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Credentialing and Recredentialing Policy for Ancillary and Managed Long Term Support Service (MLTSS) Providers

EFFECTIVE DATE:
September 27, 1996

LAST REVISED DATE:
December 10, 2021

SCOPE:
This policy applies to the Managed Care and PPO Networks (the “Network”) as they apply to the following products: Commercial (EPO, OMNIA, PPO, DA, POS, HMO, Indemnity, FEP®, and ASO* including SHBP), Medicare Advantage, Fully Integrated Dual Eligible Special Needs Plan (“FIDE‐SNP”), and Medicaid/NJ FamilyCare plans issued and/or administered by Horizon Healthcare Services, Inc. d/b/a Horizon Blue Cross Blue Shield of New Jersey and/or its affiliates, including Horizon Insurance Company, Horizon Healthcare of New Jersey, Inc., and Healthier New Jersey Insurance Company d/b/a Braven Health (collectively “Horizon BCBSNJ”).

PURPOSE:
In an effort to ensure that Horizon members receive high quality care, all ancillary and Managed Long Term Support Service (MLTSS) providers will be credentialed and recredentialed by the standards set forth below as presented in the provider's application for participation and presented for approval through Horizon's Credentials Committee. MLTSS providers are solely pertaining to Horizon NJ Health Medicaid Network.

DEFINITIONS:

The Credentialing Body
The Credentials Committee (the “Committee”), a committee of Horizon's Quality Improvement Committee, is the committee within Horizon charged with the responsibility of reviewing all provider applicants for initial and continued participation in all of Horizon's Networks. The Committee, its composition and operating procedures are described in detail in a separate policy entitled “Credentials Committee”. The Committee evaluates all applicants for participation against the Standards for Participation described in Attachment A.

Ancillary and Managed Long Term Support Service (MLTSS) Providers
The following, for the purposes of this policy, are considered Ancillary and MLTSS providers.

  • Adult Family Care Providers
  • Adult Medical Day Care
  • Ambulance/Medical Transport Providers
  • Ambulatory Surgical Centers
  • Assisted Living Program
  • Assisted Living Residence
  • Behavioral Health Facilities (Inpatient, Outpatient, Residential, Ambulatory)
  • Birthing Centers
  • Chore Services
  • Clinical Laboratories
  • Community Residential Homes
  • Comprehensive Outpatient Rehabilitation Facilities
  • Comprehensive Personal Care Home Service Providers
  • Dialysis Centers
  • Durable Medical Equipment Providers (DME)
  • Family Planning
  • Federally Qualified Health Center (FQHC)
  • Healthcare Services Firms
  • Home Delivered Meals
  • Home Health/Private Duty Nursing Providers (PDN)
  • Home Infusion
  • Hospice Providers
  • Independent Diagnostic Testing Facilities (IDTF)
  • Inpatient Acute Rehabilitation Facilities
  • Medication Dispensing Device Service Providers
  • Non‐Medical Transport Providers
  • Non‐Traditional Service Providers
  • Outpatient Rehabilitation Providers
  • Pediatric Medical Day Care Providers
  • Personal Care Assistant Providers (PCA)
  • Personal Emergency Response Services
  • Prosthetics and Orthotics
  • Radiology/Imaging Centers including Mobile X‐ray/Imaging Service Providers
  • Retail Health Clinics
  • Skilled Nursing/Sub‐acute/Long Term Care Facility Providers
  • Sleep Disorder Laboratories
  • Social Adult Day Care Providers
  • Specialty Pharmacy Providers
  • Temporary Help Agencies
  • Urgent Care Centers
  • Vaccine Network for Pharmacies

Horizon BCBSNJ Commercial Network
Ancillary/MLTSS providers that participation in Horizon BCBSNJ's Commercial Network may provide care and services on an in‐network basis to members enrolled in Horizon managed care plans/products (OMNIA Health Plans, Horizon Direct Access, Horizon EPO, Horizon HMO, Horizon POS, NJ DIRECT, Horizon Medicare Advantage and Braven Health plans) and members enrolled in Horizon PPO/Indemnity plans/products.

