HBCBS – Claim Appeal

A Claim Appeal is a written request made on the Department of Banking and Insurance (DOBI) prescribed application form by a physician, hospital or other health care professional asking for a formal review by Insurance company.

Claim Appeals process

This Claim Appeals process is available to all physicians, hospitals or other health care professionals who wish to appeal disputes relating to the payment of claims for services rendered to members/covered persons Insurance company and its subsidiaries and affiliates following insured lines of business, issued in the State:

  • Horizon HMO
  • Horizon POS
  • Horizon Direct Access
  • Horizon PPO/Indemnity

Following information are required in connection with any inquiry, complaint or Claim Appeal

  • Name and address of the physician, hospital or other health care professional and the group practice name, if applicable
  • The member/covered person’s name and ID number involved in the claim
  • Date(s) of service, the service(s) rendered and charges billed for the specific claim in question
  • A clear description regarding the claim in question
  • A copy of any and all voucher(s) relating to the claim appealed
  • The specific basis or rationale for the Claim Appeal
  • The specific remedy or relief sought and if the amount due on the claim is in question, the specific amount believed to be due and the basis, rationale and supporting documentation for such view
  • Other documentation that supports the rationale for the Claim Appeal, if necessary. Examples of documents that may be helpful include claims records, prior correspondence, payment vouchers, printouts of electronic claims systems transactions and any other documentation to adequately support the rationale for the Claim Appeal

 

Addresses for submission of appeals.

Horizon BCBSNJ
Appeals Unit – Physicians and other Healthcare Professionals
P.O. Box 10129
Three Penn Plaza East
Newark, NJ 07101-2200

Horizon BCBSNJ
Facility/Hospital Appeals Unit
P.O. Box 1770
Three Penn Plaza East
Newark, NJ 07101-2200

To file a mental health related Claim Appeal, this information must be sent to:

Magellan Behavioral Health
Participating Provider Appeals Unit
199 Pomeroy Avenue, 3rd Floor
Parsippany, NJ 07054