CMS Audits to Validate Directory Information
It's important that the information we display within our Doctor & Hospital Finder is current and accurate so our members can easily locate you and access the care and services they need.
According to the Consolidated Appropriations Act, we must verify provider directory information every 90 days. As a reminder, the Centers for Medicare & Medicaid Services (CMS) also requires Horizon to contact its provider network on a quarterly basis to ensure the information in our Doctor & Hospital Finder is accurate.
CMS monitors provider directory accuracy because Medicare Advantage members, including members enrolled in Braven Health plans, rely on this information to make informed decisions regarding their health care choices. As part of their efforts to drive industry improvement in directory accuracy, CMS conducts audits of online directory information.
CMS requires Horizon to contact its provider network to ensure information is accurate within our Doctor & Hospital Finder. As a result, Horizon BCBSNJ will contact you on a quarterly basis to validate your demographic information.
If any information changes based on the questions noted below, your network participation agreement(s) with Horizon require you to notify Horizon BCBSNJ immediately. Failure to respond to Horizon's outreach will result in your information no longer appearing within our Doctor & Hospital Finder. Repeated failure to comply with Horizon outreach may result in your termination from the Horizon Network(s).
CMS audits consist of reviewers placing calls to provider offices to verify the accuracy of the information listed in our Doctor & Hospital Finder.
If your practice is called, the reviewer will ask you the following questions:
- Does the provider see patients at this location?
- Does the provider accept the Medicare Advantage Prescription Drug (MA-PD) plan at this location?
- Does the provider participating and accepting new patients who have this MA-PD plan? (The provider directory is considered accurate if it correctly indicates if the provider is or is not accepting new patients).
- Is the provider a Primary Care Physician (PCP), cardiologist, oncologist or ophthalmologist?
- Does the practitioner have any practice limitations at this location?
- Does the practitioner have formal training and or experience treating patients with behavioral health needs?
(For behavioral health practitioners, does the practitioner have an area of expertise?)
- Is the provider's name correct?
- Is the practice name correct?
How to Make Changes to Your Demographic Information
Visit the pages below to learn about making changes to your demographic information:
- How to Make Demographic Updates: Participating Ancillary Providers
- How to Make Demographic Updates: Participating Practices
- Initiating Demographic Updates: Nonparticipating Providers
What is Important to Know
As outlined in our Provider Directory Management administrative policy, Horizon will not display any practitioner information within our Doctor & Hospital Finder that we are unable to validate. Failure to comply with the guidelines of this policy may result in termination from Horizon's network(s).