Medical
Claim forms and claims-related forms.
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.
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)
Horizon Medical Health Insurance Claim Form
When you are submitting expenses for more than one family member, please use a separate claim form for each person. It is suggested that you make copies for your own use before you submit the original bills.
ID: 7190 (0319)
Medical Transition Care Benefit Request
Transition Care, also referred to as treatment in progress, is a benefit that allows new subscribers and covered dependents to receive medical care by non-participating providers at the in-network benefit level for treatment of an acute injury or illness. Transition care is short term and not intended to replace the regular provisions of the program.
ID: 7164 (0320)
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 Quest Diagnostics 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. However, in many instances, you may obtain a pre-determination of medical benefits by calling us at 1-877-299-6682. We will confirm the pre-determination of medical benefits in writing to you.
ID: 32160 (W0114) Quest Diagnostics
