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

Use this claim form for prescriptions filled by Prime Therapeutics. Prime Therapeutics LLC is an independent company providing pharmacy benefit management services for Horizon BCBSNJ members. ID: 3272