Nj Direct Claim Form

NJ DIRECT Claim Form NJ State Health Benefits Program SHBP Please Print This Form In Color If Available. Please write your NJ DIRECT identification number clearly on the first page. CLAIM FORM MAY BE ADDITIONAL INFORMATION IS NOT SUPPLIED HELPFUL HINTS 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. WHERE TO SUBMIT YOUR CLAIM FORMS Please mail completed claim form for MEDICAL CLAIMS TO Horizon Blue Cross Blue Shield of New Jersey P. O. Box 820 Newark NJ 07101-0820 MENTAL HEALTH/SUBSTANCE ABUSE CLAIMS TO Magellan/NJ DIRECT PO Box 5172 Columbia MD 21045-5172 FRAUD WARNING ANY PERSON WHO KNOWINGLY FILES A STATEMENT OF CLAIM CONTAINING ANY FALSE OR MISLEADING INFORMATION IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES TO REPORT SUSPECTED FRAUD CALL 1-800-624-2048 AT HORIZON BLUE CROSS BLUE SHIELD OF NEW JERSEY. LAST NAME OF SUBSCRIBER 22. SEX 26. HEALTH COVERAGE PLAN NAME OR PROGRAM NAME AUTHORIZATION 27. I certify that the information provided is correct and complete and that I am claiming benefits only for charges actually incurred by the patient named. I authorize any provider who participated in care and treatment to release to Horizon Blue Cross Blue Shield of New Jersey Horizon BCBSNJ all medical or other information requested for the processing of this claim. I agree that New Jersey State auditors NJ State Health Benefits Program and Horizon BCBSNJ may see or get a copy of any such medical records. This information is for the sole use of the New Jersey State Health Benefits Program and Horizon BCBSNJ to administer and analyze the health program. Unless a law requires it information will not be given in an identifiable form to any other persons unless I agree to its release in writing. If you have any questions about how to submit your Claims please call the Customer Service 1-800-414-SHBP 7427. WHERE TO SUBMIT YOUR CLAIM FORMS Please mail completed claim form for MEDICAL CLAIMS TO Horizon Blue Cross Blue Shield of New Jersey P. This information is for the sole use of the New Jersey State Health Benefits Program and Horizon BCBSNJ to administer and analyze the health program. Unless a law requires it information will not be given in an identifiable form to any other persons unless I agree to its release in writing. I agree to reimburse Horizon BCBSNJ should this claim be incorrectly paid. 28. SIGNATURE OF PATIENT unless a minor Spouse Civil Union or Domestic Partner 2642 W0208 DATE SEE BACK OF THIS FORM FOR IMPORTANT INFORMATION An Independent Licensee of the Blue Cross and Blue Shield Association PLEASE READ THIS IMPORTANT INFORMATION WHEN YOU ARE SUBMITTING EXPENSES FOR MORE THAN ONE FAMILY MEMBER PLEASE USE A SEPARATE CLAIM FORM FOR EACH PERSON. ITEMIZED BILLS FOR COVERED SERVICES OR SUPPLIES MUST BE ATTACHED TO THIS FORM AND INCLUDE THE FOLLOWING Check that each itemized bill is legible and contains ALL of the following information NAME ADDRESS of person or institution rendering the service or supplying the item PATIENT S FULL NAME BILLS MISSING ANY OF TYPE of service rendered/produced or item supplied THIS INFORMATION MAY DATE each service rendered or item supplied BE RETURNED TO YOU AMOUNT charged for each service rendered or item supplied DIAGNOSIS of ailment Cash register receipts cancelled checks money order receipts personal itemizations and bills only noting a balance due are not acceptable. I agree to reimburse Horizon BCBSNJ should this claim be incorrectly paid. 28. SIGNATURE OF PATIENT unless a minor Spouse Civil Union or Domestic Partner 2642 W0208 DATE SEE BACK OF THIS FORM FOR IMPORTANT INFORMATION An Independent Licensee of the Blue Cross and Blue Shield Association PLEASE READ THIS IMPORTANT INFORMATION WHEN YOU ARE SUBMITTING EXPENSES FOR MORE THAN ONE FAMILY MEMBER PLEASE USE A SEPARATE CLAIM FORM FOR EACH PERSON. ITEMIZED BILLS FOR COVERED SERVICES OR SUPPLIES MUST BE ATTACHED TO THIS FORM AND INCLUDE THE FOLLOWING Check that each itemized bill is legible and contains ALL of the following information NAME ADDRESS of person or institution rendering the service or supplying the item PATIENT S FULL NAME BILLS MISSING ANY OF TYPE of service rendered/produced or item supplied THIS INFORMATION MAY DATE each service rendered or item supplied BE RETURNED TO YOU AMOUNT charged for each service rendered or item supplied DIAGNOSIS of ailment Cash register receipts cancelled checks money order receipts personal itemizations and bills only noting a balance due are not acceptable. COORDINATION OF BENEFITS If you or your covered dependent s are covered by another health insurance program please provide the information requested in the Other Health Coverage Section. Example Spouse covered by another insurance company or other Horizon Blue Cross Blue Shield of New Jersey coverage.