care Organization)
United Healthcare Medicare Advantage
Wellcare (Medicaid Managed Care Organization)
Wellcare Medicare Advantage