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Frequently Used Forms

PDF  No Surprises Act: Out of Network Provider Negotiation Request Form

Nonparticipating providers use this form to initiate a negotiation with Horizon BCBSNJ for allowed charges/amounts related to: services provided by an out-of-network provider at in-network facility; or for out-of-network services provided at an in-network facility without the patient’s informed consent or the benefit of choice. ID: 40109

PDF  Application - Appeal a Claims Determination

Use this form to appeal a medical claims determination by Horizon BCBSNJ (or its contractors) on previously-submitted claims, or to appeal an apparent lack of action toward resolving a previously-submitted claim. Do not use this form for dental appeals. ID: DOBICAPPCAR

PDF  Authorization Form - EDI/Electronic Transactions

Use this form to authorize electronic transactions between a trading partner and Horizon BCBSNJ. ID: 3193

PDF  Consent Form - Out-Of-Network (Horizon BCBSNJ)

A member's participating physician or other health care professional must complete this form with their patient when a referral is made to any out-of-network physician, other health care professional, or facility. (English) ID: 2180

PDF  Consent Form - Out-of-Network (Braven Health)

This form must be completed by a referring doctor/other health care professional and signed by the Braven Health member at the time a referral is made to a nonparticipating doctor, facility or other health care provider (including clinical labs). ID: 40054

PDF  Out-of-Network Provider Negotiation Request Form

Nonparticipating providers use this form to initiate a negotiation with Horizon BCBSNJ for allowed charges/amounts related to an inadvertent or involuntary service per the NJ Out-of-Network Consumer Protection, Transparency, Cost Containment and Accountability Act. ID: 32435

PDF  Request Form - Professional/Institutional Inquiry, Adjustment, Issue Resolution MAIL Form (for Horizon BCBSNJ patients)

Professional and Institutional providers may use this form to MAIL us inquiries, claim adjustment requests, or requests to resolve or provide information about issues related to patients enrolled in Horizon BCBSNJ plans ID: 579

PDF  W9 Form-Medical

Use this online form to provide us with information we require when making a reportable payment to you. ID: W9-M