Claim forms and claims-related forms.
ID: 2635 (1019)
ID: ID 3200 (w1106)
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)
ID: 9429 (W0718)
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