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Recredentialing Frequency

All participating ancillary/MLTSS providers shall undergo recredentialing every three 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cycle for Horizon NJ Health physicians and other health care professionals), the application shall be considered withdrawn, and the applicant will be notified in writing of termination.

Recredentialing Documentation

To be considered for continued participation in a Horizon BCBSNJ network, an ancillary/MLTSS provider must:

  1. Legibly complete and submit a recredentialing application (in a format approved by the Credentials Committee).
  2. 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.
  3. 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
    • Disclosure Statement: Hospital and Ancillary Providers (Horizon NJ Health Network only)
  4. MLTSS Providers are required to complete Horizon's Criminal History Background Form and attest that all prospective employees/providers with direct physical access to MLTSS members have conducted a criminal history background check and will provide proof of completion of the Criminal History Record Information (CHRI) upon request.
  5. Demonstrate they continue to meet all requirements for credentialing and the satisfaction of the requirements that are primary source verified.
  6. 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.

Recredentialing Application Screening

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.

Credentials Committee Review

Applicants meeting the Standards for Participation ("clean files") are presented to the Credentials Committee. 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.

Provider Notification

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.