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Medical


Claim forms and claims-related forms.


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Health Insurance Claim Form

ID: 2635 (1019)


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Coordination of Benefits

This form authorizes Horizon BCBS to obtain any and all medical records and information from providers of service and/or hospitals, relating to the subscriber and eligible dependents, to the extent required to administer the Plan.

ID: 3247 (W0312)


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Pre-Determination of Medical Benefits

This form will assist you in obtaining a pre-determination as to whether a particular service or supply will be eligible under the Merck Medical Plan and if it meets the medical necessity and reasonable and customary guidelines. The processing time is 30 calendar days from the date the form is received by Horizon Blue Cross Blue Shield of New Jersey. However, in many instances, you may obtain a pre-determination of medical benefits by calling Horizon Blue Cross Blue Shield of New Jersey at 1-877-299-6682. Horizon Blue Cross Blue Shield of New Jersey will confirm the pre-determination of medical benefits in writing to you.

ID: 3202 (W0818) Merck PD


Blue Cross Blue Shield Global Core Forms

If you need to file a claim for services provided outside of the United States, you can obtain the necessary forms from the Blue Cross Blue Shield Global Core website. Please have your ID prefix ready to enter before searching for your plan form.