Supporting Documentation for Ancillary Provider Demographic Updates
Please include the information/documentation noted along with your request for us to make the following types of changes/updates to your Ancillary Provider demographic information.
Relocation or Add a New Location
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
- Disclosure Statement for Hospital and Ancillary Providers form
- Ancillary Provider Disclosure Questions form
Change of Ownership (no change to demographic information)
Documentation required
- Communication from provider with signature on company letterhead
- New contact name, phone, fax, email
- Disclosure Statement for Hospital and Ancillary Providers form
Tax ID Number Change or Purchase of Another Entity
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
- Disclosure Statement for Hospital and Ancillary Providers form
Name Change
Documentation required
- Communication from provider with signature on company letterhead
- W-9
Billing and Remittance Change
Documentation required
- Communication from provider with signature on company letterhead
- W-9
- Please note that for Horizon NJ Health providers, the billing address cannot be a PO Box; it must be a physical location.
Change or Add a New NPI Number
Documentation required:
- Communication from provider with signature on company letterhead
- Valid/active NPI number
- Specify Horizon BCSNJ or Horizon NJ Health or both
Termination from Network(s)
Documentation required:
- Communication from provider with signature on company letterhead
- Termination date
- Termination reason
Updates to Other Demographic Information (e.g., phone number, email address, fax number, suite number)
Documentation required:
- Communication from provider with signature
Horizon Care@Home 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) should contact CareCentrix at 1-855-243-3324 to initiate any changes/updates to demographic information.