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 - Horizon BCBSNJ Continuity of Care for Medical Benefits (for ASO, SHBP/SEHBP & BlueCard Patients)
Participating Horizon providers may use this form to request continuity of care for medical benefits for patients enrolled in self-funded Administrative Services Only (ASO) group employer plans, including patients enrolled in State Health Benefits (SHBP) and School Employees' Health Benefits Programs (SEHBP). Providers that participate with another BCBS plan (other than Horizon) may use this form version to request continuity of care for medical benefits for patients enrolled in any Horizon plan. ID: 40129
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