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
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
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 - Provider Inquiries (FEP)
Federal Employee Program (FEP) providers use this form to submit request for information. ID: 3069
Request Form - Professional/Institutional Inquiry, Adjustment, Issue Resolution MAIL Form (for Horizon BCBSNJ patients)
Professional and Institutional providers may use this form to MAIL us inquiries, claim adjustment requests, or requests to resolve or provide information about issues related to patients enrolled in Horizon BCBSNJ plans. ID: 579
Request Form – Professional/Institutional Inquiry, Adjustment, Issue Resolution MAIL Form (for Braven Health℠ patients)
Professional and Institutional providers may use this form to MAIL us inquiries, claim adjustment requests, or requests to resolve or provide information about issues related to patients enrolled in Horizon BCBSNJ plans. ID: 40111
Request Form - Professional Provider Inquiry, Adjustment, Issue Resolution FAX Form (for Horizon BCBSNJ patients)
Professional providers may use this form to FAX us inquiries, claim adjustment requests, or requests to resolve or provide information about issues related to patients enrolled in Horizon BCBSNJ plans. ID: 40034
Request Form – Professional Provider Inquiry, Adjustment, Issue Resolution FAX Form (for Braven Health℠ patients)
Professional providers may use this form to FAX us inquiries, claim adjustment requests, or requests to resolve or provide information about issues related to patients enrolled in Horizon BCBSNJ plans. ID: 40112
Request Form - Hematologist/Oncologist Inquiry, Adjustment, Issue Resolution FAX Form (for Horizon BCBSNJ patients)
Hematology/Oncology providers may use this form to FAX us inquiries, claim adjustment requests, or requests to resolve or provide information about issues related to patients enrolled in Horizon BCBSNJ plans. ID: 40036
Request Form – Hematologist/Oncologist Inquiry, Adjustment, Issue Resolution FAX Form (for Braven Health℠ patients)
Hematology/Oncology providers may use this form to FAX us inquiries, claim adjustment requests, or requests to resolve or provide information about issues related to patients enrolled in Horizon BCBSNJ plans. ID: 40114
Request Form - Institutional/Facility Inquiry, Adjustment Issue Resolution FAX Form (for Horizon BCBSNJ patients)
Institutional providers may use this form to FAX us inquiries, claim adjustment requests, or requests to resolve or provide information about issues related to patients enrolled in Horizon BCBSNJ plans ID: 40035
Request Form – Institutional/Facility Inquiry, Adjustment, Issue Resolution FAX Form (for Braven Health℠ patients)
Institutional providers may use this form to FAX us inquiries, claim adjustment requests, or requests to resolve or provide information about issues related to patients enrolled in Horizon BCBSNJ plans. ID: 40113
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