Complaints

A complaint is a verbal or written expression of dissatisfaction made by a physician or other health care professional, ancillary provider or facility on their own behalf, regarding any aspect of Horizon BCBSNJ’s (or its subsidiaries’ or affiliates’) health care plans, or the plans of its ASO accounts, including Horizon BCBSNJ’s administration of those plans generally or with respect to a specific action or decision made or taken by Horizon BCBSNJ in connection with any of those health care plans.

Examples of complaints include, but are not limited to:

• Administrative difficulties;
• Claims issues; and
• Credentialing.

Complaints relating to claims may typically involve:

• Contract benefit issues;
• CPT-4 code inconsistencies;
• Incorrect coding;
• Reimbursement disagreements; and
• Rebundling of charges.

Complaints do not include issues related to specific utilization management determinations. For information on the process for appealing utilization management determinations, please refer to the appropriate Horizon BCBSNJ manual.

No provider who exercises their right to file a complaint shall be subject to any sanction, disaffiliation, termination by Horizon BCBSNJ, nor otherwise penalized solely due to such action.

Complaints may be submitted in writing to one of the following addresses.

Professional/Ancillary Providers:

Horizon BCBSNJ
PO Box 199
Newark, NJ 07101-0199

Facilities:

Horizon BCBSNJ
PO Box 1770
Newark, NJ 07101-1770

Please refer to the appropriate Horizon BCBSNJ manual for additional information on Complaints.