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 - 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

PDF  Claim Form - Medical - National Accounts

National Account members use this form to file a medical claim. ID: 6044

PDF  Claim Form - Medical - PPO-Traditional

Members of Horizon BCBSNJ PPO or Traditional plans use this form to file claims. ID: 7190

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

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

PDF  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

PDF  Claim Form - Spending-Savings Accounts - Health Reimbursement Account

This form is used to file a Horizon Health Reimbursement Account (HRA MyWay) claim. ID: 2816

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  Instructions - CMS SSN Medicare Claim Number Collection Form

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

PDF  List - BlueCard Minute Clinics (National Accounts)

List of participating BlueCard® Minute Clinics.

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