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Frequently Used Forms

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  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  Authorization Form - EDI/Electronic Transactions

Use this form to authorize electronic transactions between a trading partner and Horizon BCBSNJ. ID: 3193

PDF  Consent Form - Out-Of-Network (Horizon BCBSNJ)

A member's participating physician or other health care professional must complete this form with their patient when a referral is made to any out-of-network physician, other health care professional, or facility. (English) ID: 2180

PDF  Consent Form - Out-of-Network (Braven Health)

This form must be completed by a referring doctor/other health care professional and signed by the Braven Health member at the time a referral is made to a nonparticipating doctor, facility or other health care provider (including clinical labs). ID: 40054

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  W9 Form-Medical

Use this online form to provide us with information we require when making a reportable payment to you. ID: W9-M