Get Spu Authorization Request Form - Horizon Nj Health

Completing the SPU Authorization Request Form for Horizon NJ Health online is a straightforward process that helps ensure timely approval for necessary medical services. This guide provides step-by-step instructions on how to effectively fill out the form to prevent processing delays.

Follow the steps to complete the authorization request form:

1. Click ‘Get Form’ button to obtain the form and open it in an accessible online editor.
2. Fill in the 'Date of Request' field at the top of the form with the current date.
3. Provide the member's full name in the 'Member Name' section and include the corresponding Member ID #.
4. Enter the provider contact name along with their phone number in the designated fields.
5. Complete the 'DOB' (Date of Birth) field and include the provider's fax number.
6. If applicable, list any additional insurance in the provided fields along with the policy name and number.
7. Indicate the date or date range of service for which the authorization request is being made.
8. Specify the number of days or units requested for services.
9. Provide the primary diagnosis and any other chronic diagnoses, ensuring to use appropriate ICD-10 codes.
10. Indicate the procedures requested by listing the relevant CPT codes.
11. Provide the servicing physician's name, along with their ID # and NPI #.
12. Fill in the servicing facility's information including ID #, NPI #, and TIN #.
13. Mark whether the servicing facility is a hospital or a free-standing ambulatory surgical center.
14. If the requested provider or facility is not within the Horizon NJ Health network, include a letter of medical necessity.
15. Be specific about why an in-network provider cannot fulfill the requested services.
16. After completing the form, review all information for accuracy. Save your changes, then download or print the completed form for submission.
17. Fax the completed form to Horizon NJ Health at (609) 583-3014.

Start the process now by completing your SPU Authorization Request Form online.