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 - Reimbursement - Orally Administered Cancer Medication Coverage
Use this form to request reimbursement for cancer medication. ID: 5337
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
Horizon Health Insurance Claim Form
Horizon HMO, Horizon POS, Horizon Direct Access, Horizon EPO, Horizon PPO, Traditional, National Accounts and OMNIA Health Plan members use this form for medical claims. ID: 7190
Instructions - CMS SSN Medicare Claim Number Collection Form
Instructions for filling out the CMS SSN/Medicare Claim Number Collection Form. ID: CMC0001970D
Prescription Drug/COVID-19 At Home Test Kit Claim Form
Use this claim form to submit eligible pharmacy expenses for reimbursement, including COVID-19 at-home test kits you paid out of pocket for. You have to submit one claim form for each person and each prescription. Full instructions can be found on page 2. ID: 3272