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
No Surprises Act: 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: services provided by an out-of-network provider at in-network facility; or for out-of-network services provided at an in-network facility without the patient’s informed consent or the benefit of choice. ID: 40109
Appeal Form - Medical - BlueCard
Use this form to appeal or dispute a rejected BlueCard® claim. ID: 5373
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 (Horizon BCBSNJ)
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
Consent Form - Out-of-Network (Braven Health)
This form must be completed by a referring doctor/other health care professional and signed by the Braven Health member at the time a referral is made to a nonparticipating doctor, facility or other health care provider (including clinical labs). ID: 40054
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 - Braven Health Continuity of Practitioner Care for Medical Benefits
Use this form to request continuity of practitioner care for medical benefits for patients enrolled in Braven Health plans. ID: 40050
Request Form - Horizon BCBSNJ Continuity of Practitioner Care for Medical Benefits
Use this form to request continuity of practitioner care for patients enrolled in Horizon BCBSNJ plans. ID: H3154_6049
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