How to verify your Horizon Blue Cross Blue Shield (Commercial) mental health benefits.
Horizon Blue Cross Blue Shield is the dominant commercial carrier in New Jersey, and the OMNIA tier-1/tier-2 structure is one of its quirks: same plan family, different cost-shares based on which providers are tier-1. Positive Reset Eatontown is in OMNIA tier-1, so members of OMNIA-branded plans get the lowest available copay. Horizon also administers NJDirect (the State Health Benefits Program plan for state and local public employees) and SHBP/SEHBP retirees, all of which we accept. Horizon NJ Health is a separate Medicaid product — if your card says Horizon NJ Health rather than Horizon BCBS, use the NJ FamilyCare verification guide instead.
The call, in order.
Total time: about 10 minutes for most plans, 24 hours if the rep has to call back.
Identify your Horizon product
Your card will name the specific Horizon product: OMNIA PPO/POS, Horizon Direct Access (PPO), Horizon HMO, NJDirect, or a marketplace plan. The product name drives the tier structure and the cost-share, so the rep needs it to give an accurate answer.
Open the Horizon Blue Cross Blue Shield (Commercial)portal → (opens in new tab)
Call Horizon member services
Use the number on the back of your card. For NJDirect or SHBP/SEHBP plans, the line is administered by Horizon under contract with the State of New Jersey — same Horizon staff, just a separate phone number printed on the card.
Confirm in-network status and tier
Tell the rep: Positive Reset Eatontown, 615 Hope Rd Suite 3B, Eatontown, NJ. Ask whether we are in-network. For OMNIA plans specifically, ask whether we are tier-1 (we are). Tier-1 OMNIA copays are typically $5–$15; tier-2 copays for the same visit can be $30–$50.
Confirm deductible status and copay
Most Horizon employer plans don't apply a deductible to outpatient mental health visits — confirm with the rep. For marketplace plans (especially bronze and silver tiers), the deductible can apply, and you'll owe the deductible amount before the copay starts. Get the dollar figure pinned down before booking.
Ask about referral requirements
Horizon HMO products may require a PCP referral for behavioral health; PPO and POS products generally do not. NJDirect does not require a referral. The rep can confirm in seconds and note any open referrals in your record.
Confirm telehealth and TMS coverage
Horizon covers telehealth for behavioral health on every commercial product. For TMS (used in treatment-resistant depression), Horizon administers behavioral-health benefits in-house — prior-auth turnarounds are usually two to three business days once we submit documentation of two or more failed antidepressant trials.
Exactly what to ask the rep.
Copy this list before the call. Each item is the kind of answer that should be on the line with you, not in a follow-up email a week later.
- Is Positive Reset Eatontown in-network for outpatient mental health?
- For OMNIA plans: are we tier-1?
- What is the copay or coinsurance per visit?
- Does the deductible apply to behavioral-health visits?
- Do I need a PCP referral?
- Is telehealth covered at parity?
- What's the TMS prior-authorization timeline?
Plan-specific notes.
Horizon administers behavioral-health benefits in-house rather than routing through a national subsidiary like Optum or Carelon, and that typically means faster prior-authorization decisions. The most common Horizon products we see at the clinic are OMNIA Health Plans (tier-1 access carries the lowest cost-share), Horizon Direct Access PPO, and NJDirect for state and local public employees. Marketplace plans through Get Covered NJ may carry higher deductibles than employer plans — confirm the deductible figure before assuming the copay is the only out-of-pocket cost.
For SHBP and SEHBP retirees, behavioral-health benefits are administered through Horizon under the state contract. The verification process is identical to NJDirect.
If your card says Horizon NJ Health (rather than Horizon BCBS), that's the Medicaid managed care product — same parent company, completely different benefit structure. Use the NJ FamilyCare verification guide for that plan.
We can run the verification for you.
Call us with your member ID and we’ll do the verification call ourselves — usually 5–10 minutes for most plans, 24 hours for plans that require a callback. You’ll get the copay and coverage answer before you book your first visit.
See the full Horizon Blue Cross Blue Shield coverage page for what we treat and what’s covered.
Verifying a different plan?
Other things people ask.
Do you accept Horizon Blue Cross Blue Shield?
Yes. We accept Horizon BCBS commercial plans, including OMNIA and most employer plans. Horizon NJ Health (the Medicaid MCO) is a separate product — also accepted, but billed differently. If you have Horizon through your employer, that's commercial; if you have Horizon NJ Health through NJ FamilyCare, that's Medicaid.Do I need a referral from my primary care doctor?
For most plans, no. Commercial plans like Aetna, Cigna, Horizon BCBS, Oxford, and UnitedHealthcare typically don't require a referral for outpatient mental health. Some Medicare Advantage plans do. NJ FamilyCare doesn't require a referral for outpatient therapy or psychiatry. We tell you up front if your specific plan needs one.What if my insurance changes between visits?
Tell us as soon as possible. We re-verify benefits when an insurance plan changes — call (732) 724-1234 with the new card. Coverage of mental health care often continues without interruption, but the copay or coverage level may shift, and we want you to know what to expect for the next visit.How much will therapy cost me?
If you're insured and we're in-network, you typically pay only your plan's copay or coinsurance — usually $0 to $40 per visit. NJ FamilyCare members pay $0. Self-pay rates start at $125 for medication management and $150 for individual therapy. We tell you the exact cost before your first visit, per the No Surprises Act.
Last updated: 2026-05-23