RESOURCE CENTER

Client Service Forms
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2017 SEH Plan Change Form
The Plan Change form for small groups has been enhanced. Please begin including this enhanced AmeriHealth New Jersey Plan Change Form when submitting plan changes. Please discard all prior Plan Change forms, and replace with this updated version.
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05.17.2017
2017 Large Group Certification Form
This updated version requires employers to report the number of employees as well as number of eligible employees. As a reminder, large group certifications are required for all new business and group renewals with less than 150 enrolled employees.
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PPO Claim Form
Please discard all previous versions of the claim forms listed below and replace them with the updated versions that have the address, P.O. Box 211184, Eagan, MN 55121 on them.
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Point of Service Claim Form
Please discard all previous versions of the claim forms listed below and replace them with the updated versions that have the address, P.O. Box 211184, Eagan, MN 55121 on them.
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Influenza Vaccine Reimbursement Form
Please discard all previous versions of the claim forms listed below and replace them with the updated versions that have the address, P.O. Box 211184, Eagan, MN 55121 on them.
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Copay Reimbursement Form
Please discard all previous versions of the claim forms listed below and replace them with the updated versions that have the address, P.O. Box 211184, Eagan, MN 55121 on them.
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Handicapped Child Claim Form
Please discard all previous versions of the claim forms listed below and replace them with the updated versions that have the address, P.O. Box 211184, Eagan, MN 55121 on them.
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2017 AmeriHealth NJ SEH Certification
AmeriHealth NJ SEH certification form (released January 2017)
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2017 submission guidelines for SEH new and retention business
Please be advised that there is a new cut off date for retention business. Please remember that Brown & Brown must receive the paperwork by no later than 2pm on the day of cutoff, if not sooner, in order to allow time for processing.
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2017 SEH Application for Small Employer Health Benefits
AmeriHealth NJ SEH employer group application (optimized for 2017); INCLUDES Pediatric Dental for new business or adding for pediatric dental rider first time. No separate Group Pediatric Dental application is needed now.
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Prior Carrier Deductible Credit
If an AmeriHealth New Jersey member incurred expenses that were applied to his or her deductible under a previous carrier’s group plan within the calendar year, he or she may be eligible for a deductible credit toward the AmeriHealth New Jersey plan.
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10.01.2016
FutureScripts mail-order form
Form to be completed by member and provider for mail-order prescription
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Guest Advantage Application
Guest Advantage is a program which allows members to maintain access to a comprehensive range of medical benefits while they are outside the AmeriHealth New Jersey service area for an extended period of at least three months.
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