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
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
Dispute Form - Spending-Savings Accounts - Flexible Spending Account - Benny Card
Use this form to file a Benny Card transaction dispute. ID: 8303
Notification Form - Intent to Appeal Adverse Utilization Management (UM) Decision - Stage 1
Use this form to notify of an intent to file a Stage 1 appeal to an adverse Utilization Management (UM) decision. ID: DOBIST1
Notification Form - Intent to Appeal Adverse Utilization Management (UM) Decision - Stage 2
Use this form to notify of an intent to file a Stage 2 appeal to an adverse Utilization Management (UM) decision. ID: DOBIST2
Notification Form - Intent to Appeal Adverse Utilization Management (UM) Decision - Stage 3
To provide notice of an intent to file a Stage 3 appeal to an adverse utilization management (UM) decision. ID: DOBIST3
