Exceptions to Using Horizon Data Submission Template

Specify whether you are closing an existing location and/or adding an additional location.

Documentation required

• Communication from provider with signature on company letterhead
• W-9
• Americans with Disabilities Act (ADA) survey, if applicable
• License
• Malpractice insurance
• Accreditation or state survey, if applicable

Please note that for Horizon NJ Health providers, the billing address cannot be a PO Box; it must be a physical location.

Documentation required

• Communication from provider with signature on company letterhead
• New contact name, phone, fax, email

Note whether you are or are not assuming liability of prior tax ID number.

Documentation required

• Communication from provider with signature on company letterhead
• W-9
• Application
• License
• Malpractice insurance
• Accreditation or state survey, if applicable
• ADA survey, if applicable
• Copy of signed agreement

Documentation required

• Communication from provider with signature on company letterhead
• W-9

Documentation required

• Communication from provider with signature on company letterhead
• Valid/active NPI number
• Specify Horizon BCBSNJ, Horizon NJ Health or both

Documentation required

• Communication from provider with signature on company letterhead
• Termination date
• Termination reason

For information about terminating a Horizon NJ Health network Agreement, please review Section 12: Policies and Procedures within our Provider Administrative Manual.

For information about terminating a Horizon Managed Care or Horizon PPO Networks, review the Policies, Procedures and General Guidelines section of our Ancillary Provider Office Manual.