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Horizon BCBS NJCommercial · Administrative · Claims & Billing · NJMedium impact

Claim Payment Determination Appeals

Effective date
Not stated in the notice
Identified
Oct 10, 2026

Summary

This is historical material (published December 2022, discovered October 2026) documenting Horizon BCBS NJ's claim payment determination appeal process for fully insured plans. It establishes a mandatory internal appeal requirement within 90 days before external arbitration through Maximus under the New Jersey PICPA program. The policy outlines two-level appeals, a 30-calendar-day internal review window, and clarifies that audit interactions are not considered formal appeals.

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What to do

Action · 3 steps
01Already effective (source published December 2022): Verify whether the practice has implemented the documented claim payment determination appeal process for Horizon BCBS NJ fully insured plans and confirm current applicability.
02Specifically, confirm: (1) billing/appeals staff are aware of the mandatory 90-day deadline to submit the NJ DOBI Health Care Provider Application to Appeal a Claims Determination form to Horizon BCBS NJ Appeals Department (PO Box 10129, Newark, NJ 07101-3129); (2) internal appeals processes reference the Inquiries, Complaints and Appeals sections of Horizon provider manuals; (3) staff understand that audit findings and peer-to-peer discussions with auditors do not constitute formal claim payment determination appeals; and (4) the practice tracks the 30-calendar-day Horizon response window for first-level HCAPPA appeal determinations.
03Do not treat this as a new requirement; instead, check whether the process described aligns with current Horizon BCBS NJ guidance, as policies may have been updated since December 2022.

Original notice

Claim Payment Determination Appeals
horizonblue.com · Always check the source before changing claims.
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