Date of Request:_______________________
Non-Par Physician Authorization Request Form
Requirements: A letter of medical necessity for services by a non-participating provider/physician is required.
Please be specific as to why a par provider/physician cannot provide this service. Notification required for
any date of service change. Please complete this form in its entirety, in order to prevent processing delays.
Fax completed form to: Horizon NJ TotalCare (HMO SNP) at 1-609-583-3013
General Information
Member Name:
Member ID #:
Office Contact Name:
Phone #:
Member Address:
DOB:
Fax #:
Member Phone #:
List Any Additional Insurance:
Policy Number:
Medical Information Needed
Date/Date Range of Service:
#Days/Units Requested:
Primary Diagnosis:
ICD 9 Codes:
_____ ICD 10 Codes: ______________
(ICD 9 Codes active until 9/30/14)
ICD 9 Codes:
_____ ICD 10 Codes: _______________
Other Chronic Diagnosis:
Procedures(s) Requested:
CPT/HCPCS Codes Requested:
Requesting Provider:
ID# or NPI#:
Additional Required Information
Servicing Provider Name:
Specialty: ___________________________
Group Practice Name: ____________________________________________________________________________________
Tax ID# __________________________________________ NPI#:
Address: ______________________________________ City: _____________________ State: ________Zip: _____________
Billing Address: _________________________________ City: ____________________State: ________ Zip: _____________
Treatment Setting:
MD Office
Outpatient Hospital
Non-Par Contact Person:
Hospital SPU/OR
Phone #:
Other
Fax#:

Do you accept Medicaid/DSNP rates?

Timeframe this non-par provider/physician has been treating this member:

Is surgery anticipated?
Expected date:


Has there been any surgery performed by this provider/physician for this member in the past?
Affiliated with par hospital? Yes
No
Hospital Name:
Yes
No
Is this for continuity of care?
Yes
No
If yes, please fax to Horizon NJ TotalCare (HMO SNP) the most recent visit and plan of care and test results
with this form.
Revised Date: 11/2016
Yes
No If yes, where will surgery be done:
Yes
Non-Par Physician Form
No