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Medical

PDF  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

PDF  Appeal Form - Medical - BlueCard

Use this form to appeal or dispute a rejected BlueCard® claim. ID: 5373

PDF  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

PDF  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

PDF  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

PDF  Authorization Form - EDI/Electronic Transactions

Use this form to authorize electronic transactions between a trading partner and Horizon BCBSNJ. ID: 3193

PDF  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

PDF  Claim Form - Medical (FEP)

Federal Employee Program (FEP) members use this form to file a medical claim. ID: 10407

PDF  Claim Form - Medical - Reimbursement - Orally Administered Cancer Medication Coverage

Use this form to request reimbursement for cancer medication. ID: 5337

PDF  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

PDF  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

PDF  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

PDF  Request Form - Continuity of Practitioner Care for Medical Benefits

Use this form to request continuity of practitioner care for medical benefits. ID: H3154_6049

PDF  Request Form - Medical - Change Provider File Info

This form is used to update the provider’s Horizon BCBSNJ file. ID: 9093

PDF  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