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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, including Braven Health Members 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 be reimbursed for any services provided to Medicare members. Ancillary/MLTSS providers that have an employed physician or other healthcare professional who is on the Preclusion List will also be prohibited from participation from reimbursement for 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 site visit. Copies of all such site reviews must be provided to Horizon 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. for Commercial Products only.

  • Durable Medical Equipment, which also includes diabetic supplies, medical foods & home medical supplies
  • Specialty Pharmacy
  • Home Infusion Therapy (HIT) Services
  • Orthotics and Prosthetics (O&P)

Verifications

All verifications must be performed within 180 calendar days prior to the credentialing/recredentialing decision.

Standing in the Medical Community Requirements

In addition to the following requirements, the ancillary /MLTSS provider must be judged to be in good standing in the medical community as evidenced by:

  1. 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/MLTSS provider's offices or within the private medical practice in which the ancillary/MLTSS 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.
  2. 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/MLTSS 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.
  3. There must be no history of criminal conviction having been taken against the ancillary/ MLTSS provider or any physician or healthcare professional associated with the ancillary/MLTSS 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/MLTSS 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
  4. There is no evidence of inappropriate utilization, administrative or billing practices by the Ancillary/MLTSS provider or any physician or healthcare professional associated with the ancillary/MLTSS 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.
  5. There is no evidence that the ancillary/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.
  6. The following sites are primary source verified to confirm the ancillary/MLTSS provider is in good standing: National Practitioner Data Bank (NPDB), NPPES NPI Registry, OIG Exclusions Database, System for Award Management (SAM) and Debarment list, Medicare Opt Out and Medicare Preclusion.

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 Credentials 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 Credentials 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 below sites are primary source verified for each ancillary/MLTSS services provider:

Reports from the Department of Health and Human Services, Office of Inspector General (OIG),

  • System for Award Management (SAM)
  • New Jersey Treasury Website (NJ Department)
  • NPPES NPI Registry
  • The National Practitioner Data Bank (NPDB)
  • 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

Ancillary/MLTSS providers with a history of having a denied application for participation with at least one Network may be denied again if an application is made to any of the other Networks. Likewise, any ancillary/MLTSS provider that has a participation restriction, suspension or termination action (collectively "sanction") within the past 3 years shall be denied participation if a new application is received.

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 Health and Network Solutions 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) & Description(s)

Horizon BCBSNJ will collect taxonomy code(s) and their description(s) for each credentialed specialty in our network(s) when available. Horizon BCBSNJ 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.

  • Adult Family Care Providers

    The following requirements apply to Adult Family Care providers in regard to participation in the Horizon NJ Health network. Adult Family Care providers are not credentialed for participation in the Horizon BCBSNJ Commercial Network and the Horizon Casualty Network.

    Requirement Documentation
    Licensure Verification from the appropriate State Licensing Board/Agency indicating:
    • State of NJ Business Registration
    • License number
    • License expiration date
    • Restrictions placed on the license if applicable
    General or Commercial Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy number
    • Coverage amount(s) of at least $1M per occurrence and $3M per aggregate
    Professional Liability N/A
    Worker's Compensation N/A
    Accreditation N/A
    Medicare Participation N/A
    ADA Survey N/A

  • Adult Medical Day Care

    The following requirements apply to Adult Medical Day Care providers in regard to participation in the Horizon NJ Health Network. Adult Medical Day Care providers are not credentialed for participation in the Horizon BCBSNJ Commercial Network and the Horizon Casualty Network.

    Requirement Documentation
    Licensure Verification from the appropriate State Licensing Board/Agency indicating:
    • License number
    • License expiration date
    • Restrictions placed on the license if applicable
    General or Commercial Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amount(s) of at least $1M per occurrence and $3M per aggregate
    Professional Liability N/A
    Worker's Compensation N/A
    Accreditation N/A
    Medicare Participation Current documentation of Medicare participation
    ADA Survey One ADA survey per location

  • Ambulance/Medical Transport Providers

    The following requirements apply to Ambulance/Medical Transport Providers in regard to participation in the Horizon BCBSNJ Commercial Network, the Horizon Casualty Network and/or the Horizon NJ Health Network.

