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HEALTH
Braven Health Inquiry Request and Adjustment Form
Please DO NOT use this form for initial claim submissions. Date of Contact
Provider Type
Physician/Health Care Professional
Institutional Provider
Request For (check one)
Adjustment
Recapture/Overpayment
Other
Corrected Claim
Claim Inquiry
Enrollment Issue
Benefit Inquiry
Place of Service (check one only)
Office
Inpatient
Other
Ambulatory Surgery Center
Skilled Nursing Facility
Outpatient
Home Health Care
Claim Type (check one only)
Full Benefit/
Braven Health Primary
Other
BlueCard/lTS
COB
Secondary to Medicare
Workers' Comp/No-Fault
Physician/Health Care Professi
onal/Institutional Provider
Name
Street Address
C
ity
State
ZIP Code
Tax ID#
NPI #
Health Plan ID #
Office Contact Name
Telephone #
Subscriber/Patient Information
Subscriber's Name
Subscriber's ID#
Patient Name
Patient DOB
Patient Account #
Date of Service/Admission
Last Date of Service
Claim#
Total Charges
Details of Request
If submitting a corrected claim, specify the correction. Please attach supporting documents related to the request.
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40111 (0322)
RESET
Professional providers may mail completed forms, along with all pertinent supporting documentation, to
BRAVEN HEALTH
PO BOX 199
NEWARK NJ 07101-0199
Institutional providers may mail completed forms, along with all pertinent supporting documentation, to
BRAVEN HEALTH
PO BOX 1770
NEWARK NJ 07101-1770
Visit our webpage for information on your appeal rights.
This Section for Braven Health Internal Use Only
Amount Paid
Payee
Provider
Subscriber
Penalty Against
Provider
Subscriber
Deductible
Copayment
Coinsurance
Claim#
Claim Process Date
Service Request #
Check#
Check Amount
Check Status
Date Cashed
Representative Name
Date of Response
Details of
Braven Health Response
Products are provided by Horizon Healthcare Services, Inc. d/b/a Horizon BCBSNJ, Horizon Healthcare of New Jersey, Inc. (d/b/a Horizon NJ Health for
Medicaid line of business), Horizon Insurance Company and Healthier New Jersey Insurance Company d/b/a Braven Health. 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 and Horizon Healthcare Services, Inc. d/b/a Horizon BCBSNJ are independent licensees of the Blue Cross and Blue Shield Association. The
Blue Cross® and Blue Shield
®
names and symbols are registered marks of the Blue Cross and Blue Shield Association. The Horizon
®
name and
symbols are registered marks of Horizon Blue Cross Blue Shield of New Jersey. ©2022 Horizon BCBSNJ, Three Penn Plaza East, Newark, New Jersey
07105.
