Form Blue Horizon 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?No
Fillable fields0
Avg. time to fill out30 sec
Other namesnj unemployment claim benefits form, claim health nj form, new jersey form direct, form blue horizon

Form Preview Example

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)

16. RELATIONSHIP TO INSURED

 

 

 

17. PATIENT’S STATUS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Self

Spouse*

 

Child

 

Other

 

 

Single

 

Married

 

Other

Employed

 

 

 

 

 

 

 

 

 

 

 

18. IS PATIENT’S CONDITION RELATED TO:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

19. DATE OF CURRENT ILLNESS

a. EMPLOYMENT? (Current or Previous)

 

b. AUTO ACCIDENT?

PLACE (State)

 

 

C. OTHER ACCIDENT

 

 

 

 

 

 

 

 

 

No

 

 

 

Yes

 

 

 

 

No

 

 

Yes

 

 

 

 

 

 

 

No

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MM

DD

 

YYYY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

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:

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 # 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