PLEASE READ THIS IMPORTANT INFORMATION
WHEN YOU ARE SUBMITTING EXPENSES FOR MORE THAN ONE FAMILY MEMBER, PLEASE USE A SEPARATE CLAIM FORM FOR EACH PERSON.
ITEMIZED BILLS FOR COVERED SERVICES OR SUPPLIES MUST BE ATTACHED TO THIS FORM AND INCLUDE THE FOLLOWING:
Check that each itemized bill is legible and contains ALL of the following information:
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NAME & ADDRESS of person or institution rendering the service or supplying the item
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Health Care Professional Federal Tax Identification Number (Required)
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Health Care Professional NPI Number
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PATIENT’S FULL NAME
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TYPE of service rendered/produced or item supplied
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DATE each service rendered or item supplied
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AMOUNT charged for each service rendered or item supplied
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DIAGNOSIS of ailment
Cash register receipts, cancelled checks, money order receipts, personal itemizations, and bills only noting a "balance due" are not acceptable.
Note that by completing Box 28 payment will go directly to the Provider.
COORDINATION OF BENEFITS?
If you or your covered dependent(s) are covered by another health insurance program, please provide the information requested in Section III. Example:
Spouse covered by another insurance company or other Horizon Blue Cross Blue Shield of New Jersey coverage.
When submitting charges for services or supplies that have been partially paid or declined by other group health insurance, attach a copy of the Notice
of Payment or Explanation of Benefits from the other health care insurer along with itemized bill(s).
MEDICARE?
If PATIENT is eligible for Medicare Benefits, be sure you include the Explanation of Medicare Benefits
(EOMB) that was sent to patient explaining the charges paid or not paid by Medicare.
To process a claim for your Horizon Blue Cross Blue Shield of New Jersey, supplementary
insurance,we need a copy of the Explanation of Medicare Benefits (EOMB). This EOMB should have
been sent to you when Medicare processed your claim. If your EOMB has more than one page, send
us copies of all pages. Please write your Horizon Blue Cross Blue Shield of New Jersey identification
number clearly on the first page.
HELPFUL HINTS
When you are submitting expenses for more than one family member, please use a separate claim form for each person.
It is suggested that you make copies for your own use before you submit the original bills.
Prescription Drugs? Bills must show the patient’s name and date of service, prescription number and amount paid, name, strength & quantity of drug and
the name and address of the pharmacy.
Durable medical equipment? (Wheel chair, crutches, braces, oxygen, etc.) Your doctor’s certification must be submitted indicating the expected length of
time the equipment will be in use. If renting, please have your medical equipment supplier also indicate the purchase price of the equipment on the bill.
Please mail completed claim form to: Horizon Blue Cross Blue Shield of New Jersey
P.O. Box 1609
Newark, New Jersey 07101-1609
FRAUD WARNING
ANY PERSON WHO KNOWINGLY FILES A STATEMENT OF CLAIM CONTAINING ANY FALSE OR
MISLEADING INFORMATION IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES
TO REPORT SUSPECTED FRAUD CALL 1-800-624-2048 AT HORIZON BLUE CROSS BLUE SHIELD OF NEW JERSEY
MEMBER WILL BE NOTIFIED
OF BILLS MISSING ANY OF
THIS INFORMATION.
CLAIM WILL REJECT IF
THIS INFORMATION IS
NOT SUPPLIED.
7190 (0319)
HORIZON MEDICAL HEALTH INSURANCE CLAIM FORM