    Requirement Documentation
    Licensure Verification from the appropriate State Licensing Board/Agency indicating:
    • License number
    • License expiration date
    • Restrictions placed on the license if applicable
    • Type of transport services [i.e. Basic Life Support (BLS), Specialty Care Transport (SCT), Mobile Assistance Vehicle (MAV)]
    General or Commercial Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amount(s) of at least $1M per occurrence and $3M per aggregate
    Professional Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amounts of at least $1M per occurrence and $3M per aggregate
    Worker's Compensation N/A
    Accreditation N/A
    Medicare Participation Current documentation of Medicare participation
    ADA Survey N/A

  • Ambulatory Surgical Centers

    The following requirements apply to Ambulatory Surgical Centers in regard to participation in the Horizon BCBSNJ Commercial Network, the Horizon Casualty Network and/or the Horizon NJ Health Network.

    Requirement Documentation
    Licensure Verification from the appropriate State Licensing Board/Agency indicating:
    • License number
    • License expiration date
    • Restrictions placed on the license if applicable
    General or Commercial Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amount(s) of at least $1M per occurrence and $3M per aggregate
    Professional Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amounts of at least $1M per occurrence and $3M per aggregate
    Worker's Compensation N/A
    Accreditation Current verification of accreditation from one of the following:
    • AAAHC (Accreditation Association for Ambulatory Health Care)
    • AAASF (American Association for Accreditation of Ambulatory Surgery Facilities)
    • The Joint Commission
    Medicare Participation Current documentation of Medicare participation
    ADA Survey One ADA survey per location

    If radiology/imaging services are provided, the requirements within the Radiology/Imaging Centers including Mobile X-Ray/Imaging Service Providers section of this policy must also be met.

    One Room Ambulatory Surgery Centers located in a practitioner's office may submit a Registration issued by the State in lieu of a license.

  • Assisted Living Programs

    The following requirements apply to Assisted Living Programs regard to participation in the Horizon NJ Health Network. Assisted Living Programs are not credentialed for participation in the Horizon BCBSNJ Commercial Network and/or the Horizon Casualty Network.

    Requirement Documentation
    Licensure Verification from the appropriate State Licensing Board/Agency indicating:
    • License number
    • License expiration date
    • Restrictions placed on the license if applicable
    General or Commercial Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amount(s) of at least $1M per occurrence and $3M per aggregate
    Professional Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amounts of at least $1M per occurrence and $3M per aggregate
    Worker's Compensation N/A
    Accreditation N/A
    Medicare Participation Current documentation of Medicare participation
    ADA Survey N/A

    The following additional requirements apply to Assisted Living Programs, if the subservice Respite Care is provided.

    Requirement Documentation
    Business Documentation A copy of one of the following:
    • Business Entity Information (New Jersey Tax Certification or Trade Name Registration)
    • State of NJ Business Registration

  • Assisted Living Residence

    The following requirements apply to Assisted Living Residences regard to participation in the Horizon NJ Health Network. Assisted Living Residences are not credentialed for participation in the Horizon BCBSNJ Commercial Network and/or the Horizon Casualty Network.

    Requirement Documentation
    Licensure Verification from the appropriate State Licensing Board/Agency indicating:
    • License number
    • License expiration date
    • Restrictions placed on the license if applicable
    General or Commercial Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amount(s) of at least $1M per occurrence and $3M per aggregate
    Professional Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amounts of at least $1M per occurrence and $3M per aggregate
    Worker's Compensation N/A
    Accreditation N/A
    Medicare Participation Current documentation of Medicare participation
    ADA Survey One ADA survey per location

    The following additional requirements apply to Assisted Living Residences, if the subservice Respite Care is provided.

    Requirement Documentation
    Business Documentation A copy of one of the following:
    • Business Entity Information (New Jersey Tax Certification or Trade Name Registration)
    • State of NJ Business Registration

  • Behavioral Health Facilities (Inpatient, Outpatient, Residential, Ambulatory)

    Note: This includes Free Standing Psychiatric Day/Night Care Facility, Home Health Agency, Outpatient Psychiatric Facility, Psychiatric Hospital and Substance Abuse Rehab Facility.

