Claim Form : simplebooklet.com

PLEASE READ THIS IMPORTANT INFORMATIONWHEN 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:úNAME & ADDRESS of person or institution rendering the service or supplying the itemúHealth Care Professional Federal Tax Identification Number (Required)úHealth Care Professional NPI NumberúPATIENT’S FULL NAMEúTYPE of service rendered/produced or item suppliedúDATE each service rendered or item suppliedúAMOUNT charged for each service rendered or item suppliedúDIAGNOSIS of ailmentCash register receipts, cancelled checks, money order receipts, personal itemizations, and bills only noting a "balance due" are not acceptable.Note that by completing Box 28 payment will go directly to the Provider.COORDINATION OF BENEFITS?If you or your covered dependent(s) are covered by another health insurance program, please provide the information requested in Section III. 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 insurance, attach a copy of the Noticeof 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 Horizon Blue Cross Blue Shield of New Jersey, supplementaryinsurance,we need a copy of the Explanation of Medicare Benefits (EOMB). This EOMB should havebeen sent to you when Medicare processed your claim. If your EOMB has more than one page, sendus copies of all pages. Please write your Horizon Blue Cross Blue Shield of New Jersey identificationnumber clearly on the first page.HELPFUL HINTSMEMBER WILL BE NOTIFIED OF BILLS MISSING ANY OF THIS INFORMATION. CLAIM WILL REJECT IF THIS INFORMATION IS NOT SUPPLIED. 7190 (0921)HORIZON MEDICAL HEALTH INSURANCE CLAIM FORMWhen 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.Prescription Drugs? Bills must show the patient’s name and date of service, prescription number and amount paid, name, strength & quantity of drug and the name and address of the pharmacy.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.How do I submit my out-of-network claims?For those that use the Horizon Blue app Use the Horizon Blue app to submit your claims for reimbursement:• Take a picture of your medical bill and completed claim form.• Look for the More button on the lower right-hand side of the app and click Claims.• Then click Submit a Claim to upload.Make sure your pictures are legible and clear. To download the app, text GetApp to 422-272 or go to the App Store® or Google Play®. If you already have the Horizon Blue app, make sure you have the latest version by visiting the appropriate app store for updates.For technical support, call the eService desk at 1-888-777-5075, weekdays, 7 a.m. to 6 p.m., Eastern Time.OR

27. I certify that the information provided on this claim form is correct and complete, and that I am claiming benefits only for charges actually incurred by the patient named.I authorize any hospital, physician or other provider who participated in the care and treatment of the patient to release to Horizon Blue Cross Blue Shield of New Jerseyall medical or other information requested for the processing of this claim form. I hereby agree to reimburse Horizon Blue Cross Blue Shield of New Jersey, in full shouldthis claim be incorrectly paid.28. SIGNATURE OF PATIENT (unless a minor) DATE 28. AUTHORIZATION FOR ASSIGNMENT OF BENEFITS29. Horizon Blue Cross Blue Shield of New Jersey, at its discretion, may accept an Assignment of Benefits. I the undersigned, authorize and request Horizon Blue Cross Blue Shield of New Jersey, to make payment for benefits which may be due herein to: Payment will be sent to the Provider if this section is completed.NAME OF HEALTH CARE PROFESSIONAL TAX NUMBER (Required) NPI NUMBERSIGNATURE OF INSURED DATEMIOTHER INSURANCE INFORMATION22. SEXM F21. DATE OF BIRTH20. LAST NAME OF POLICY HOLDERFIRST NAMEMM DD YYYY26. INSURANCE PLAN NAME OR PROGRAM NAME4. IDENTIFICATION NUMBER2. DATE OF BIRTH1. LAST NAME FIRST NAMEMIHorizon Medical Health Insurance Claim Form THIS FORM CAN BE DOWNLOADED FROM OUR WEB SITE AT www.HorizonBlue.comPlease Print This Form In Color (If Available).SEE BACK OF THIS FORM FOR IMPORTANT INFORMATION7190 (0921)An Independent Licensee of the Blue Cross and Blue Shield AssociationINSURED’S INFORMATIONPATIENT’S INFORMATION (If Patient is the same as the Insured, please skip to #16)EDOCPIZ ETATSYTIC SSERDDA .67. TELEPHONE NUMBER3. SEX8. EMPLOYER’S NAME9. INSURANCE PLAN NAME OR PROGRAM NAME 10. IS THERE ANOTHER INSURANCE PLAN?(Include Area Code)24. TELEPHONE NUMBER25. EMPLOYER’S NAME OR SCHOOL NAME(Include Area Code)(No., Street) EDOCPIZ ETATSYTIC SSERDDA .51(No., Street) Prefix (if any) Number Portion 23. IDENTIFICATION NUMBERMM DD YYYYM F13. SEXM FAUTHORIZATION16. RELATIONSHIP TO INSURED12. DATE OF BIRTH11. LAST NAME IMEMANTSRIF14. TELEPHONE NUMBER17. PATIENT’S STATUSEMPLOYED FULL-TIME STUDENTPART-TIME STUDENT(Include Area Code)Self Spouse/DP Child Other Single MarriedOtherMM DD YYYY19. DATE OF CURRENT ILLNESSILLNESS (First symptom) ORINJURY (Accident) ORPREGNANCY (LMP)MM DD YYYYNo Yes18. IS PATIENT’S CONDITION RELATED TO:a. EMPLOYMENT? (Current or Previous)No Yesb. AUTO ACCIDENT? PLACE (State)seY oNseY oNC. OTHER ACCIDENTIF YES, COMPLETEITEMS 20 - 26/ // // // // // /You may complete the required elds below 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 le and save the form with your information to your computer. Reset Form

Claim Form

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