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
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
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
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
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
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
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
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
