Medical

Claim forms and claims-related forms.

Application for Continued Enrollment for Dependents with Disabilities

Initial Application
If your dependent child is turning 26 during this calendar year, their coverage under your SHBP/SHEBP Horizon health benefits will end as of December 31. However, if your dependent child is turning 26 and not capable of self-support due to a mental or physical disability, please complete the New Jersey Division of Pensions and Benefits (NJDPB) application for Continued Enrollment for Dependents with Disabilities. Submit this directly to the State, per instructions on the form, no later than January 31 after your child turns 26. Please note: This initial application form should not be sent to Horizon.

Annual Renewal
If you currently have continued coverage for your overage disabled child from Horizon and you need to reapply for continuation of coverage beyond the end date, use Horizon’s application for Annual Renewal of Continued Enrollment for Dependents with Disabilities. You must complete Part 1, while your dependent’s attending physician must complete Part 2. Please be sure that every question is answered, and both Parts 1 and 2 are sent together. Missing information may result in processing delays or termination of coverage.

The completed renewal application must be returned to Horizon within 30 days to the mailing address on the form. For faster processing, you may also email an electronic copy to SHBPEnrollment@horizonblue.com.

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.

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)