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Initial Credentialing

Application/Documentation Submission

To be considered for participation in a Horizon BCBSNJ Network and/or Horizon NJ Health Network, an ancillary/MLTSS provider must:

  1. Complete and submit an application (in a format approved by the Credentials Committee)
  2. 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)
    • Disclosure Statement ((Hospital and Ancillary Providers (Horizon NJ Health Network only)
  3. MLTSS Providers are required to complete Horizon's Criminal History Background Attestation Form and attest that all prospective employees/providers who provide face-to-face services to MLTSS members have conducted a criminal history background check as well as a finger-print based background check and will provide proof of completion of the Criminal History Record Information (CHRI) upon request.

Application Screening

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.

Primary Source Verification

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 If the ancillary/MLTSS provider fails to respond within the 15-day period, the application shall be considered withdrawn and the applicant shall be notified as such in writing.

Credentials Committee Review

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 may:

  • Approve the applicant and the offering of a contract to the ancillary/MLTSS provider. Horizon's receipt of the executed contract shall render the ancillary/MLTSS provider a participating provider.
  • Request in writing additional information and/or an interview before making a decision. The ancillary/MLTSS provider shall have 15 days to provide the requested information If the requested information is not received within 15 days, the application will still be presented at the next scheduled Credentials 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.

Credentialing Report

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).

Provider Notification

The ancillary/MLTSS provider is notified in writing of the Credentials Committee's decision to their application:

  • Applicants to Horizon NJ Health will be notified within 5 business days of the Credentials Committee's decision.
  • All other applicants will be notified within 30 days of the Credentials Committee's decision.