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

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