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.
Question | Answer |
---|---|
Form Name | Horizon Claim Form |
Form Length | 2 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 30 sec |
Other names | horizon claim online, horizon bcbs clain form, horizon care claim form, horizon insurance claim form |
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 |
|
|
||
|
|
|
|
|
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
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