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Claim Payment Determination Appeals

Participating and nonparticipating practices, providers and facilities have the right to appeal claim payment determination with which they disagree. Our appeals processes are documented within the Inquiries, Complaints and Appeals sections of our online provider manuals.

Please note that you must complete our internal claim payment appeal process BEFORE proceeding to submit a request to the state’s external arbitrator, Maximus, in regard to a fully insured claim payment determination. This process is in compliance with the New Jersey Program for Independent Claims Payment Arbitration (PICPA) program established by the Health Claims Authorization, Processing and Payment Act (HCAPPA), P.L. 2005, c. 352.

Appealing a Claim Payment Determination

As noted in the Inquiries, Complaints and Appeals section of our online provider manuals practices, providers and facilities may appeal a claim payment determination related to services provided to a patient enrolled in a fully insured plan, by completing and submitting a copy of the NJ Department of Banking and Insurance’s (DOBI’s) Health Care Provider Application to Appeal a Claims Determination form within 90 days of our determination.

Please mail this form along with all pertinent information/ necessary to help us understand why you disputed our claim determination to:

  • Horizon BCBSNJ
    Appeals Department
    PO Box 10129
    Newark, NJ 07101-3129

If it is concluded that your request meets the eligibility criteria for a first-level HCAPPA appeal, we will advise of our determination in writing within 30 calendar days of receipt.

If that determination is unfavorable to you, we will provide instructions for your second-level appeal, a referral to external arbitration.

Audit Findings

You have the right to initiate a claim payment determination or first-level HCAPPA appeal following an audit performed by Horizon or by a vendor on our behalf, but please note that your interactions with the auditing entity (e.g., a final audit determination or any peer-to-peer discussions disagreeing with an audit determination) are not considered a claim payment determination appeal or first-level HCAPPA appeal.

After Horizon has generated an official notice of claim denial or claim reimbursement recovery, as required by NJ State Law, you may submit a claim payment determination appeal or a first-level HCAPPA appeal to us for review as noted above.

Published on: November 14, 2022, 09:57 a.m. ET
Last updated on: November 14, 2022, 14:43 p.m. ET