Horizon Claim Form Details

Have you ever had to submit a Horizon claim form? If so, you know that it can be a bit of a hassle. But did you know that there are ways to make the process easier? In this blog post, we will discuss some tips for filling out a Horizon claim form. We will also provide some helpful resources that can assist you with the process. So whether you are new to filing Horizon claims or you have experience with it, we hope that this blog post will be helpful for you.

We've gathered some statistical facts about the horizon claim form. Our tip is that you check out this info before you decide to begin working with the file.

QuestionAnswer
Form NameHorizon Claim Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameshorizon claim online, horizon bcbs clain form, horizon care claim form, horizon insurance claim form

Form Preview Example

Horizon Managed Care 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).

 

 

 

 

 

 

 

 

INSURED’S INFORMATION

 

 

 

 

 

 

1. LAST NAME

 

 

 

 

 

FIRST NAME

 

MI

2. DATE OF BIRTH

 

3. SEX

 

4. IDENTIFICATION NUMBER

 

 

 

MM

DD

YYYY

M

F

Prefix (if any)

Number Portion

 

 

6. ADDRESS

 

 

 

 

CITY

 

STATE

ZIP CODE

(No., Street)

 

 

 

 

 

 

 

 

7. TELEPHONE NUMBER

 

 

 

8. EMPLOYER’S NAME

 

 

 

 

 

 

 

 

 

 

(Include Area Code)

 

 

 

 

 

 

 

9. INSURANCE PLAN NAME OR PROGRAM NAME

 

 

10. IS THERE ANOTHER INSURANCE PLAN?

 

 

 

 

 

 

 

 

IF YES, COMPLETE

 

 

 

 

 

 

No

Yes

ITEMS 20 - 26

 

 

 

 

 

 

 

PATIENT’S INFORMATION (If Patient is the same as the Insured, please skip to #16)

11. LAST NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FIRST NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

MI

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12. DATE OF BIRTH

 

 

 

 

 

13. SEX

 

 

 

 

 

14. TELEPHONE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MM

DD

 

YYYY

M

F

 

 

(Include Area Code)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15. ADDRESS

 

CITY

 

STATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ZIP CODE

(No., Street)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

16. RELATIONSHIP TO INSURED

 

 

 

17. PATIENT’S STATUS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Self

Spouse/DP Child

 

Other

 

 

 

Single

 

 

Married

 

Other

18. IS PATIENT’S CONDITION RELATED TO:

 

 

 

 

 

 

a. EMPLOYMENT? (Current or Previous)

 

b. AUTO ACCIDENT?

PLACE (State)

 

No

 

Yes

 

 

 

 

No

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYED

 

FULL-TIME STUDENT

 

PART-TIME STUDENT

 

 

 

 

 

19. DATE OF CURRENT ILLNESS

C. OTHER ACCIDENT

 

 

 

No

Yes

MM

DD

YYYY

ILLNESS (First symptom) OR INJURY (Accident) OR PREGNANCY (LMP)

OTHER INSURANCE INFORMATION

20. LAST NAME OF POLICY HOLDER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FIRST NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MI

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

21. DATE OF BIRTH

 

 

 

 

 

22. SEX

 

 

 

 

23. IDENTIFICATION NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MM

DD

 

YYYY

M

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

24. TELEPHONE NUMBER

 

25. EMPLOYER’S NAME OR SCHOOL NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Include Area Code)

26. INSURANCE PLAN NAME OR PROGRAM NAME

AUTHORIZATION

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.

SIGNATURE OF PATIENT (unless a minor)

DATE

SEE BACK OF THIS FORM FOR IMPORTANT INFORMATION

0834 (W0509)

An Independent Licensee of the Blue Cross and Blue Shield Association

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:

☑NAME & ADDRESS of person or institution rendering the service or supplying the item

☑Health Care Professional Federal Tax Identification Number (Required)

☑Health Care Professional NPI Number

☑PATIENT’S FULL NAME

☑TYPE of service rendered/produced or item supplied

☑DATE each service rendered or item supplied

☑AMOUNT charged for each service rendered or item supplied

☑DIAGNOSIS of ailment

BILLS MISSING ANY OF THIS INFORMATION MAY BE RETURNED TO YOU

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 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.

CLAIM FORM WILL BE RETURNED TO YOU IF THIS ADDITIONAL INFORMATION IS NOT SUPPLIED

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 Managed Care Claims

Horizon Blue Cross Blue Shield of New Jersey

P.O. Box 820

Newark, New Jersey 07101-0820

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

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