Form 0704 (W1106) - Traditional Plan Claim Form - Horizon Blue Cross Blue Shield Page 2

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PLEASE READ THIS IMPORTANT INFORMATION CAREFULLY

COORDINATION OF BENEFITS

If you or your dependent(s) are covered by another health insurance program, please complete the information requested in Section III.

Example: Spouse covered by another insurance company or other Horizon Blue Cross Blue Shield of New Jersey coverage.

When submitting charges for services or supplies that have been partially paid or declined by other group health insurance, including claims related to auto accidents, attach a

copy of the Notice of Payment or Explanation of Benefits from the other health care insurer along with itemized bill(s).

MEDICARE

If you or your dependent(s) are eligible for Medicare Benefits and Medicare is your primary insurer, be

CLAIM FORM WILL BE

sure you include the Explanation of Medicare Benefits (EOMB) that was sent by Medicare explaining the

RETURNED TO YOU IF THIS

charges paid or not paid.

ADDITIONAL INFORMATION

IS NOT SUPPLIED

If your EOMB has more than one page, send us copies of all pages.

HELPFUL HINTS

When you are submitting expenses for more than one family member, please complete a separate claim form for each person. Itemized bills for covered services or supplies

must be attached to the form and include the following:

Check that each itemized bill is legible and contains ALL of the following information:

√

NAME & ADDRESS of Health Care Professional rendering the service or supplying the item

√

HEALTH CARE PROFESSIONAL’S Federal Tax Identification Number (required) and NPI Number

BILLS MISSING ANY OF

√

PATIENT’S FULL NAME

THIS INFORMATION WILL

√

DELAY PROCESSING AND

TYPE of service rendered or item supplied

√

MAY BE RETURNED

DATE each service rendered or item supplied

TO YOU

√

AMOUNT charged for each service rendered or item supplied

√

DIAGNOSIS

Cash register receipts, cancelled checks, money order receipts, personal itemizations, and bills only noting a "balance due" are not acceptable.

If you have any questions about how to submit your Claims, please call the Customer Service # 1-800-414-SHBP (7427).

Please make copies of your bills for your records before you submit the original bills.

Prescription Drugs Bills must show the prescription number, name of drug and the name and address of the pharmacy.

Durable medical equipment? (Wheel chair, crutches, braces, oxygen, etc.) Your doctor’s certification must be submitted indicating the expected length of time the equipment

will be in use. If renting, please have your medical equipment supplier also indicate the purchase price of the equipment on the bill.

Foreign Claim? Bills for services incurred outside of the U.S. must include an English translation and the exchange rate at the time of services.

WHERE TO SUBMIT YOUR CLAIM FORMS

Horizon Blue Cross Blue Shield of New Jersey

P.O. Box 1609

Newark, New Jersey 07101-1609

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