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HORIZON BLUE CROSS BLUE SHIELD OF NEW JERSEY (Office Ally)

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We agree that any and all Notice of Admissions/Req Auths sent electronically contain true,
accurate and complete information. We agree that it is our responsibility to assure that Horizon
BCBSNJ has received our Notice of Admissions/ Req Auths by reconciling response reports
returned to us.
We agree to authorize the billing service or clearinghouse named below to submit our Horizon
BCBSNJ claims electronically. We realize that it is our responsibility to assure that we receive
from our billing service or clearinghouse any and all reports that are sent electronically from
Horizon BCBSNJ to our billing service or clearinghouse detailing the results of our transmission(s).
We agree to notify Horizon BCBSNJ if we discontinue sending electronic transmission through the
below named trading partner and before beginning to use any other trading partner to send
electronic transmissions.
We agree to fully program all aspects of the Horizon BCBSNJ Specification for the transactions we
desire to send electronically to assure accurate and complete data transmission. We agree to
program all transaction specific edits as outlined in the Horizon BCBSNJ Specification to assure a
limited number of rejects. We agree to make all programming changes requested by Horizon
BCBSNJ as promptly as reasonably possible. We agree to maintain the confidentiality of our Test
and Production Submission IDs and Passwords and prevent unauthorized users from committing
data security violations with our Submission IDs and Passwords. We realize that it is our
responsibility to retrieve any and all reports that are put in our electronic mailbox by Horizon
BCBSNJ detailing the results of our transmission(s). We agree to notify Horizon BCBSNJ if we
discontinue sending electronic transmissions and before beginning to use other means of electronic
transmissions.
32303 (W0517)
Page 1
Health Care Professional, Hospital, Facility or Trading Partner Name: __________________________________
Address: __________________________________________________________________________________
City: ________________________________________________________ State: ________ ZIP: ___________
Contact: ___________________________________________________________________________________
Phone: _________________________________ Fax: ______________________________________________
E-mail Address: _____________________________________________________________________________
Tax ID: ____________________________________ Group NPI Number: ______________________________
(Required for Hospital, Facility, Physician & Other Health Care Professional)
Individual NPI Number: ___________________________
Alpha Suffix(s): ____________________________ Sub Part ID Number: ______________________________
(Required for Multi specialty Groups with assigned suffix)
Hospital and Facility Number: _________________ Sub Part ID Number: _____________________________
(Required for Hospital and Facility only)
Mode of Transmission:
Please check only one.
M Hospital, Facility,
Physician or Other
Health Care
Professional
Programming
Horizon BCBSNJ
Specification
M
Notice of Admission/
Request for
Authorization
Specific to: Rules and Regulations
M *Clearinghouse
Or
M *Billing Service
*
If you checked Software Vendor, Clearinghouse or Billing Service (“Trading Partner”), please provide the name of your software
vendor, clearinghouse, or billing service below:
Name of Trading Partner: ______________________________________________________________________________
Horizon Blue Cross and Blue Shield of New Jersey is an independent licensee of the Blue Cross and Blue Shield Association.
HORIZON BLUE CROSS BLUE SHIELD OF NEW JERSEY
ELECTRONIC TRANSACTION AUTHORIZATION FORM
✔
Office Ally, Inc (FTPT544)
Electronic Transactions Available:
Please check ONLY the electronic transactions that you are applying for:
Claims:
M Physician or other
Health Care
Professional
Or
M Hospital or F
acility
M Requests for
Authorization
(Req Auth)
M Referrals
M Premium
Payment
M Benefit
Enrollment
M Claim Status
M
Eligibility
______________________________________________________ __________________________________
Signature Title
______________________________________________________ __________________________________
Print/Type Name Date
We agree that the information on claims submitted electronically will be true, accurate and complete;
and agree to keep such records as are necessary to disclose fully the extent of services and allow
Horizon BCBSNJ reasonable access to all source documents and medical records related to any
claim. We accept the liability for all claims submitted to Horizon BCBSNJ and will promptly refund any
overpayment made by Horizon BCBSNJ on electronic claims. We realize that anyone who falsifies
electronic claims information may, on conviction, be subject to fines and/or imprisonment under
Federal Law. We agree that it is our responsibility to reconcile claim response reports / messages
received from Horizon BCBSNJ, including acknowledgement of claim receipt from Horizon BCBSNJ, to
assure our claims were received by Horizon BCBSNJ.
We agree that any and all Req Auths sent electronically contain true, accurate and complete
information. We agree that it is our responsibility to assure that Horizon BCBSNJ has received our
Req Auths by reconciling response reports returned to us.
We realize that the eligibility information returned by Horizon BCBSNJ is contingent on the
information available at the moment of transmission. We understand that eligibility for a particular
patient may change between the time of inquiry and the time the claim is processed. Payment
determinations will be made based on eligibility at the time that services are provided.
We agree that any and all information contained on our electronic referrals is based on medical
necessity. We understand that acceptance of this referral does not guarantee payment. We
understand that payments are determined based on contracts and contract limitations. We agree
that it is our responsibility to assure that Horizon BCBSNJ has received our referrals by reconciling
response reports returned to us.
We realize that this transaction is used for the purpose of reporting payroll deducted and other group
premiums for all users sending premium payments to Horizon BCBSNJ. We agree that it is our
responsibility to ensure funds are available to cover premiums.
We agree that the information submitted electronically will be true, accurate and complete. We
realize this transaction is used only to transfer enrollment information from the sponsor of the
insurance coverage, benefits, or policy to Horizon BCBSNJ. We accept the liability for all files
submitted to Horizon BCBSNJ.
We realize that the request for the status of a health care claim or encounter is contingent on the
claim information available at the time of transmission.
Horizon Blue Cross and Blue Shield of New Jersey is an independent licensee of the Blue Cross and Blue Shield Association.
Page 2
Mail or Fax completed form to:
Horizon Blue Cross Blue Shield of New Jersey
EDI Services PP-11C
3 Penn Plaza East
Newark, NJ 07105-2200
Fax Number: 1-973-274-4353
32303 (W0517)
✔
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HORIZON BLUE CROSS BLUE SHIELD OF NEW JERSEY (Office Ally)

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Completed 15 June 2021

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