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Reimbursement / Payment

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  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 - Adjustment to Capitation for Multiple People

Use this form to request that Horizon BCBSNJ adjust capitation for multiple people. ID: 32339

PDF  Request Form - Adjustment to Capitation for One Person

Use this form to request that Horizon BCBSNJ adjust capitation for one person. ID: 32340