Nj Direct Claim PDF Details

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.

QuestionAnswer
Form NameNj Direct Claim
Form Length2 pages
Fillable?Yes
Fillable fields62
Avg. time to fill out12 min 58 sec
Other namesnj direct form, bcbs nj direct claim form, nj direct claims form, nj direct claim forms

Form Preview Example

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

 

 

 

 

 

 

 

 

 

2. DATE OF BIRTH

 

 

3. SEX

 

4. IDENTIFICATION NUMBER

 

 

 

 

MM

DD

 

YYYY

M

F

N J X

3 H Z

N

Number Portion

 

 

 

Prefix

CITY

 

STATE

ZIP CODE

6. ADDRESS

 

 

 

 

 

 

 

 

(No., Street)

 

 

 

 

 

8. EMPLOYER’S NAME

 

 

 

 

7. TELEPHONE NUMBER

 

 

 

 

 

 

 

(Include Area Code)

 

 

 

 

 

 

 

10. DO YOU HAVE OTHER HEALTH COVERAGE?

9. PLAN NAME

 

 

R E C T

 

 

 

 

 

N J

D

I

 

 

 

 

 

No

Yes

IF YES, COMPLETE

 

 

 

 

 

ITEMS 20 - 26

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

FIRST NAME

MI

11. LAST NAME

 

 

12. DATE OF BIRTH

13. SEX

14. TELEPHONE NUMBER

 

 

MM

DD

YYYY

M

F

(Include Area Code)

CITY

STATE

15. ADDRESS

 

 

 

 

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?

 

 

 

No

 

 

 

Yes

 

 

 

 

No

 

 

Yes

 

 

 

 

 

 

 

No

 

Yes

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MI

20. LAST NAME OF SUBSCRIBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

21. DATE OF BIRTH

 

 

 

 

22. SEX

 

 

 

 

23. IDENTIFICATION NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MM

 

DD

 

YYYY

 

 

M

 

 

 

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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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claim form nj pdf empty spaces to consider

Remember to provide the information inside the segment No, Street, RELATIONSHIP, TO, INSURED Child, Spouse, Other, PATIENTS, STATUS Single, Married, Other, EMPLOYED, FULL, TIME, STUDENT PART, TIME, STUDENT Yes, bAU, TO, ACCIDENT, Yes PLACE, State and C, OTHER, ACCIDENT, Yes

claim form nj pdf NoStreetRELATIONSHIPTOINSURED, Child, Spouse, Other, PATIENTSSTATUS, Single, Married, Other, EMPLOYED, FULLTIMESTUDENT, PARTTIMESTUDENT, Yes, bAUTOACCIDENTYes, PLACEState, and COTHERACCIDENTYes fields to complete

Describe the relevant data in the SIGNATURE, OF, PATIENT, unless, a, minor and DATE area.

step 3 to entering details in claim form nj pdf

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