Form 0704 (W1106) - Traditional Plan Claim Form - Horizon Blue Cross Blue Shield

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NEW JERSEY

STATE HEALTH BENEFITS PROGRAM

Clear

Traditional Plan Claim Form

DO NOT WRITE ABOVE THIS LINE

(PLEASE TYPE OR PRINT)

1. MEMBER’S NAME (Last, First, Middle Initial)

2. MEMBER’S IDENTIFICATION NUMBER

PREFIX

ALPHA-NUMERIC PORTION

YHA

3HZN

3. MEMBER’S ADDRESS (No., Street)

CITY

STATE

ZIP CODE

5. MEMBER’S STATUS

5a. EMPLOYMENT STATUS

4. TELEPHONE NUMBER (Include Area Code)

5b. MEMBER’S BIRTH DATE

5c. MEMBER’S SEX

Month

Day

Year

Single

Divorced

Active

COBRA

(

)

Male

Female

Married

Widowed

Retired

6. PATIENT’S NAME (Last, First, Middle Initial)

9. IS PATIENT’S CONDITION RELATED TO:

a. EMPLOYMENT?

d. DATE OF ACCIDENT

YES

(Current or Previous)

8. PATIENT’S STATUS

7. PATIENT’S BIRTH DATE

7a. PATIENT’S SEX

YES

b. AUTO ACCIDENT

Month

Day

Year

Single

Divorced

STATE IN WHICH AUTO

Male

Female

c. OTHER ACCIDENT

YES

Married

Widowed

ACCIDENT OCCURRED:

10. PATIENT’S RELATIONSHIP TO MEMBER

11. IS PATIENT EMPLOYED?

YES

Spouse/

IF YES, LIST EMPLOYER:

Self

Child

Other

Domestic Partner

12. IS PATIENT COVERED BY ANOTHER GROUP HEALTH PLAN, HMO,

12a. DOES THE PATIENT HAVE:

MEDICAID OR ANY OTHER FEDERAL, STATE OR GOVERNMENTAL AGENCY?

MEDICARE PART A?

YES

EFFECTIVE DATE:

MEDICARE PART B?

YES

EFFECTIVE DATE:

YES

If Yes, Complete Questions 12a through 12h

REASON FOR ENTITLEMENT?

AGE

DISABILITY

ESRD

12b. OTHER POLICYHOLDER’S NAME

12c. OTHER POLICYHOLDER’S

12d. OTHER POLICYHOLDER’S DATE OF BIRTH

EMPLOYMENT STATUS

Month

Day

Year

Active

COBRA

Retired

12e. OTHER HEALTH PLAN NAME

12f. OTHER HEALTH PLAN IDENTIFICATION NUMBER AND GROUP NUMBER

12g. OTHER HEALTH PLAN ADDRESS (No., Street)

CITY

STATE

ZIP CODE

12h. COMPLETE IF YOU DO NOT HAVE MEDICARE COVERAGE AND IF YOU CHECKED ACTIVE OR COBRA IN SECTION 5a.

IF YOU HAVE SINGLE COVERAGE ONLY, DID YOUR INCOME LAST YEAR (AS FILED ON IRS 1040 FORM) EXCEED $14,000?

YES

IF "NO" PLEASE ATTACH COPY OF LAST YEAR’S IRS 1040 FORM.

IF YOU ARE COVERING DEPENDENTS, DID YOUR FAMILY INCOME LAST YEAR (AS FILED ON IRS 1040 FORM) EXCEED $20,000?

YES

IF "NO" PLEASE ATTACH COPY OF LAST YEAR’S IRS 1040 FORM.

13. THE FOLLOWING AUTHORIZATION TO RELEASE INFORMATION MUST BE COMPLETED:

For claim adjudication, analysis, and administration, I agree that New Jersey State auditors, NJ State Health Benefits Program and Horizon Blue Cross Blue Shield of New Jersey may see, or get a copy

of, ALL RECORDS which pertain to claims I submit or incur for myself or my covered dependents under the New Jersey State Health Benefits Traditional Plan.

This information is for the sole use of New Jersey State to administer and analyze its health program,

or Horizon Blue Cross Blue Shield of New Jersey, which will process the claim. Unless a law requires

it, information will not be given in an identifiable form to any other persons unless I agree to its release

Signature of Patient (unless a minor)

Date

in writing.

14. I the undersigned, authorize and request Horizon Blue Cross Blue Shield of New Jersey, to make payment for benefits which may be due herein to:

NAME OF HEALTH CARE PROFESSIONAL AND THEIR TAX ID (REQUIRED) AND NPI NUMBER

MEMBER’S SIGNATURE

DATE

Horizon Blue Cross Blue Shield of New Jersey is an Independent

0704 (W1106)