Horizon Data Submission Template
The Horizon Data Submission Template for Practitioners is another option you can use to make updates to your provider data in our systems. This new process provides a faster turnaround so your updated information is displayed on our Doctor & Hospital Finder.
Getting Started with the Horizon Data Submission Template
Our reply to your email will have #Secure# added to the front of the subject line.
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Request a blank template
You will need a blank template to make changes to your data.-
Email a request for a blank template to autosubmission_@HorizonBlue.com
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The subject line needs to be Requesting Practitioner Template
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Establish a secure (encrypted) connection with us
The email you will receive back from Horizon will be using Horizon's Secure Blue encryption protocol which has created a secure connection between Horizon and you with the reply email.-
Secure Blue is Horizon's encryption protocol which ensures the data included in the email cannot be read by anyone other than those on the distribution list of the email.
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To maintain the secure connection, please send us your completed template by replying to the email that included the blank template.
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The Secure Blue Connection will expire after 10 days of Horizon sending you the template.
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If you reply after the 10 days, you will need to request another template to establish a new secure connection or use one of the other acceptable secure (encrypted) channels: Transport Layer Security (TLS), Zix.
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Enter your data in the template
You will need to input your data for all the mandatory fields and provide the required supporting documentation before you send us back the template. -
Include the required supporting documentation
Please include the supplemental documentation noted along with your data submission template so we can make the following types of changes/updates to your demographic information.
| Change Request Type | Supplemental Documentation Required |
|---|---|
| Specialty Changes | Specialty Change Form |
| TIN Changes | W-9 Form |
| Group Legal Entity Name Changes | W-9 Form |
| Type 2 NPI Changes | NPPES Registry Documentation |
| Practice DBA Name Changes | W-9 Form |
| Network Terminations | Communication from provider with signature on company letterhead and network Agreement(s) to be terminated. |
| Add New Location/Add Provider to New Location | Americans with Disabilities Act Provider Survey (for Horizon NJ Health providers only) |
| Add a Participating Practitioner to a Group Practice that only includes Nonparticipating Practitioners | Mixed Status Group Attestation form |
| Name Changes | Applicable legal documentation |
| Practitioner Legal Name Change | Legal documentation (e.g., Marriage or Divorce decree) |
A practitioner cannot elect to cease participating solely for Medicare Advantage (MA) plan members. Practitioners who no longer wish to participate for MA plan members must terminate completely from our Horizon Managed Care Network.