Braven Health Inquiry/Request FAX Form for Professional Providers
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HEALTH
Braven Health Inquiry/Request FAX Form for Professional Providers
Professional providers may use this form to FAX Braven HealthSM claim inquiries or requests, along with pertinent supporting documentation, to 1-973-274-4159.
Provider Name
Provider Tax ID Number
Requestor Name
Inquiry/Request Date
Requestor Phone Number
Requestor FAX Number
INQUIRY/REQUEST DETAILS
List one inquiry/request per line below. Insufficient or illegible information may result in a delay in our response. Use additional sheets as necessary.
Patient
Name
Subscriber
ID Number
Date of Service
HORIZON REPLY CODE KEY
A:Claim adjusted to pay
B: Claim previously paid
C: Claim not on file
D: Submit EOB from Primary
E: Subscriber not enrolled w/Braven Health
F: Claim was rejected
Horizon
Reply Code
Inquiry/Request Details
HORIZON REPLY CODE KEY
G: Cannot identify patient based on info provided
H: Claim has been processed
I: Claim received. Please allow 3 weeks for processing.
M: Medical documentation required
X: Inquiry does not meet Fax criteria.
Please allow 3 weeks for processing.
ABBREVIATIONS KEY
AR: Accounts receivable
DOS: Date of service
CHK: Check
CLM: Claim
PMT: Payment
Horizon Received Date
Horizon Response Date
Horizon Service Request Number
Horizon Representative
40112 (0522)
Horizon
Response Details
ABBREVIATIONS KEY
PD: Paid
PIF: Paid in full
SR: Service request
SUB: Subscriber
Products and services are provided by Horizon Healthcare Services, Inc. d/b/a Horizon BCBSNJ, Horizon Healthcare of New Jersey, Inc. d/b/a Horizon NJ Health, Horizon Insurance Company, Healthier New Jersey Insurance Company d/b/a Braven Health and
Horizon Casualty Services, Inc. Communications may be issued by Horizon Healthcare Services, Inc. d/b/a Horizon BCBSNJ in its capacity as administrator of programs and provider relations for its companies. Horizon Healthcare of New Jersey, Inc. d/b/a Horizon
NJ Health, Horizon Insurance Company, Healthier New Jersey Insurance Company d/b/a Braven Health , Horizon Casualty Services, Inc. and Horizon Healthcare Services, Inc. d/b/a Horizon BCBSNJ are independent licensees of the Blue Cross and Blue Shield
Association. ?2022 Horizon Blue Cross Blue Shield of New Jersey Three Penn Plaza East, Newark, New Jersey 07105.
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