Appeal / Dispute

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

Appeal Form – Waiver of Liability Statement

Nonparticipating providers use this form as part of an appeal of a rejected claim for services provided to a Medicare Advantage member. ID: 31284

Application - Appeal a Claims Determination

Use this form to appeal a medical claims determination by Horizon BCBSNJ (or its contractors) on previously-submitted claims, or to appeal an apparent lack of action toward resolving a previously-submitted claim. Do not use this form for dental appeals. ID: DOBICAPPCAR

Application - Appeal to Independent Health Care Appeals Program (IHCAP)

If a member’s medical appropriateness request is denied by the Horizon BCBSNJ appeals process, that member can use this form to appeal that decision to the Independent Health Care Appeals Program (IHCAP) run by the New Jersey Department of Banking and Insurance (DOBI). ID: MC-3