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Appealing Claims Denied for Post-Service Medical Necessity

Members, 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 claim determination involving a post-service medical necessity decision made by Horizon Blue Cross Blue Shield of New Jersey.

An adverse claim determination involving a post-service medical necessity decision is a decision to deny a service or procedure based on Horizon BCBSNJ’s medical necessity criteria. Adverse claim determinations may usually be appealed up to three times.*

To initiate a first-level medical appeal in response to an adverse determination, you must submit a completed copy of our Post Service Medical Necessity Appeal Request form along with all pertinent supporting documentation to us:

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

For more information about appealing adverse claim determinations involving a post-service medical necessity decision, visit our web page, Appeals of Post Service Medical Necessity Determinations.

If you have questions, please contact your Network Specialist.

*Individual consumer plans and some ASO/self-insured plans only allow one level of 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 policy, and members/covered persons of certain plans, such as individual consumer, ASO accounts and self-insured accounts, may not have the appeal rights described here.

Published on: September 18, 2017, 11:54 a.m. ET
Last updated on: September 18, 2017, 12:03 p.m. ET