Claim Forms
Claim Form - Dental
Members of any Horizon BCBSNJ dental plan may use this form to submit a dental claim. ID: 7902
Claim Form - Medical - BlueCard
Members use this form to file a claim if they received covered medical services outside the U.S., Puerto Rico, and the U.S. Virgin Islands. ID: N-12-420
Claim Form - Medical - HMO-POS-Direct Access – EPO – OMNIA Health Plans
Horizon HMO, Horizon POS and Horizon Direct Access, Horizon EPO and OMNIA Health Plan members use this form for medical claims. ID: 0834
Claim Form - Medical - National Accounts
National Account members use this form to file a medical claim. ID: 6044
Claim Form - Medical - PPO-Traditional
Members of Horizon BCBSNJ PPO or Traditional plans use this form to file claims. ID: 7190
Claim Form - Medical - Reimbursement - Orally Administered Cancer Medication Coverage
Use this form to request reimbursement for cancer medication. ID: 5337
Claim Form - Spending-Savings Accounts - Flexible Spending Account - Medical and Dependent Care
This form is used to file a Horizon BCBSNJ Flexible Spending Account (FSA) claim. ID: 6051
Claim Form - Spending-Savings Accounts - Health Reimbursement Account
This form is used to file a Horizon Health Reimbursement Account (HRA MyWay) claim. ID: 2816
Collection Form - CMS SSN Medicare Claim Number
This form authorizes Horizon BCBSNJ to report specific information about beneficiaries to the Centers for Medicare & Medicaid Services (CMS), as a CMS mandate requires of group health insurance plans. CMS uses this information to properly coordinate payment of benefits among health plans so that claims are paid accurately. ID: 4984
Instructions - CMS SSN Medicare Claim Number Collection Form
Instructions for filling out the CMS SSN/Medicare Claim Number Collection Form. ID: CMC0001970D
List - BlueCard Minute Clinics (National Accounts)
List of participating BlueCard® Minute Clinics.
Prescription Drug Claim Form - Prime Therapeutics
For commercial, non-Medicare members. Use this claim form for reimbursement from Prime Therapeutics for covered prescriptions. Prime Therapeutics LLC is an independent company providing pharmacy benefit management services for Horizon BCBSNJ members. ID: 3272
