Nj Direct Claim – Fill Out and Use This PDF

The NJ Direct Claim Form is a crucial document for subscribers of the State Health Benefits Program (SHBP) and School Employees’ Health Benefits Program (SEHBP), providing a streamlined process for claim submissions. Detailed instructions are provided to ensure the submission of complete and correct information, facilitating the efficient processing of healthcare expense reimbursements. For smoother handling of your medical and healthcare-related claims, ensure that all the necessary details are accurately filled out before submission.

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Nj Direct Claim PDF Details

Navigating healthcare paperwork can often feel overwhelming, especially when it involves submitting claims for medical expenses. The NJ Direct Claim Form serves as a critical document for members of the State Health Benefits Program (SHBP) and School Employees’ Health Benefits Program (SEHBP), facilitating the reimbursement process for healthcare services. This particular form, available for download on the Horizon Blue website, requires detailed information from subscribers, including personal identification, employment, and coverage details, alongside specifics of the patient’s condition and any other health coverage they might have. Its purpose is to ensure that subscribers can efficiently claim benefits for the medical charges incurred, emphasizing the importance of submitting complete and accurate information. This includes the medical provider’s details, dates of service, and charges, as well as diagnosis. Key sections of the form address the patient’s status—whether related to employment, an auto accident, or another incident—details for coordination of benefits when there is additional health coverage, and explicit instructions for claims related to durable medical equipment or services incurred outside of the U.S. The form also incorporates an authorization statement for the release of medical information necessary for claim processing. Completing and submitting the NJ Direct Claim Form accurately is crucial, as it includes a certification by the subscriber to reimburse any incorrectly paid claims, highlighting the shared responsibility in maintaining the integrity of healthcare benefits administration.

Question	Answer
Form Name	Nj Direct Claim
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	nj direct claim, claim health nj form, new jersey form direct, form blue horizon

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17. PATIENT’S STATUS

State Health Benefits Program (SHBP) and

School Employees’ Health Benefits Program(SEHBP)

THIS FORM CAN BE DOWNLOADED FROM OUR WEB SITE AT www.HorizonBlue.com/SHBP	NJ DIRECT Claim Form
	Please Print This Form In Color (If Available).

SUBSCRIBER’S INFORMATION									FIRST NAME		MI
1. LAST NAME									FIRST NAME		MI
2. DATE OF BIRTH				3. SEX		4. IDENTIFICATION NUMBER
MM	DD		YYYY	M	F	N J X	3 H Z	N	Number Portion
MM	DD		YYYY	M	F	Prefix	CITY		Number Portion	STATE	ZIP CODE
6. ADDRESS							CITY			STATE	ZIP CODE
(No., Street)						8. EMPLOYER’S NAME
7. TELEPHONE NUMBER						8. EMPLOYER’S NAME
(Include Area Code)									10. DO YOU HAVE OTHER HEALTH COVERAGE?
9. PLAN NAME			R E C T						10. DO YOU HAVE OTHER HEALTH COVERAGE?
N J	D	I							No	Yes	IF YES, COMPLETE
N J	D	I									ITEMS 20 - 26
											ITEMS 20 - 26

PATIENT’S INFORMATION (If Patient is the same as the Subscriber, please skip to #16)			FIRST NAME	MI
11. LAST NAME			FIRST NAME	MI
12. DATE OF BIRTH	13. SEX	14. TELEPHONE NUMBER

MM	DD	YYYY	M	F	(Include Area Code)	CITY	STATE
15. ADDRESS						CITY	STATE

ZIP CODE

(No., Street)

16. RELATIONSHIP TO INSURED

EMPLOYED

Self

Spouse*

Child

Other

Single

Married

Other

18. IS PATIENT’S CONDITION RELATED TO:

PLACE (State)

C. OTHER ACCIDENT

a. EMPLOYMENT? (Current or Previous)

b. AUTO ACCIDENT?

Yes

FULL-TIME STUDENT		PART-TIME STUDENT
FULL-TIME STUDENT		PART-TIME STUDENT

19.DATE OF CURRENT ILLNESS

MM DD YYYY

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

OTHER HEALTH COVERAGE INFORMATION

FIRST NAME

20. LAST NAME OF SUBSCRIBER

21. DATE OF BIRTH

22. SEX

23. IDENTIFICATION NUMBER

YYYY

25. EMPLOYER’S NAME

24. TELEPHONE NUMBER

(Include Area Code)

26. HEALTH COVERAGE PLAN NAME OR PROGRAM NAME

27AUTHORIZATION.I certify that the information provided is correct and complete, and that I am claiming benefits only for charges actually incurred by the patient named. I authorize 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.

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.

*Spouse, Civil Union or Domestic Partner	SEE BACK OF THIS FORM FOR IMPORTANT INFORMATION
2642 (W0714)	An Independent Licensee of the Blue Cross and Blue Shield Association

BILLS MISSING ANY OF THIS INFORMATION MAY BE RETURNED TO YOU

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

☑ 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

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 PATIENTis 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.

CLAIM FORM MAY 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.

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:

MEDICALHorizonCLAIMSBlue CrossTO:Blue Shield of New Jersey

P.O. Box 820

Newark, NJ 07101-0820

MENTALHorizonHEALTH/SUBSTANCEABUSEBlue Cross Blue Shield of NewCLAIMSJersey TO:

Horizon Behavioral Health

P.O. Box 10191

Newark, NJ 07101-3189

ANY PERSON WHO KNOWINGLY FILESFRAUDA STATEMENTWARNINGOF 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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Remember to provide the information inside the segment OTHER HEALTH COVERAGE INFORMATION, LAST NAME OF SUBSCRIBER, FIRST NAME, DATE OF BIRTH, SEX, IDENTIFICATION NUMBER, YYYY, TELEPHONE NUMBER, EMPLOYERS NAME, Include Area Code, HEALTH COVERAGE PLAN NAME OR, AUTHORIZATION, I certify that the information, SIGNATURE OF PATIENT unless a, and DATE.

nj direct claim forms OTHER HEALTH COVERAGE INFORMATION, LAST NAME OF SUBSCRIBER, FIRST NAME, DATE OF BIRTH, SEX, IDENTIFICATION NUMBER, YYYY, TELEPHONE NUMBER, EMPLOYERS NAME, Include Area Code, HEALTH COVERAGE PLAN NAME OR, AUTHORIZATION, I certify that the information, SIGNATURE OF PATIENT unless a, and DATE fields to complete

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