    The following requirements apply to Behavioral Health Facilities (Inpatient, Outpatient, Residential, and Ambulatory) in regard to participation in the Horizon BCBSNJ Commercial Network, the Horizon Casualty Network and/or the Horizon NJ Health Network

    Requirement Documentation
    Licensure Verification from the appropriate State Licensing Board/Agency, if applicable, in which the facility operates indicating:
    • License number
    • License expiration date
    • Restrictions placed on the license if applicable
    General or Commercial Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amount(s) of at least $1M per occurrence and $3M per aggregate
    Professional Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amounts of at least $1M per occurrence and $3M per aggregate
    Worker's Compensation N/A
    Accreditation Current verification of accreditation from one of the following:
    • Commission on Accreditation of Rehabilitation Facilities (CARF)
    • Community Health Accreditation Program (CHAP)
    • The Joint Commission
    • Council on Accreditation (COA)
    • Healthcare Facilities Accreditation Program (HFAP)
    • Accreditation Association for Ambulatory Healthcare (AAAHC)
    • National Integrated Accreditation for Healthcare Organizations (of DNV-GL) (NIAHO®)
    • Accreditation Commission for Healthcare, Inc (ACHC) – Behavioral Health
    Medicare Participation Current documentation of Medicare participation (if applicable to offered services)
    ADA Survey ADA survey per location

    If radiology/imaging services are provided, the requirements within the Radiology/Imaging Centers including Mobile X-Ray/Imaging Service Providers section of this policy must also be met.

    Standards for All Types of Medical and Dental Diagnostic Radiology and Imaging Facilities

    Behavioral Health Facilities (Inpatient, Outpatient, Residential, Ambulatory)

    Licensure related exceptions/criteria for Behavioral Health

    Facilities with conditional licenses or no licensure for specific programmatic services:

    • Horizon will accept conditional licensure if facility is newly licensed and being recommended for participation by the Horizon Behavioral Health Network Team.
    • Facilities with conditional licenses that are the result of licensing deficiencies during ongoing licensure renewal process will be sent as refer files and copy of site visit report and provider's action plan will be included for review/discussion.
    • Horizon will accept accreditation and a Horizon site visit in lieu of a license for residential psychiatric treatment facilities (i.e., eating disorder residential treatment), who hold an accreditation by an accepted accrediting body but not licensed due to lack of established licensure standards for these programs

    Eating Disorder Outpatient Facilities

    • Eating disorder outpatient, intensive outpatient and partial care programs may be considered for credentialing and re-credentialing on the basis of Joint Commission accreditation with eating disorder specific standards if program is exclusively treating eating disorders and no other mental health conditions that would require full programmatic licensure by the state of New Jersey. Horizon will periodically, at minimum every three years, reassess NJ licensing standards to determine if any change in standards warrants reinstating the licensure requirement for eating disorder treatment programs. To assure that the offered clinical services align with our program requirements for these levels of care and that the facility is maintaining quality standards, Horizon will include the following in our assessment of the facility:
      • Review and approval of program description(s) by the Behavioral Health clinical and team
      • Facility attests that scope of services is limited to eating disorders only
      • Review of complaints, grievances and quality of care concerns
    • Additionally, Horizon will ensure that the facility is in good standing with State and Federal requirements by confirming that the facility has no adverse findings via sanction monitoring verifications including:
      • New Jersey Treasury Website (Debarment)
      • Medicare Opt Out
      • Office of Inspector General (OIG)
      • System for Award Management (SAM)
      • National Plan and Provider Enumeration System (NPPES)

    BH facilities being presented for credentialing or recredentialing that do not hold accreditation must have a State Site Visit Report submitted from their most recent state site review including corrective action plan to remediate the identified deficiencies.

  • Birthing Centers

    The following requirements apply to Birthing Centers in regard to participation in the Horizon BCBSNJ Commercial Network, the Horizon Casualty Network and/or the Horizon NJ Health Network.

    Requirement Documentation
    Licensure Copy of the Department of Health license indicating: Verification from the appropriate State Licensing Board/Agency indicating:
    • License number
    • License expiration date
    • Restrictions placed on the license if applicable
    General or Commercial Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amount(s) of at least $1M per occurrence and $3M per aggregate
    Professional Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amounts of at least $1M per occurrence and $3M per aggregate
    Worker's Compensation N/A
    Accreditation Accreditation/Certification by American Association of Birthing Centers (AABC)
    Medicare Participation Current documentation of Medicare participation
    ADA Survey ADA survey per location

  • Chore Services

    The following requirements apply Chore Services providers in regard to participation in the Horizon NJ Health Network. Chore Services providers are not credentialed for participation in the Horizon BCBSNJ Commercial Network or the Horizon Casualty Network.

    Requirement Documentation
    Licensure Copy of one of the following:
    • Business Entity Information (New Jersey Tax Certification or Trade Name Registration)
    • State of NJ Business Registration
    General or Commercial Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amount(s) of at least $1M per occurrence and $3M per aggregate
    Professional Liability N/A
    Worker's Compensation A copy of the Worker's Compensation Insurance certificate
    Accreditation N/A
    Medicare Participation N/A
    ADA Survey N/A

    The following additional requirements apply to Chore Services, if the subservices Cleaning and or Maintenance Services are provided.

