Supporting Documentation Requirements for Practitioner Demographic Updates
Please include the information/documentation noted along with your request for us to make the following types of changes/updates to your demographic information.
Practitioner Specialty Change
Include supporting documentation:
- Completed copy of our Provider Specialty Change Request Form.
We do not credential practitioners in more than one specialty in the Horizon Managed Care Network or Horizon PPO Network.
Changes in Practitioner Location
Link to or remove locations within an existing practice
Include supporting documentation:
- List of practice locations.
- List of affiliated practitioners/NPIs per practice location.
If the practitioner being removed is a Primary Care Practitioner (PCP) and has assigned panel members, please advise what should be done with these impacted panel members. Will the panel members:
- Move with the departing practitioner?
- Remain with the practice? Please indicate to which practitioner members may be transferred.
Practitioner Leaving Practice (Retirement or Move)
Include supporting documentation:
- List of practice locations.
- List of affiliated practitioners/NPIs per practice location.
If the moving practitioner is a PCP and has assigned panel members, please advise if panel members will:
- Move with the departing practitioner
- Remain with the practice. Please indicate to which practitioner members may be transferred.
Termination from Network(s)
Termination letters must:
- Be addressed to the attention of your Network Specialist.
- Be signed by the practitioner.
- Clearly indicate the network Agreement(s) to be terminated.
- Include the reason for termination.
Your effective date of termination (unless we agree upon another date) will be:
- 90 days following the receipt of your termination letter from our Horizon Managed Care Network.
- 30 days following the receipt of your termination letter from our Horizon PPO Network.
These 90- and 30-day periods leading up to your effective date of termination do not run concurrently with our Continued Provision of Care periods (review our Participating Physician and Other Health Care Professional Office Manual for more information).
Please note that 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.