Horizon NJ Health network
Ancillary/MLTSS providers that participation in the Horizon NJ Health network may provide care and services on an in‐network basis to members enrolled in the following plans/products/programs: Horizon NJ Health (Medicaid managed Care), NJ Family Care, Managed Long‐Term Services & Supports (MLTSS) and Horizon NJ TotalCare (HMO SNP).

PROCEDURE:
Confidential information obtained in the credentialing and/or recredentialing processes shall be used and disclosed in accordance with Horizon BCBSNJ's privacy policies or as otherwise required by law.

Initial Credentialing:

  1. To be considered for participation in a Horizon BCBSNJ Network and/or Horizon NJ Health Network, an ancillary and/or MLTSS provider must:
    • Complete and submit an application (in a format approved by the Credentials Committee)
    • Provide the following supporting documentation (as applicable):
      • Licensure
      • Accreditation
      • Certification with Medicare for facilities
      • Professional Liability Coverage
      • Business Liability Coverage
      • Dates of Health and Safety Inspections and findings
      • Ongoing State Board Monitoring or Investigations
      • Workers Compensation Certificate or Attestation Form
      • Letter with Medicaid Provider Number (Horizon NJ Health Network only)
  2. The Horizon BCBSNJ Ancillary Account Executive screens the application for completeness.
    • Complete applications are forwarded to the Physician Data Management (PDM) Department for processing and uploaded to the Ancillary SharePoint site.
  3. The Horizon BCBSNJ Physician Data Management (PDM) Department validates/verifies the supporting documentation through primary source verification.
    • If the credentialing information obtained from other sources varies substantially from the information obtained from the ancillary/MLTSS provider, the PDM staff will notify the ancillary/MLTSS provider in writing within 30 days of receipt of the application.

      The notification informs the ancillary/MLTSS provider of any discrepancies and their right to seek to have erroneous information obtained via another source corrected or to correct their own submitted information to Horizon BCBSNJ.
    • Ancillary/MLTSS providers must respond within 15 days by submitting a response and correction(s) to the PDM Department.

      If the ancillary/MLTSS provider fails to respond within the 15‐day period, the application shall be considered withdrawn and the applicant shall be notified as such in writing.
  4. Applicants meeting the Standards for Participation (“clean files”) are presented for review by the Credentials Committee (or the Credentials Subcommittee) no more than ninety (90) days of our receipt of the application/required supporting documentation.

    The Credentials Committee (or Credentials Subcommittee) may:

    • Approve the applicant and the offering of a contract to the ancillary/MLTSS provider.

      Upon which execution and receipt (by Horizon BCBSNJ shall render the ancillary/MLTSS provider a participating provider.
    • Request more information and/or an interview before making a decision.

      If the Committee requires additional information, an email will be sent to the Ancillary Account Executive.The Ancillary Account Executive will request (in writing) that the ancillary/MLTSS provider provide the requested information within 15 days of the Committee's request.

      If the requested information is not received within 15 days, the application will still be presented at the next scheduled Committee meeting.
    • Find that the applicant does not meet the Standards for Participation in the network and decline the applicant.
    • Take other action as appropriate.
  5. Following the Credentials Committee meeting, a Credentialing/Recredentialing Committee Report indicating the ancillary/MLTSS status (i.e., approved or denied) is completed, copied and forwarded to the appropriate Ancillary Account Executive(s).
  6. The Ancillary Account Executive notifies the ancillary/MLTSS provider in writing of the decision of the Committee in regard to their application:
    • Applicants to Horizon NJ Health will be notified within 10 business days of the Credentials Committee's decision.
    • All other applicants will be notified within 60 days of the Credentials Committee's decision.

