27.I certifythat the information provided is correct and complete, and that I am claiming benefits only for chargesactuallyincurredby the patient named.Iauthorize any provider who
participated in care and treatment to release to Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ) all medical or other information requested for the processing of
this claim. I agree that New Jersey State auditors, State Health Benefits Program, School Employees’ Health Benefits Program and Horizon BCBSNJ may see, or get a copy of
any such medical records. This information is for the sole use of the State Health Benefits Program, School Employees’ Health Benefits Program and Horizon BCBSNJ to
administer and analyze the health program. Unless a law requires it, information will not be given in an identifiable form to any other persons unless I agree to its release in
writing. I agree to reimburse Horizon BCBSNJ should this claim be incorrectly paid.
28. SIGNATURE OF PATIENT (unless a minor) DATE
You may complete the required fields online and then save or print a
copy for submission. To save a completed copy to your computer, choose
File > Save As to rename the file and save the form with your information to your computer.
MI
OTHER HEALTH COVERAGE INFORMATION
22. SEX
M F
21. DATE OF BIRTH
20. LAST NAME OF SUBSCRIBER
FIRST NAME
MM DD YYYY
26. HEALTHCOVERAGE PLAN NAME OR PROGRAM NAME
4. IDENTIFICATION NUMBER2. DATE OF BIRTH
1
. LAST NAME
FIRST NAME
M
I
State Health Benefits Program (SHBP) and
S
chool Employees’ Health Benefits Program (SEHBP)
THIS FORM CAN BE DOWNLOADED FROM OUR WEB SITE AT www.HorizonBlue.com/SHBP
SEE BACK OF THIS FORM FOR IMPORTANT INFORMATION
2642 (W0714) An Independent Licensee of the Blue Cross and Blue Shield Association
SUBSCRIBER’S INFORMATION
PATIENT’S INFORMATION
(
If Patient is the same as the Subscriber, please skip to #16)
6. ADDRESS CITY STATE ZIP CODE
7
. TELEPHONE NUMBER
3. SEX
8. EMPLOYER’S NAME
9. PLAN NAME 10. DOYOU HAVE OTHER HEALTH COVERAGE?
(Include Area Code)
24. TELEPHONE NUMBER
25. EMPLOYER’S NAME
(Include Area Code)
(No., Street)
15. ADDRESS CITY STATE ZIP CODE
(No., Street)
P
refix Number Portion
23. IDENTIFICATION NUMBER
MM DD YYYY
M F
13. SEX
M F
AUTHORIZATION
16. RELATIONSHIPTO INSURED
12. DATE OF BIRTH
11. LAST NAME FIRST NAME MI
14. TELEPHONE NUMBER
17. PATIENT’S STATUS
EMPLOYED
FULL-TIME STUDENT PART-TIME STUDENT
(Include Area Code)
Self
S
pouse*
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. AUTOACCIDENT? PLACE (State)
No Yes No Yes
C. OTHER ACCIDENT
I
F YES, COMPLETE
ITEMS 20 - 26
NJ D I
R
ECT
NJX 3H
N
Z
NJ DIRECT Claim Form
Please Print This Form In Color (If Available).
*Spouse, Civil Union or Domestic Partner
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:
嘼
NAME & ADDRESS of person or institution rendering the service or supplying the item
嘼
PATIENT’S FULL NAME
嘼
TYPE of service rendered/produced or item supplied
嘼
DATE each service rendered or item supplied
嘼
AMOUNT charged for each service rendered or item supplied
嘼
DIAGNOSIS of ailment
Cash register receipts, cancelled checks, money order receipts, personal itemizations, and bills only noting a "balance due" are not acceptable.
COORDINATION OF BENEFITS?
If you or your covered dependent(s) are covered by another health insurance program, please provide the information requested in the Other Health
Coverage Section. 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 coverage, 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 NJ DIRECT secondary coverage, we need a copy of the 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 NJ DIRECT 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.
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.
Foreign Claim? Bills for services incurred outside of the U.S. must include an English translation and the exchange rate at the time of services.
If you have any questions about how to submit your Claims, please call the Customer Service # 1-800-414-SHBP (7427).
WHERE TO SUBMIT YOUR CLAIM FORMS
Please mail completed claim form for:
MEDICAL CLAIMS TO: MENTAL HEALTH/SUBSTANCE ABUSE CLAIMS TO:
Horizon Blue Cross Blue Shield of New Jersey Horizon Blue Cross Blue Shield of New Jersey
P.O. Box 820 Horizon Behavioral Health
Newark, NJ 07101-0820 P.O. Box 10191
Newark, NJ 07101-3189
FRAUD WARNING
ANY PERSON WHO KNOWINGLY FILES A STATEMENT OF CLAIM CONTAINING ANY FALSE OR
MISLEADING INFORMATION IS SUBJECT TO CRIMINALAND CIVIL PENALTIES
TO REPORT SUSPECTED FRAUD CALL 1-800-624-2048 AT HORIZON BLUE CROSS BLUE SHIELD OF NEW JERSEY
BILLS MISSING ANY OF
THIS INFORMATION MAY
BE RETURNED TO YOU
CLAIM FORM MAY BE
RETURNED TO YOU IF THIS
ADDITIONAL INFORMATION
IS NOT SUPPLIED
