P.O. Box 487
Syosset, NY 11791
Phone: (800) 449-0738
Fax (800) 356-0488
Email: love_review@crosslandmed.com
   
Horizon BCBSNJ Physician Medical Necessity External Review Request Form
* - Required fields
 
  Physician Information
Name *
NPI Number *
Tax ID *
Specialty *
Billing Address *
City *
State
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Zip Code *  
Phone Number *  
Fax Number *  
     
  Subscriber Information
Name *
Subscriber ID *  
Group Name *  
Group Number *  
Patient Name *  
Patient ID *  
Patient Address *  
City *  
State
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Zip Code *  
     
  Appeal Information
Claim Number *  
Date of Service from
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Horizon Service Request # *  
CPT/HCPCS Codes  
Diagnosis Codes  
Modifiers
Amount in Dispute *  
Summary of Appeal *
Filing Fee Submitted
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  Medical Records Upload
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