Appeal / Dispute

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  Appeal Form - Medical - BlueCard

Use this form to appeal or dispute a rejected BlueCard® claim. ID: 5373

PDF  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

PDF  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

PDF  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

PDF  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

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

Use this form to file a Benny Card transaction dispute. ID: 8303

PDF  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

PDF  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

PDF  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