Recredentialing:

Recredentialing Frequency: All participating ancillary/MLTSS providers shall undergo recredentialing every three (3) years.

  • An Ancillary/MLTSS provider due for recredentialing shall be deemed in compliance with the three‐year cycle if the recredentialing decision is made within the month that is 36 months from the month of the previous credentialing or recredentialing decision.
  • In the event that the recredentialing application is not returned by the applicant by 30 days prior to the end of the 36 month recredentialing cycle (to the end of the 36 month recredentialing cycle for Horizon NJ Health physicians and other health care professionals), the application shall be considered withdrawn, and the applicant will be notified in writing of termination.
  1. To be considered for continued participation in a Horizon BCBSNJ network, an ancillary and/or MLTSS provider must:
    • Legibly complete and submit a recredentialing application (in a format approved by the Credentials Committee).

      If information included on the recredentialing application has not changed since the ancillary/MLTSS provider was last credentialed/recredentialed, the ancillary/MLTSS provider must attest that this is the case.
    • Provide the following supporting documentation (as applicable):
      • Licensure
      • Accreditation
      • Professional Liability Coverage
      • Business Liability Coverage
      • Dates of Health and Safety Inspections and findings
      • Ongoing State Board Monitoring or Investigations
      • Workers Compensation Certificate or Attestation Form
        • Demonstrate they continue to meet all requirements for credentialing and the satisfaction of the requirements that are primary source verified.
        • Be judged to be a member in good standing in the network(s) in which they participate.

          Any quality information obtained through the complaint or quality case review process is included in the recredentialing file.
  2. The Physician Data Management (PDM) Department screens the recredentialing application for completeness.

    If a recredentialing application is incomplete, the ancillary/MLTSS provider shall be notified in writing of the deficiency no later than 60 days following receipt. The ancillary or MLTSS provider shall have 60 additional days to complete the application. If the 60 day period expires and the application remains incomplete, the application shall be considered withdrawn and the ancillary/MLTSS provider notified in writing. The Physician Data Management (PDM) Department validates/verifies the documentation submitted in support of the recredentialing application through primary source verification.

    In the event the recredentialing information obtained from other sources varies substantially from the information obtained by the ancillary/MLTSS provider, the ancillary/MLTSS provider will be notified in writing by the PDM Department. The ancillary/MLTSS provider shall have 15 days to submit a response. If the 15 day period expires, and the ancillary/MLTSS provider has failed to respond, the application shall be considered withdrawn and the applicant notified of termination in writing.
  3. Applicants meeting the Standards for Participation (“clean files”) are presented to the Credentials Committee. These “clean files” can also be reviewed and approved by the Credentials Subcommittee.

    If the Committee requires additional information, the ancillary/MLTSS provider will be notified of the information needed in writing and will be given 15 days to produce such information. If the requested information is not received within 15 days, the ancillary/MLTSS provider will be notified in writing that the application is considered withdrawn.
  4. Following the Credentials Committee meeting, the ancillary/MLTSS status will be advised in writing of the decision of the Committee:
    • Applicants to Horizon NJ Health will be notified within 10 business days of the Credentials Committee's decision.
    • All other applicants will be notified within 30 days of the Credentials Committee's decision.

ATTACHMENT A

Standards for Participation
All ancillary/MLTSS providers applying for initial credentialing or recredentialing in Horizon's networks must meet the Standards for Participation, as set forth below and on the following pages of this attachment.

Medicare/Medicaid Participation
Ancillary/MLTSS providers seeking participation in the Horizon Managed Care Network must participate with Medicare.

  • Ancillary/MLTSS provider types that are not eligible to treat Medicare beneficiaries (e.g., mammography facilities that are not FDA‐approved) will not be credentialed for Horizon BCBSNJ Medicare Advantage plans/products. However, Horizon may credential providers without Medicare participation for other (non-MA) managed care network plans/products.
  • Participating Medicare provider numbers must be provided as part of required additional documentation during the credentialing process.

