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If you see an in-network doctor for care, you only get a medical bill if you owe:

• A copay
• A deductible
• A coinsurance amount
• For services not covered under your plan

When you receive a bill for care, you should review your Explanation of Benefits (EOB). Your EOB tells you what costs are covered for medical care or services you’ve received.

Medical Claims

You can submit out-of-network medical claims by mail or use the Horizon Blue App. This includes claims for behavioral health, prescriptions, eyeglasses, and durable medical equipment like breast pumps, sleep apnea machines, diabetic supplies, orthotics, etc.

Dental Claims

You can submit out-of-network dental claims by mail. Dental claims are not accepted on the Horizon Blue app.

Submitting a Claim

1. Download and complete the appropriate claim form.
2. Include an itemized bill. An itemized bill includes:
   • Patient name
   • Member ID number
   • Date of service
   • Diagnosis code(s)
   • Procedure code(s)
   • Place of service
   • Total charge
3. Submit your claim by mail to the address printed on the form or use the Horizon Blue App.

For Medicare claims, you must include a Medicare Explanation of Benefits (EOB). An Explanation of Benefits (EOB) is the notice that your Medicare Advantage Plan or Part D prescription drug plan typically sends you after you receive medical services or items. You only receive an EOB if you have Medicare Advantage or Part D. An EOB is not the same as a Medicare Summary Notice. It is also important to remember that an EOB is not a bill.

For claims that are sent by mail to Horizon BCBSNJ, there is a 30-day processing period. If the claim you are looking for was mailed within the last 30 days, please allow Horizon BCBSNJ the full time frame for processing.

If it has been over 30 days since you mailed your claim, please call Member Services at the phone number on the back of your member ID card. Depending on your plan, you may also be able to sign in and email or chat with a Member Services Representative.

You can update your additional insurance information by following the steps below:

1. Click Benefits & Coverage.
2. Click Benefits Overview.
3. Click the Coordination of Benefits tab. Note: If you are using a mobile device such as a smartphone, tablet or notebook, you will instead need to scroll down to the bottom of the screen to view Coordination of Benefits and select Yes or No.

Please provide the most up-to-date insurance information for all covered family members to help with the processing of your claims.

If your claim was denied because Coordination of Benefits (COB) information is requested, please call the Horizon BCBSNJ’s Member Services phone number on the back of your member ID card. Depending on your plan, you may also be able to sign in and send us an email or chat with a Member Services Representative.

Generally, this means that your Horizon BCBSNJ plan does not cover that specific treatment or service. To get information about your benefits and eligibility, sign in and follow the steps below:

1. Click Benefits & Coverage.
2. Then click What’s Covered.
3. Make a selection from the Service you may need dropdown menu to view coverage details.

If your claim has been denied because we did not receive the Medicare EOB (MEOB), please send the missing MEOB to:

Horizon BCBSNJ
PO BOX 1609
Newark, NJ 07101

Horizon BCBSNJ has up to 30 days to process your claim from the date we received the additional information.If Medicare is not the primary payer for your claims, please call the Horizon BCBSNJ’s Member Services phone number on the back of your member ID card, send us an email, or chat with us.

Your Horizon BCBSNJ plan requires you to receive prior authorization or a referral for certain services or treatments. The Explanation of Benefits (EOB) statement includes information in the Message Codes section about why your claim was denied. Under the Detail Information field on the EOB, you will see a column listing the Message Codes that apply to the processing of your claim. There will be a full description of your Message Codes explaining why your claim was either paid, pending or denied. The Message Code M737 means that your claim has been denied because there was no prior authorization or referral on file for this visit.

If you used an in-network doctor, other health care professional or facility, the provider should have submitted the request for prior authorization or given you a referral.

Prior authorization (sometimes called pre-authorization, prior approval or pre-certification) is the written approval by Horizon BCBSNJ, prior to the date of service, for a doctor or other health care professional or facility to provide specific services or supplies. Your Horizon BCBSNJ plan may require prior authorization for certain services before you receive them, except in an emergency. Prior authorization isn’t a promise your health insurance plan will cover the cost for services. Your participating doctor will work with Horizon BCBSNJ to obtain required prior authorization.

A referral is a written recommendation from your Primary Care Physician (PCP) or participating physician for you to receive specific care from a participating doctor or facility. Your Horizon BCBSNJ plan will determine if you need a referral. Please call your PCP or participating physician to submit a request for a referral for specialty care or services. A referral is not a guarantee of coverage.

You can view your enrollment information by signing in and following the steps below:

1. Click Benefits & Coverage.
2. Then click Benefits Overview to view the Plan Details for the eligibility status of each enrolled member, as well as the effective date of the plan. You can view your Horizon BCBSNJ medical, dental, prescription and vision plans, as applicable, and the dependents covered under those plans.

If the displayed information is incorrect and you have your Horizon BCBSNJ insurance through your employer, please contact your company’s Benefit Administrator. If you purchased your coverage directly through Horizon BCBSNJ, the Exchange (the federal Marketplace) or the New Jersey State Based Exchange (SBE), please call Horizon BCBSNJ’s Member Services phone number on the back of your member ID card.

Generally, this means that you went to a nonparticipating doctor and your Horizon BCBSNJ plan does not cover nonemergency services or treatment from out-of-network (nonparticipating) health care professionals. Your Explanation of Benefits (EOB) includes specific information in the Message Codes section about why your claim was denied. To view your EOB, sign in and follow the steps below:

1. Click Claims.
2. Click Statements of Payment.
3. Locate the appropriate claim, and click the claim number hyperlink.
4. Click View Explanation of Benefits.

Under the Detail Information field on the EOB, you will see a column listing the Message Codes that apply to the processing of your claim. There will be a full description of your Message Codes explaining why your claim was denied.

To get deductible information, including how much has been applied to your deductible and the amount you have left to meet it, follow the steps below once signed in:

1. Click My Accounts.
2. Click Out of Pocket Expenses.

You will be able to view the amount applied to your deductible, as well as your maximum out-of-pocket expenses, by plan member, for a selected benefit period for both in and out of network, as applicable.

The deductible information displayed is based on the claims that have been processed and finalized as of the date you are viewing the information.