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Appealing Claims Denied for Post Service Medical Necessity

Members and physicians and other health care professionals on behalf of the member, and with the member’s written consent, generally have the right to pursue an appeal of any adverse benefit determination involving a post service medical necessity decision made by Horizon BCBSNJ.

An adverse benefit determination involving a post service medical necessity decision includes a decision to deny a service or procedure based on Horizon BCBSNJ’s medical necessity criteria. Adverse benefit determinations may usually be appealed up to three times, including the right to an external review by an independent review organization.1

To initiate a first level medical appeal in response to an adverse benefit determination, please send a letter providing the medical rationale for the appeal and include all pertinent supporting documentation and submit it to us as follows:

By Fax: 1-732-938-1417
By Mail: Horizon BCBSNJ Claim Policy Appeals Department
Mail Station PP-09E
PO Box 220
Newark, NJ 07101-0420

Please ensure your patient’s name and Horizon BCBSNJ member ID number are noted on all submitted pages of the appeal request and supporting documentation.

First level medical appeals are reviewed by our Medical Director or Medical Director’s designee. First level urgent and emergent medical appeals are reviewed within 24 hours. Non-emergent medical appeals are reviewed within 10 calendar days.

If the denial is upheld, information will be provided about submission of a second level medical appeal, if available through the member’s benefits.

This and other important information is included in our 2017 Participating Physician and Other Health Care Professional Office Manual. To access this manual, registered NaviNet users may visit NaviNet.net, access our Horizon BCBSNJ plan central page and:

  • Mouse over References and Resources and click Provider Reference Materials
  • Mouse over Resources and click Manuals & User Guides

If you have questions, please contact your Network Specialist.

1Individual consumer plans and some ASO/self-insured plans only allow one internal level of appeal, followed by an external appeal. Members/covered persons enrolled in some plans do not have the appeal rights described here. For example, our Medicare Advantage members follow a different appeal process.

Published on: May 22, 2017, 15:13 p.m. ET
Last updated on: May 22, 2017, 16:01 p.m. ET