Inquiry / Request
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
Change Request Forms - Provider and/or Office File Info
This form is used by dental providers to update their file maintained by Horizon BCBSNJ. ID: 2813
Request Form - Adjustment to Capitation for Multiple People
Use this form to request that Horizon BCBSNJ adjust capitation for multiple people. ID: 32339
Request Form - Adjustment to Capitation for One Person
Use this form to request that Horizon BCBSNJ adjust capitation for one person. ID: 32340
Request Form - Adjustment to Credit Balance
Use this form to request an adjustment to a credit balance. ID: 20374
Request Form - Braven Health Continuity of Practitioner Care for Medical Benefits
Use this form to request continuity of practitioner care for medical benefits for patients enrolled in Braven Health plans. ID: 40050
Request Form - Horizon BCBSNJ Continuity of Practitioner Care for Medical Benefits
Use this form to request continuity of practitioner care for patients enrolled in Horizon BCBSNJ plans. ID: H3154_6049
Request Form - HRA Check Reissue Form
ID: 32222
Request Form - Infertility Services History
Use this form to show a history of infertility and provide it in conjunction with the authorization request form for infertility services. ID: FCSTMS102
Request Form - Inquiry, Adjustment, Issue Resolution
This form is used to make inquiries, request adjustments, or request resolution of certain issues. ID: 40033
Request Form - Provider Inquiries (FEP)
Federal Employee Program (FEP) providers use this form to submit request for information. ID: 3069
Request Form - Provider Inquiries (Hematology-Oncology Groups)
Hematology/Oncology providers use this form to submit requests for information. ID: 40036
Request Form - Provider Inquiries (Institutions-Facilities)
Health care institutions/facilities use this form to request or inquire about information. ID: 40035
Request Form - Provider Inquiries
Providers use this form to submit requests for information. ID: 40034
Request Form - Provider Specialty Change Request
Use this form to request that we change or add an additional provider specialty type or to add a subspecialty or specialized service type to your provider file. ID: 32263
Request Form – Merck Members – Flexible Spending Account – Check Reissue
If a Flexible Spending Account (FSA) reimbursement check is not received, this form is used to request a new one. ID: 16115
