Appeals of Post Service Medical Necessity Determinations

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 claim determination involving a post service medical necessity decision made by Horizon BCBSNJ.

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, please submit a completed copy of our Post Service Medical Necessity Appeal Request form along with all pertinent supporting documentation to us:

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.

*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.