Nj Direct Claim – Fill Out and Use

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

PATIENT’S INFORMATION (If Patient is the same as the Subscriber, 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)

OTHER HEALTH COVERAGE INFORMATION

20. LAST NAME OF SUBSCRIBER

FIRST NAME

MI

21. DATE OF BIRTH

22. SEX

23. IDENTIFICATION NUMBER

MM

DD

YYYY

M

F

24. TELEPHONE NUMBER

25. EMPLOYER’S NAME

(Include Area Code)

26. HEALTH COVERAGE PLAN NAME OR PROGRAM NAME

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:

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?

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:
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 07101-0820	Columbia, MD 21045-5172

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