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Use Our Revised Out-of-Network Consent Form

An updated version of our Consent for Referral to an Out-of-Network Provider Form is available online. . Please dispose of previous form versions you may have downloaded and begin to use this new version today.

The new form requires referring physicians to indicate the name of the out-of-network provider being referred to. Additionally, your patients will need to acknowledge that they understand the impact of using their out-of-network benefits and that Horizon BCBSNJ may contact them to ask about amounts paid to the out-of-network provider.

To help ensure that your patients with out-of-network benefits understand their potential out-of-pocket costs when using a nonparticipating physician, other health care professional and/or facility, Horizon BCBSNJ requires participating physicians and other health care professionals to comply with the guidelines of Out-of-Network Referral Policy, which includes completing a Consent for Referral to an Out-of-Network Provider Form.

As stated in our Out-of-Network Referral Policy, when treating a patient enrolled in a Horizon BCBSNJ plan that includes out-of-network benefits, physicians and other health care professionals are required to:

  1. Complete the form:
    • Before referring a patient to an out-of-network physician, facility or other health care professional
    • Before sending a patient’s laboratory sample to an out-of-network clinical laboratory
    • Before you use an out-of-network physician (e.g., an anesthesiologist, co-surgeon or assistant at surgery) to perform a service
  1. Have a discussion with your patient (or his/her parent, guardian or personal representative) before using an out-of-network provider to advise that:
    • An out-of-network, facility or other health care professional will be involved in your patient’s care
    • Claims for services provided by out-of-network providers will be processed at the patients’ out-of-network level of benefits
    • Your patient will be responsible for his/her out-of-network cost sharing amounts (copayments, deductible and coinsurance amounts, as applicable) AND the difference between Horizon BCBSNJ’s allowance for eligible services and the out-of-network provider’s billed charges
  1. Have your patient (or his/her parent, guardian or personal representative) initial/sign this form to attest that the patient:
    • Is aware of and agrees to the use of an out-of-network physician, facility or other health care professional
    • Understands the financial impact of the decision to use an out-of-network physician, facility or other health care professional
  1. Retain the original completed form in the patient’s medical record and provide a copy to your patient.

Our Out-of-Network Referral Policy does not apply to members enrolled in plans that do not include out-of-network benefits (e.g., Horizon HMO, Horizon EPO, OMNIASM Health Plans, Horizon Medicare Blue Value (HMO) etc.). Please do not complete our Consent for Referral to an Out-of-Network Provider Form for patients enrolled in these plans.

If you have questions, please contact your Network Specialist.


Access our Out-of-Network Referral Policy

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 Polices
Published on: November 15, 2018, 12:15 p.m. ET
Last updated on: November 15, 2018, 12:53 p.m. ET