Ancillary/MLTSS providers seeking participation in the Horizon New Jersey Health Network must participate with Medicaid.

  • Participating Medicaid provider numbers must be provided as part of required additional documentation during the credentialing process.

Medicare Preclusion
Effective January 1, 2019, Ancillary/MLTSS provider types who appear on the Medicare Preclusion list may not participate in any Horizon networks. Therefore, the validation and verification process includes the review of the Medicare Preclusion list. The Medicare Preclusion list must be checked at the time of initial credentialing and monthly thereafter. Results will be reported to the Credentials Committee on a quarterly basis. Ancillary/MLTSS provider types who appear on the Medicare Preclusion list may not be credentialed for any line of business nor can he/she be reimbursed for any services provided to Medicare members.

Accreditation
An ancillary/MLTSS provider that is not accredited by an accrediting body as noted on the following pages must submit information in lieu of such accreditation.

A CMS or DOHSS site review may be substituted for a Horizon BCBSNJ site visit. Copies of all such site reviews must be provided to Horizon BCBSNJ as proof that a facility was reviewed and that it passed inspection.

Credentialing of Practitioners
Please refer to the ancillary contract that addresses the process for ensuring that ancillary providers credential their practitioners.

Horizon Care@Home Delegation
The following specialties are under full delegation from Horizon to CareCentrix, Inc. (excluding Horizon NJ Health and Horizon Casualty Services).

  • Durable Medical Equipment, which also includes diabetic supplies, medical foods & home medical supplies
  • Hemophilia factor drugs
  • Home Infusion therapy (HIT) services
  • Orthotics and Prosthetics (O&P)

Verifications
Please note that ALL verifications must have been performed no more than 180 calendar days prior to the credentialing/recredentialing decision.

Standing in the Medical Community Requirements
In addition to the following requirements, the ancillary or MLTSS services provider must be judged to be in good standing in the medical community as evidenced by:

  • There must be no history of active or stayed, reclassification, suspension, revocation or restriction of licensure, having been taken against the ancillary provider or any physician or healthcare professional associated with the ancillary provider who serves in a substantial capacity within the ancillary provider's offices or within the private medical practice in which the ancillary provider's offices or within the private medical practice in which the ancillary provider or healthcare professional's is located, by a hospital, managed care or other similar organization, or any State or Federal agency within the past three years.
  • There must be no history of any disciplinary action (including but not limited to voluntarily and involuntarily submitting to censure, reprimand, non‐routine supervision, non‐routine admissions review, or monitoring, or remedial education or training) having been taken against the ancillary provider or any physician or healthcare professional associated with the ancillary provider who serves in a substantial capacity within the ancillary provider is located by a hospital, managed care or other similar organization, or any State or Federal agency within the past three years.
  • There must be no history of criminal conviction having been taken against the ancillary or MLTSS provider or any physician or healthcare professional associated with the ancillary provider who serves in a substantial capacity within the ancillary provider by a hospital, managed care or other similar organization, accrediting body, or any State or Federal agency within the past three years The ancillary provider or any physician associated with the ancillary provider who serves in a substantial capacity within the ancillary provider's offices or within the private medical practice in which the ancillary provider is located must not be currently under investigation for matters related to professional practice; and
  • There is no evidence of inappropriate utilization, administrative or billing practices by the Ancillary or MLTSS provider or any physician or healthcare professional associated with the ancillary provider who serves in a substantial capacity within the ancillary provider's offices or within the private medical practice in which the ancillary provider is located. Any evidence determined by Horizon, a court, a State or Federal agency, insurance carrier, a hospital or managed care organization that indicates that the provider has engaged in inappropriate billing, inappropriate utilization management or other inappropriate administrative practices including a finding that the provider has engaged in fraud or fraudulent conduct shall be considered evidence of lack of good standing in the medical community for purposes of this Policy.
  • There is no evidence that the ancillary or MLTSS provider nor any physician or healthcare professional, employee, board of director or subcontractor of the ancillary provider that provides services to Horizon's members has been barred from participation in any federal health program. Upon request, provider will present an attestation on an annual basis confirming compliance.
  • Provider must check the OIG exclusion, System for Award Management (SAM) and debarment list, as well as the Medicare opt‐out list and Medicare preclusion for any physician or healthcare professional employed by the ancillary provider at the time of hire and at least annually thereafter.

