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

ADMINISTRATIVE POLICY:

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

EFFECTIVE DATE:

September 27, 1996

LAST REVISED DATE:

December 14, 2022

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, a sub-committee of Horizon's Quality Improvement Committee, is charged with the responsibility of reviewing all provider applicants for initial and continued participation in Horizon's Networks against the Standards for Participation set forth in this policy. The composition and operating procedures of the Credentials Committee are described in detail in the Credentials Committee Charter.

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

PROCEDURE:

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

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-003-121142022