Submitting your Horizon MyWay HRA Claim

You must complete all sections above.

Review the back of this form for Helpful Hints on How to Successfully File a Claim. Failure to complete allsections of this form or to attach sufficient claim documentation will delay your reimbursement.

Send the Horizon MyWay HRA Claim Form and supporting expense documentation to Horizon BCBSNJ:

FAX: 1-973-274-4185Mailing Address: Horizon MyWay, PO Box 1369, Newark, NJ 07101-1369

Questions: Visit our Web site at www.HorizonMyWay.com or call 1-800-355-BLUE.

James JonesVice PresidentDental Services

Horizon Blue Cross Blue Shield of New Jersey

PO Box 1369Newark, NJ 07101-13691-800-355-BLUEwww.HorizonMyWay.com

2816 (W0212) An independent licensee of the Blue Cross and Blue Shield Association.

Company Name: ________________________________________ Social Security # ________________________

Your Name: _______________________________________________________ ______________________ ________Last First MI

Home Address: ___________________________________________________________________________________

City: ______________________________________________________________ State: ________ ZIP: ____________

Check here if new address

Phone #: _______ - _______ - _____________ Email Address: ___________________________________________

Expense Information (please print)

Complete the following information for each claim expense item. If you have multiple items of similar types of service (forexample, six prescriptions), you may combine them on one line. Attach supporting documentation for each expense. Theclaim form and documentation must list the date(s) that the service was performed, provider name, type of service, patientname, and your portion of the charge for the service.Date Expense IncurredMM DD YYYY

Total Requested Reimbursement Amount $

Name of Service Provider ExpenseDescription

Person for WhomExpense Incurred

Net Amount

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Horizon MyWay HRAClaim Form

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You may complete the required fields below online and then save or print a copy for submission. To save a completed copy to your computer, choose File > Save As to rename the file and save the form with your information to your computer.

Important Horizon MyWay HRA Claim Submission Information

Definition of “Incurred”The term “incurred” refers to the date you or your eligible dependent is provided with the care that gives rise to the medical,dental, vision, prescription, or other qualifying expense. This date could be different that the date you are billed or pay for theexpense. Per IRS regulations, the date the service is incurred determines the plan year in which it is considered forreimbursement.

Additional Employee CertificationI certify the expenses for which I am claiming:

• Were incurred by me or my eligible dependents (spouse is considered a dependent) during a plan year in which I and/ormy dependent(s) were covered under the Plan.

• If over-the-counter medication, was incurred solely to alleviate or treat personal injury or sickness.• Will not be claimed as a deduction or credit on any personal income tax return.• Are eligible according to the terms of the Plan. If I’ve received reimbursement for expenses later found ineligible, I will

be responsible for any penalties arising from the ineligible expense.

Helpful Hints on How to Successfully File a Claim3 The documentation must clearly list the date the service was incurred, provider name, type of service, patient name, and

your portion of the charge for the service.3 If the expense incurred is reimbursable by an insurance company, you must submit the expense to the insurance

company first. You can then use the Explanation of Benefits (EOB) received from the insurance company as yourexpense documentation. The EOB you receive from your insurance company is the best source of expensedocumentation for use in submitting your claims.

3 Canceled checks, ‘balance forward’ statements, ‘previous balance’ statements, ‘paid on account’ statements or receipts,charge card receipts, or charge card statements are not acceptable forms of expense documentation according to theIRS as they do not clearly indicate the date or type of service.

3 For prescription expenses, submit the prescription receipt you received with the medication purchased showing thepatient name, medication name, the date the prescription was filled, and the amount owed for medication. Cashregister receipts or charge slips for prescription purchases cannot be accepted as they do not indicate themedication name or patient.

3 For over-the-counter medications, submit a receipt that clearly indicates the item purchased (such as cold medicine,antacid, allergy medicine, or pain reliever). You may write the name of the item purchased next to the amount charged ifthe receipt does not clearly indicate the item purchased.

3 Claims can be submitted at your convenience. Claims incurred during the plan year can be submitted at any timeduring the plan year or during the grace period (referred to as the “timely filing period”) after the Plan Year has ended.Claims received after the timely filing period has expired for the plan year in which they were incurred cannotbe considered for reimbursement.

3 All expenses must be incurred prior to being considered for reimbursement. If the expense has not been incurred it willbe sent back to you without reimbursement.

3 Keep copies of your claim and DO NOT SEND ORIGINALS.

Some Expenses that are NOT Eligible for Reimbursement• Dietary supplements or vitamins for general well-being• Over-the-counter medication if specifically excluded by your plan• Teeth bleaching or whitening• Athletic or health club memberships• Supplements from a chiropractor, acupuncturist, holistic healer, etc• Cosmetic surgery• Weight loss programs for general well-being

DefinitionsDates of Service - The date the service was incurred. This date could be different than the date you are billed or the dateyou pay for the expense. Prescription drugs are based on the date the prescription is filled and eyeglass/contact lenspurchases are based on the date ordered. These dates could be different than the date picked up or the date paid.Name of Service Provider / Expense Description - Doctor name, store name, dentist, hospital, etc. along with the serviceperformed (example, ‘Dr Jones / Office Visit’ or “CVS Pharmacy / Rx).Net Amount - The amount of the expense you are responsible for paying.Total Requested Reimbursement Amount - The total of all Net Amount expense line items.

Horizon Blue Cross Blue Shield of New JerseyPO Box 1369

Newark, NJ 07101-13691-800-355-BLUE