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Inquiry / Request

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  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

PDF  Request Form - Adjustment to Capitation for Multiple People

Use this form to request that Horizon BCBSNJ adjust capitation for multiple people. ID: 32339

PDF  Request Form - Adjustment to Capitation for One Person

Use this form to request that Horizon BCBSNJ adjust capitation for one person. ID: 32340

PDF  Request Form - Adjustment to Credit Balance

Health care facilities use this form to request an adjustment to a credit balance. ID: 20374

PDF  Request Form - Continuity of Practitioner Care for Medical Benefits

Use this form to request continuity of practitioner care for medical benefits. ID: H3154_6049

PDF  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

PDF  Request Form - Inquiry, Adjustment, Issue Resolution

This form is used to make inquiries, request adjustments, or request resolution of certain issues. ID: 579

PDF  Request Form - Medical - Change Provider File Info

This form is used to update the provider’s Horizon BCBSNJ file. ID: 9093

PDF  Request Form - Provider Inquiries (FEP)

Federal Employee Program (FEP) providers use this form to submit request for information. ID: 3069

PDF  Request Form - Provider Inquiries (Hematology-Oncology Groups)

Hematology/Oncology providers use this form to submit requests for information. ID: 5275

PDF  Request Form - Provider Inquiries (Institutions-Facilities)

Health care institutions/facilities use this form to request or inquire about information. ID: 9611

PDF  Request Form - Provider Inquiries

Providers use this form to submit requests for information. ID: 2187

PDF  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

PDF  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