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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  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

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

Use this form to request an adjustment to a credit balance. ID: 20374

PDF  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

PDF  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

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 - Provider Inquiries (FEP)

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

PDF  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

PDF  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

PDF  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

PDF  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

PDF  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

PDF  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

PDF  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

PDF  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

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