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:
ú
NAME & ADDRESS of person or institution rendering the service or supplying the item
ú
Health Care Professional Federal Tax Identification Number (Required)
ú
Health Care Professional NPI Number
ú
PATIENT’S FULL NAME
ú
TYPE of service rendered/produced or item supplied
ú
DATE each service rendered or item supplied
ú
AMOUNT charged for each service rendered or item supplied
ú
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
27. I certify that the information provided on this claim form is correct and complete, and that I am claiming benefits only for charges actually incurred by the patient named.
I authorize any hospital, physician or other provider who participated in the care and treatment of the patient to release to Horizon Blue Cross Blue Shield of New Jersey
all medical or other information requested for the processing of this claim form. I hereby agree to reimburse Horizon Blue Cross Blue Shield of New Jersey, in full should
this claim be incorrectly paid.
28. SIGNATURE OF PATIENT (unless a minor) DATE
28. AUTHORIZATION FOR ASSIGNMENT OF BENEFITS
29. Horizon Blue Cross Blue Shield of New Jersey, at its discretion, may accept an Assignment of Benefits. I the undersigned, authorize and request Horizon Blue Cross Blue
Shield
of New Jersey, to make payment for benefits which may be due herein to: Payment will be sent to the Provider if this section is completed.
NAME OF HEALTH CARE PROFESSIONAL TAX NUMBER (Required) NPI NUMBER
SIGNATURE OF INSURED DATE
MI
OTHER INSURANCE INFORMATION
22. SEX
M F
21. DATE OF BIRTH
20. LAST NAME OF POLICY HOLDER
FIRST NAME
MM DD YYYY
26. INSURANCE PLAN NAME OR PROGRAM NAME
4. IDENTIFICATION NUMBER2. DATE OF BIRTH
1. LAST NAME FIRST NAME
MI
Horizon Medical Health
Insurance Claim Form
THIS
FORM CAN BE DOWNLOADED FROM OUR WEB SITE AT www.HorizonBlue.com
Please Print This Form In Color (If Available).
SEE BACK OF THIS FORM FOR IMPORTANT INFORMATION
7190 (0319)
An Independent Licensee of the Blue Cross and Blue Shield Association
INSURED’S INFORMATION
PATIENT’S INFORMATION
(If Patient is the same as the Insured, please skip to #16)
EDOCPIZ ETATSYTIC SSERDDA .6
7. TELEPHONE NUMBER
3. SEX
8. EMPLOYER’S NAME
9. INSURANCE PLAN NAME OR PROGRAM NAME 10. IS THERE ANOTHER INSURANCE PLAN?
(Include Area Code)
24. TELEPHONE NUMBER
25. EMPLOYER’S NAME OR SCHOOL NAME
(Include Area Code)
(No., Street)
EDOCPIZ ETATSYTIC SSERDDA .51
(No., Street)
Prefix (if any) Number Portion
23. IDENTIFICATION NUMBER
MM DD YYYY
M F
13. SEX
M F
AUTHORIZATION
16. RELATIONSHIP TO INSURED
12. DATE OF BIRTH
11. LAST NAME IMEMANTSRIF
14. TELEPHONE NUMBER
17. PATIENT’S STATUS
EMPLOYED FULL-TIME STUDENT
PART-TIME STUDENT
(Include Area Code)
Self Spouse/DP Child Other Single Married
Other
MM DD YYYY
19. DATE OF CURRENT ILLNESS
ILLNESS (First symptom) OR
INJURY (Accident) OR
PREGNANCY (LMP)
MM DD YYYY
No Yes
18. IS PATIENT’S CONDITION RELATED TO:
a. EMPLOYMENT? (Current or Previous)
No Yes
b. AUTO ACCIDENT? PLACE (State)
seY oNseY oN
C. OTHER ACCIDENT
IF YES, COMPLETE
ITEMS 20 - 26
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