Medical
Out-of-Network Provider Negotiation Request Form
Nonparticipating providers use this form to initiate a negotiation with Horizon BCBSNJ for allowed charges/amounts related to an inadvertent or involuntary service per the NJ Out-of-Network Consumer Protection, Transparency, Cost Containment and Accountability Act. ID: 32435
Appeal Form - Medical - BlueCard
Use this form to appeal or dispute a rejected BlueCard® claim. ID: 5373
Application - Medical - EFT Application for Ancillary Facilities
Medical providers use this form to establish Automated Clearing House (ACH) electronic funds transfer (EFT) from Horizon BCBSNJ. ID: 5922
Appeal Form – Post Service Medical Necessity Decision
Use this form to appeal a claim determination involving a post service medical necessity decision made by Horizon BCBSNJ. ID: 32325
Assessment Form - Patient Health (PHQ-9)
This Patient Health Questionnaire (PHQ-9) is a brief self-reported depression assessment form used in primary care. ID: 6652
Authorization Form - EDI/Electronic Transactions
Use this form to authorize electronic transactions between a trading partner and Horizon BCBSNJ. ID: 3193
Checklist - EDI Services Trading Partner - 835 Transaction
This checklist provides information to set up EDI capabilities for the EDI 835 transaction between a provider and Horizon BCBSNJ. ID: 3192
Claim Form - Medical (FEP)
Federal Employee Program (FEP) members use this form to file a medical claim. ID: 10407
Claim Form - Medical - Reimbursement - Orally Administered Cancer Medication Coverage
Use this form to request reimbursement for cancer medication. ID: 5337
Consent Form - Out-Of-Network
This form must be completed by a referring doctor/other health care professional and signed by the member at the time a referral is made to a nonparticipating doctor, facility or other health care provider (including clinical labs). ID: 2180
Election Form - Installment Payments for Maternity Services
Participating and non-participating obstetrical providers use this form to request payment on an installment basis for maternity services rendered during the term of a covered Horizon BCBSNJ member’s pregnancy. ID: 7145
Request Form - Authorization for Post-Acute Facility Admission
Use this form to request authorization for admission to a post-acute (Acute Rehab, Subacute, SNF or LTAC) facility. ID: 4155
Request Form - Continuity of Practitioner Care for Medical Benefits
Use this form to request continuity of practitioner care for medical benefits. ID: H3154_6049
Request Form - Medical - Change Provider File Info
This form is used to update the provider’s Horizon BCBSNJ file. ID: 9093
Request Form - Provider Specialty Change Request
Use this form to request that we change or add an additional provider specialty type or to add a subspecialty or specialized service type to your provider file. ID: 32263
