When you are in an accident, it is important to file a claim with your insurance company as soon as possible. This will help to ensure that you receive the benefits that you are entitled to. The Nj Direct Claim Form is the form that you will need to fill out in order to submit a claim. In this blog post, we will provide you with information on how to complete the form and what information you will need to provide. We also provide a link to download the form so that you can get started right away.
Below is the details relating to the PDF you were seeking to fill out. It will tell you the length of time you will require to complete nj direct claim, what fields you will need to fill in and a few other specific details.
Question | Answer |
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Form Name | Nj Direct Claim |
Form Length | 2 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 30 sec |
Other names | nj unemployment claim benefits form, claim health nj form, new jersey form direct, form blue horizon |
NJ State Health Benefits Program (SHBP) NJ DIRECT Claim Form
THIS FORM CAN BE DOWNLOADED FROM OUR WEB SITE AT www.HorizonBlue.com/SHBP |
PLEASE PRINT THIS FORM IN COLOR (IF AVAILABLE). |
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SUBSCRIBER’S INFORMATION |
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1. LAST NAME |
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FIRST NAME |
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2. DATE OF BIRTH |
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3. SEX |
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4. IDENTIFICATION NUMBER |
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Number Portion |
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6. ADDRESS |
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CITY |
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STATE |
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(No., Street) |
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7. TELEPHONE NUMBER |
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8. EMPLOYER’S NAME |
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(Include Area Code) |
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9. PLAN NAME |
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10. DO YOU HAVE OTHER HEALTH COVERAGE? |
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IF YES, COMPLETE |
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No |
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ITEMS 20 - 26 |
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PATIENT’S INFORMATION (If Patient is the same as the Subscriber, please skip to #16)
11. LAST NAME |
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FIRST NAME |
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12. DATE OF BIRTH |
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13. SEX |
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14. TELEPHONE NUMBER |
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(Include Area Code) |
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15. ADDRESS |
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CITY |
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(No., Street)
16. RELATIONSHIP TO INSURED |
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17. PATIENT’S STATUS |
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Self |
Spouse* |
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Child |
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Other |
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Single |
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Married |
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Other |
Employed |
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18. IS PATIENT’S CONDITION RELATED TO: |
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19. DATE OF CURRENT ILLNESS |
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a. EMPLOYMENT? (Current or Previous) |
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b. AUTO ACCIDENT? |
PLACE (State) |
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C. OTHER ACCIDENT |
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No |
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Yes |
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No |
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Yes |
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No |
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Yes |
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ILLNESS (First symptom) OR INJURY (Accident) OR PREGNANCY (LMP)
OTHER HEALTH COVERAGE INFORMATION
20. LAST NAME OF SUBSCRIBER |
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FIRST NAME |
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MI |
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21. DATE OF BIRTH |
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22. SEX |
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23. IDENTIFICATION NUMBER |
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24. TELEPHONE NUMBER |
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25. EMPLOYER’S NAME |
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(Include Area Code) |
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26. HEALTH COVERAGE PLAN NAME OR PROGRAM NAME |
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AUTHORIZATION
27.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, NJ State 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 New Jersey State 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 |
*Spouse,Civil Union or Domestic Partner |
SEE BACK OF THIS FORM FOR IMPORTANT INFORMATION |
2642 (W0208) |
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
☑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 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.
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 #
WHERE TO SUBMIT YOUR CLAIM FORMS
Please mail completed claim form for: |
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MEDICAL CLAIMS TO: |
MENTAL HEALTH/SUBSTANCE ABUSE CLAIMS TO: |
Horizon Blue Cross Blue Shield of New Jersey |
Magellan/NJ DIRECT |
P.O. Box 820 |
PO Box 5172 |
Newark, NJ |
Columbia, MD |
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