    Requirement Documentation
    Business Documentation Copy of one of the following:
    • Business Entity Information (New Jersey Tax Certification or Trade Name Registration)
    • State of NJ Business Registration

  • Clinical Laboratories

    The following requirements apply to Clinical Laboratories in regard to participation in the Horizon BCBSNJ Commercial Network, the Horizon Casualty Network, and/or the Horizon NJ Health Network.

    Requirement Documentation
    Licensure N/A
    Commercial or General Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amount(s) of at least $1M per occurrence and $3M per aggregate
    Professional Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amounts of at least $1M per occurrence and $3M per aggregate
    Worker's Compensation N/A
    Accreditation Accreditation by the College of American Pathologist (CAP)
    Medicare Participation Current documentation of Medicare participation
    ADA Survey ADA survey per location
    Certification of the Clinical Laboratory Improvement Agency (CLIA) Certification from the CLIA

  • Community Residential Services

    The following requirements apply Community Residential Services in regard to participation in the Horizon NJ Health Network. Community Residential Services are not credentialed for participation in the Horizon BCBSNJ Commercial Network or the Horizon Casualty Network.

    Requirement Documentation
    Licensure Copy of one of the following:
    • Business Entity Information (New Jersey Tax Certification or Trade Name Registration)
    • State of NJ Business Registration
    General or Commercial Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amount(s) of at least $1M per occurrence and $3M per aggregate
    Professional Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amounts of at least $1M per occurrence and $3M per aggregate
    Worker's Compensation N/A
    Accreditation N/A
    Medicare Participation N/A
    ADA Survey N/A

  • Comprehensive Outpatient Rehabilitation Facilities

    The following requirements apply to Comprehensive Outpatient Rehabilitation Facilities in regard to participation in the Horizon BCBSNJ Commercial Network, the Horizon Casualty Network, and/or the Horizon NJ Health Network.

    Requirement Documentation
    Licensure Verification from the appropriate State Licensing Board/Agency indicating:
    • License number
    • License expiration date
    • Restrictions placed on the license if applicable
    General or Commercial Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amount(s) of at least $1M per occurrence and $3M per aggregate
    Professional Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amounts of at least $1M per occurrence and $3M per aggregate
    Worker's Compensation N/A
    Accreditation The Joint Commission
    Medicare Participation Current documentation of Medicare participation
    ADA Survey ADA survey per location

  • Comprehensive Personal Care Home

    The following requirements apply to Comprehensive Personal Care Home Service providers in regard to participation in the Horizon NJ Health Network. Comprehensive Personal Care Home Service providers are not credentialed for participation in the Horizon BCBSNJ Commercial Network and/or the Horizon Casualty Network.

    Requirement Documentation
    Licensure Verification from the appropriate State Licensing Board/Agency indicating:
    • License number
    • License expiration date
    • Restrictions placed on the license if applicable
    General or Commercial Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amount(s) of at least $1M per occurrence and $3M per aggregate
    Professional Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amounts of at least $1M per occurrence and $3M per aggregate
    Worker's Compensation N/A
    Accreditation N/A
    Medicare Participation Current documentation of Medicare participation
    ADA Survey N/A

    The following additional requirements apply to Comprehensive Personal Care Home Service Providers, if the subservice Respite Care is provided.

    Requirement Documentation
    Business Documentation A copy of one of the following:
    • Business Entity Information (New Jersey Tax Certification or Trade Name Registration)
    • State of NJ Business Registration

  • Dialysis Centers

    The following requirements apply to Dialysis Centers in regard to participation in the Horizon BCBSNJ Commercial Network, the Horizon Casualty Network, and/or the Horizon NJ Health Network.

    Requirement Documentation
    Licensure Verification from the appropriate State Licensing Board/Agency in which the facility operates indicating:
    • License number
    • License expiration date
    • Restrictions placed on the license if applicable
    General or Commercial Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amount(s) of at least $1M per occurrence and $3M per aggregate
    Professional Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amounts of at least $1M per occurrence and $3M per aggregate
    Worker's Compensation N/A
    Accreditation N/A
    Medicare Participation Current documentation of Medicare participation
    ADA Survey ADA survey per location
    Certification of the Clinical Laboratory Improvement Agency (CLIA) Current verification of certification from the CLIA, if applicable

    CLIA license is only necessary if the dialysis center is performing laboratory services on site.

