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Horizon BCBS NJCommercial · Prior Auth · Prior Authorization · NJ · General Surgery, Ophthalmology, Pain Management +5 moreHigh impact

SHBP Outpatient Elective Surgical Procedure Review Program to Start June 2026

Act
by Jun 27, 2026
Effective date
Jun 27, 2026
Identified
Oct 3, 2026

Summary

Effective June 27, 2026, Horizon Blue Cross Blue Shield will implement a new Prior Authorization requirement for 12 categories of outpatient elective surgical procedures for New Jersey State Health Benefits Program (SHBP) members only. PA reviews will assess medical necessity and/or Site of Service appropriateness for Hospital Outpatient Department (HOPD) procedures, though Ambulatory Surgery Center (ASC) procedures are exempt from SOS review.

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What to do

by Jun 27, 2026 · 6 steps
01Billing team must implement prior authorization requirements in billing system for all SHBP members undergoing the following outpatient elective procedures: endoscopy, intraocular lens procedures, somatic nerve injections/nerve blocks, spine/spinal cord injections/drainage/aspiration, neurolytic destruction procedures, paravertebral spinal nerve blocks, hernia surgery, carpal tunnel surgery, arthroscopy, knee arthrotomy, lumpectomies, tonsillectomies, and colonoscopy.
02Update billing software to flag and require PA submission for these 12 procedure categories before claim submission for SHBP members.
03Obtain and reference the detailed procedure code list from Horizon Blue's Outpatient Elective Surgical Procedure Review Program resource page to configure system rules accurately.
04Configure system to distinguish between HOPD (requires medical necessity AND SOS review) and ASC (requires medical necessity review only).
05Train front-desk and billing staff to obtain PA prior to scheduling/billing for affected procedures.
06Communicate with providers about medical necessity documentation requirements and SOS review criteria.
If missed: Failure to obtain prior authorization will result in claim denials for SHBP members.

Original notice

SHBP Outpatient Elective Surgical Procedure Review Program to Start June 2026
horizonblue.com · Always check the source before changing claims.
View original ↗

Related policy hubs

Horizon BCBS NJ policiesNJ policy changesGeneral SurgeryOphthalmologyPain ManagementNeurosurgeryENT (Ear, Nose & Throat)OrthopedicsPlastic SurgeryGastroenterology

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