Exceptions to Using Horizon Data Submission Template
You cannot use the Horizon Data Submission Template to make updates to certain data elements and service types. Please contact the appropriate resource to make updates to the data elements below.
CONTACT US
For Ancillary Providers in our: | Contact Method |
---|---|
Horizon Managed Care/PPO Networks | Email: Ancillary_ProviderNetwork@HorizonBlue.com or call your Ancillary Contract Specialist. |
Horizon NJ Health Network | Contact your Ancillary Contract Specialist. |
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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.
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Documentation required
- Communication from provider with signature on company letterhead
- New contact name, phone, fax, email
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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
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Documentation required
- Communication from provider with signature on company letterhead
- W-9
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Documentation required
- Communication from provider with signature on company letterhead
- Valid/active NPI number
- Specify Horizon BCBSNJ, Horizon NJ Health or both
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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.
CONTACT EVICORE: ANCILLARY RADIOLOGY PROVIDERS (Horizon Commercial Only)
Participating commercial ancillary radiology providers need to submit demographic updates/changes to eviCore via email at credentialing@evicore.com or by calling 1-800-918-8924.
Send updates to eviCore for:
- Add/change locations
- Add/change modalities
- Changes in ownership or TIN
CONTACT CARECENTRIX: HORIZON CARE@HOME PROVIDERS (Horizon Commercial Only)
Ancillary providers (Durable Medical Equipment including Medical Foods [Enteral] and Diabetic and Other Medical Supplies); Specialty Pharmacy, Orthotics and Prosthetics and Home Infusion Therapy Services, including hemophilia) participating with our Horizon Care@Home program should contact CareCentrix at 1-855-243-3324 to initiate any changes/updates to demographic information.