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CMS Audits to Validate Directory Information

It’s important that the information we display within our Online 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 Online Doctor & Hospital Finder is accurate.

CMS Audits
CMS monitors provider directory accuracy because Medicare Advantage members 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 Online 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 HorizonJ’s outreach will result in your information no longer appearing within our Online Doctor & Hospital Finder. Repeated failure to comply with Horizon BCBSNJ outreach may result in your termination from the Horizon BCBSNJ Network(s).

CMS audits consist of reviewers placing calls to provider offices to verify the accuracy of the information listed in our Online Doctor & Hospital Finder.

Audit Questions
If your practice is called, the reviewer will ask you the following questions:

  1. Does the provider see patients at this location?
  2. Does the provider accept the Medicare Advantage Prescription Drug (MA-PD) plan at this location?
  3. 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).
  4. Is the provider a Primary Care Physician (PCP), cardiologist, oncologist or ophthalmologist?
  5. Does the practitioner have any practice limitations at this location?
  6. 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?)
  7. Is the provider’s name correct?
  8. Is the practice name correct?

How to Convey Demographic Updates to Us

Send an Email
Email a request letter, along with all appropriate supporting documentation, to EnterprisePDM@HorizonBlue.com.

By Mail

You may mail documents to:
Horizon BCBSNJ Provider Files
3 Penn Plaza East, PP-14C
Newark, NJ 07105-2200

On the Phone

You can validate or provide demographic updates during Horizon’s quarterly outreach process. However, we encourage you to update with us any time practice information changes.

Use CAQH ProView™
The easiest way to ensure that practitioner information is current, accurate and complete is to use CAQH ProView.

If you’re not already registered in CAQH ProView, visit ProView.caqh.org/pr to self-register.

Via the CMS National Plan & Provider Enumeration System (NPPES)
You can log on and update your NPPES profile at https://npiregistry.cms.hhs.gov.
Updating with CAQH or NPPES will remove the need to validate via quarterly outreach.

What is Important to Know
As outlined in our Provider Directory Management administrative policy, Horizon will not display any practitioner information within our Online 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).

Review our Provider Directory Management administrative policy.