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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  Continuity of Care Coverage Agreement

Physicians who limit their practice to providing services only in their office use this form to advise us of an established arrangement with other participating physicians/groups to care for patients requiring acute care at a network hospital, thereby satisfying our credentialing requirement to have network hospital privileges. ID: 5714

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  Provider Network Special Needs Survey

A copy of this survey must be completed by physicians (MD/DO) and other healthcare professionals who are seeking to join our network(s). ID: 32210

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

PDF  Requirements for Other Healthcare Professionals (not an MD or DO) Checklist

Other healthcare professionals must complete this form to help ensure that all information/documentation is included in a request to join the Horizon Managed Care Network and/or the Horizon PPO Network. ID: 32244

PDF  Requirements for Physicians (MD or DO) Checklist

Physicians (MDs and DOs) must complete this form to help ensure that all information/documentation is included in a request to join the Horizon Managed Care Network and/or the Horizon PPO Network. ID: 32214

PDF  Statement of Collaboration

Certified Nurse Midwives, Certified Registered Nurse Anesthetists, Advanced Practice Nurses and Physician Assistants use this form to establish a consultative, collaborative management and referral relationship with an appropriate Horizon BCBSNJ participating physician. ID: 5712