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Claim Forms

PDF  Claim Form - Dental

Members of any Horizon BCBSNJ dental plan may use this form to submit a dental claim. ID: 7902

PDF  Claim Form - Medical - Reimbursement - Orally Administered Cancer Medication Coverage

Use this form to request reimbursement for cancer medication. ID: 5337

PDF  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

PDF  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

PDF  Instructions - CMS SSN Medicare Claim Number Collection Form

Instructions for filling out the CMS SSN/Medicare Claim Number Collection Form. ID: CMC0001970D

PDF  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