BlueCard Claims Appeal Form Submit to: BlueCard Claim Appeals Horizon Blue Cross Blue Shield of NJ P.O. Box 1301 Neptune, NJ 07754-1301 Office/Facility Name: ___________________________________________________________________________________________ Office/Facility Address: _________________________________ City: ______________________ State: _______ ZIP: ___________ Business Office Representative: __________________________________________________________________________________ Telephone Number: _______ – _______ – _____________ Date of Request: _____ / _____ / ________ MM DD YYYY Subscriber’s Name: ________________________________________________ ______________________ ___________ Last First MI Patient’s Name: ___________________________________________________ ______________________ ___________ Last First MI Patient’s Date of Birth: _____ / _____ / ________ Patient’s Account Number: ____________________________________________ MM DD YYYY First Date of Service: _____ / _____ / ________ Last Date of Service: _____ / _____ / ________ MM DD YYYY MM DD YYYY Details of Request: Please submit all applicable documents to support the appeal: • The relevant CMS 1500(s) or UB04(s) • The relevant Explanation(s) of Benefits or Remittance Advice • Information previously requested that you have not yet submitted, if available • Pertinent correspondence related to this matter • A description of pertinent communications on this matter that was not in writing • Relevant sections of the National Correct Coding Initiative (CCI) or other coding support you relied upon IF the appeal concerns the disposition of billing codes • Other documents you may believe support your position in this appeal including Medical Records/Notes *** If you are submitting this appeal on behalf of the member please include the appropriate authorization form*** Signature: ________________________________________________________ Date: _____ / _____ / ________ MM DD YYYY 5373 (W0312) An Independent Licensee of the Blue Cross and Blue Shield Association. 7 8 0 You may complete the required fields below online and then save or print a copy for submission. To save a completed copy to your computer, choose File > Save As to rename the file and save the form with your information to your computer.

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BlueCard Claims Appeal Form

Submit to: BlueCard Claim AppealsHorizon Blue Cross Blue Shield of NJP.O. Box 1301Neptune, NJ 07754-1301

Office/Facility Name: ___________________________________________________________________________________________

Office/Facility Address: _________________________________ City: ______________________ State: _______ ZIP: ___________

Business Office Representative: __________________________________________________________________________________

Telephone Number: _______ – _______ – _____________ Date of Request: _____ / _____ / ________MM DD YYYY

Subscriber’s Name: ________________________________________________ ______________________ ___________Last First MI

Patient’s Name: ___________________________________________________ ______________________ ___________Last First MI

Patient’s Date of Birth: _____ / _____ / ________ Patient’s Account Number: ____________________________________________MM DD YYYY

First Date of Service: _____ / _____ / ________ Last Date of Service: _____ / _____ / ________MM DD YYYY MM DD YYYY

Details of Request:

Please submit all applicable documents to support the appeal:• The relevant CMS 1500(s) or UB04(s)• The relevant Explanation(s) of Benefits or Remittance Advice• Information previously requested that you have not yet submitted, if available• Pertinent correspondence related to this matter• A description of pertinent communications on this matter that was not in writing• Relevant sections of the National Correct Coding Initiative (CCI) or other coding support you relied upon IF the appeal concerns

the disposition of billing codes• Other documents you may believe support your position in this appeal including Medical Records/Notes

*** If you are submitting this appeal on behalf of the member please include the appropriate authorization form***

Signature: ________________________________________________________ Date: _____ / _____ / ________MM DD YYYY

5373 (W0312) An Independent Licensee of the Blue Cross and Blue Shield Association.

7 8 0

You may complete the required fields below online and then save or print a copy for submission. To save a completed copy to yourcomputer, choose File > Save As to rename the file and save the form with your information to your computer.