For purposes of the foregoing requirements, a physician or healthcare professional who serves in a substantial capacity shall include serving as an owner, chief executive officer, chief operating officer, administrator, medical director or individual practitioner of professional services within the ancillary services provider or private practitioner offices.

Note: When there is history of any of the above, the Committee reserves the right to determine whether such matters are indicative of a current or continuing quality of care matter that would preclude an approval of credentialing. When there is history of any of the above for years prior to the past three years, the Committee reserves the right to determine whether such matters are indicative of a current or continuing quality of care matter that precludes approval of credentialing.

Documentation Requirements
In addition to the basic requirements described above, the ancillary or MLTSS services provider must provide copies of the following documentation:

  • Reports from the Department of Health and Human Services, Office of Inspector General (OIG), and System for Award Management (SAM),
  • Reports from the NJ State Board of Medical Examiners, or the NJ State Department of Health & Senior Services,
  • Reports from Horizon regarding the applicant's utilization, billing and/or other administrative procedural pattern,
  • Documentation of review and approval of such reports by the Credentials Committee,
  • The National Practitioner Data Bank (NPDB) or the Healthcare Integrity Protection Data Bank (HIPDB), OIG and System for Award Management (SAM).

Providers with any history of having an application for participation with any of the Networks denied shall be denied if application is made to any of the other Networks. Likewise, any ancillary provider being the subject of any participation restriction, suspension or termination action (collectively “sanction”) taken relating to their participation in any of the Horizon Networks shall be denied as well with respect to another Horizon Network within the past 3 years.

EXCEPTIONS – REQUIRED PROCEDURES:
Individual exceptions to the Standards for Participation, on a case by case basis must be made in writing to the Director of Ancillary Contracting. The written request shall include the compelling reason(s) for the exception and all other relevant information, necessary documentation and the completed application. A Medical Director of Horizon, an Ancillary Account Executive, a delegate of Horizon or an affiliated organization of Horizon may recommend to the Director of Ancillary Contracting that an exception be made provided that such requests include the compelling reason(s) for the exception and all other relevant information, necessary documentation and the completed ancillary provider application.

The Director of Ancillary Contracting shall submit the request to the Executive Medical Director Quality and Care Management or designee who shall then submit the request to the Credentials Committee. The Credentials Committee, during its next regularly scheduled meeting, shall review the exception request and either 1) approve the request, 2) deny the request, or 3) request additional information in order to make a decision.

Other Exceptions Are Prohibited
Except as specifically set forth above, no exceptions may be made to the Standards for Participation.

Taxonomy Code(s) and Description(s)
Horizon will collect taxonomy code(s) and their description(s) for each credentialed specialty in our network(s) when available. Horizon reserves the right not to credential specific taxonomy code specialties.

Standards for Participation by Ancillary/MLTSS Provider Type
In addition to the general Standards for Participation noted above, all ancillary/MLTSS providers applying for initial credentialing or recredentialing in Horizon's networks must also meet the specific Standards for Participation listed below by provider type. Click the appropriate ancillary/MLTSS provider type to review these standards.

REFERENCES:

  • NCQA – Current Standards and Guidelines for the Accreditation of Health Plans
  • CMS 42 C.F.R.422.204(b)
  • N.J.A.C 11:24A-4.7, 4.8
  • N.J.A.C 11:24-3.9
  • Current DMAHS MLTSS Services Dictionary

HCM‐PP‐CRED‐003‐121021