Updated Out-of-Network Consent Forms Available
We’re pleased to advise that we recently made updated versions of our Consent for Referral to an Out-of-Network Provider form available online.
Out-of-Network Consent Form – Horizon BCBSNJ (2180)
For patients enrolled in fully insured commercial plans that include OON benefits.
Out-of-Network Consent Form – Braven Health (40054B)
For patients enrolled in Braven HealthSM plans that include OON benefits.
Out-of-Network Consent Form – Horizon Medicare Advantage (40054H)
For patients enrolled in Horizon Medicare Advantage plans that include OON benefits.
We encourage you to visit HorizonBlue.com/consent to access these forms and begin using them immediately in place of previous versions you may have downloaded.
OUT-OF-NETWORK REFERRAL POLICY
Our Out-of-Network Consent Forms are key to your complying with the guidelines of our Out-of-Network Referral Policy. This policy helps us ensure that our members enrolled in plans that include out-of-network benefits are aware that they are using their out-of-network benefits, agree with the use of a nonparticipating provider and understand that higher out-of-pocket expenses will be incurred.
Per the guidelines of this administrative policy, ALL participating providers are required to complete these forms to document discussions that were held with patients enrolled in Horizon and Braven Health plans that include out-of-network benefits BEFORE:
- Referring a patient to any out-of-network provider (including but not limited to physicians, other health care professionals, ambulatory surgery centers, specialty pharmacies, facilities, etc.).
- Sending a patient’s laboratory sample to an out-of-network clinical laboratory.
- Using an out-of-network physician (for example, an anesthesiologist, co-surgeon or assistant at surgery) to perform services.
To access our Out-of-Network Referral Policy, log on to NaviNet.net, select Horizon BCBSNJ from the My Health Plans menu, and:
- Mouse over References and Resources and select Provider Reference Materials.
- Mouse over Policies and Procedures and select Policies.
- Select Administrative Policies.
Please note that our Out-of-Network Referral Policy does not apply to members enrolled in plans that do not include out-of-network benefits. Do not complete our Consent for Referral to an Out-of-Network Provider Form for patients enrolled in plans that do not include out-of-network benefits.
If you have questions about these forms or this administrative policy, please contact your Network Specialist.