Appeal / Dispute

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

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

Appeal / Dispute

Out-of-Network Provider Negotiation Request Form

No Surprises Act: Out of Network Provider Negotiation Request Form

Appeal Form - Medical - BlueCard

Appeal Form – Post Service Medical Necessity Decision

Appeal Form – Waiver of Liability Statement

Application - Appeal a Claims Determination

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

Dispute Form - Spending-Savings Accounts - Flexible Spending Account - Benny Card

Notification Form - Intent to Appeal Adverse Utilization Management (UM) Decision - Stage 1

Notification Form - Intent to Appeal Adverse Utilization Management (UM) Decision - Stage 2

Notification Form - Intent to Appeal Adverse Utilization Management (UM) Decision - Stage 3