  • Durable Medical Equipment (DME) Providers

    The following requirements apply to all Durable Medical Equipment (DME) Providers in regard to participation in the Horizon NJ Health Network and/or the Horizon Casualty Network.

    Please note:
    The credentialing/recredentialing of Durable Medical Equipment (DME) Providers for participation in the Horizon BCBSNJ Commercial Network is delegated to CareCentrix, Inc through the Horizon Care@Home program. Durable Medical Equipment (DME) Providers interested in participating in the Horizon Care@Home program may call CareCentrix at 1-855-243-3324 for information about participation, credentialing and recredentialing.

    Requirement Documentation
    Licensure N/A
    General or Commerical Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amount(s) of at least $1M per occurrence and $3M per aggregate
    Professional Liability N/A
    Worker's Compensation N/A
    Accreditation Current verification of accreditation by one of the following:
    • The Joint Commission,
    • Community Health Accreditation Program (CHAP)
    • The Compliance Team (TCT)
    • Accreditation Commission for Health Care (ACHC)
    • National Association of Board of Pharmacy (NABP)
    • Healthcare Quality Association on Accreditation (HQAA)
    • Commission on Accreditation of Rehabilitation Facilities (CARF)
    • American Board for Certification (ABC)
    • Board of Certification (BOC)

    Accreditation or a site visit is not required if the provider does provide 100% DME services. For DME suppliers of sleep medicine devices only (equipment related to oral appliances) the above Accreditation requirements are replaced by the following requirements.

    • American Academy of Dental Sleep Medicine (AADSM)

    For DME suppliers of electronic devices only (equipment without clinical monitoring), the above Accreditation requirements are replaced by the following requirements.

    • Horizon BCBSNJ Architecture Review Committee (ARC) approval
    Medicare Participation Current documentation of Medicare participation
    ADA Survey ADA Survey per location as applicable

    The following additional requirements apply to Durable Medical Equipment (DME) Providers if the subservices, Medical Dispensing Devices and/or Personal Emergency Response System are provided.

    Requirement Documentation
    Business Documentation A copy of one of the following:
    • Business Entity Information (New Jersey Tax Certification or Trade Name Registration)
    • State of NJ Business Registration

  • Family Planning Centers

    The following requirements apply to Family Planning Centers in regard to participation in the Horizon BCBSNJ Commercial Network, the Horizon Casualty Network, and/or the Horizon NJ Health Network

    Requirement Documentation
    Licensure Verification from the appropriate State Licensing Board/Agency in which the facility operates indicating:
    • License number
    • License expiration date
    • Restrictions placed on the license if applicable
    General or Commercial Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amount(s) of at least $1M per occurrence and $3M per aggregate
    Professional Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amounts of at least $1M per occurrence and $3M per aggregate
    Worker's Compensation N/A
    Accreditation Current verification of accreditation from one of the following:
    • The Joint Commission
    • Planned Parenthood Federation of America (PPFA)
    • Another applicable accrediting agency, body or entity
    Medicare Participation Current documentation of Medicare participation
    ADA Survey ADA survey per location
    FQHC Documentation Documentation evidencing that the provider is a Federally Qualified Health Center
    Medical Director FQHC must have a licensed physician designated as Medical Director who is responsible for overall clinical quality Current verification showing the Medical Director's
    • Name
    • Specialty
    • NPI
    • Proof of License

  • Federally Qualified Health Centers (FQHC)

    The following requirements apply to Federally Qualified Health Centers (FQHCs) in regard to participation in the Horizon BCBSNJ Commercial Network, the Horizon Casualty Network, and/or the Horizon NJ Health Network

    Requirement Documentation
    Licensure Verification from the appropriate State Licensing Board/Agency in which the facility operates indicating:
    • License number
    • License expiration date
    • Restrictions placed on the license if applicable
    General or Commercial Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amount(s) of at least $1M per occurrence and $3M per aggregate
    Professional Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amounts of at least $1M per occurrence and $3M per aggregate
    Worker's Compensation N/A
    Accreditation N/A
    Medicare Participation Current documentation of Medicare participation
    ADA Survey ADA survey per location
    FQHC Documentation Documentation evidencing that the provider is a Federally Qualified Health Center
    Medical Director FQHC must have a licensed physician designated as Medical Director who is responsible for overall clinical quality Current verification showing the Medical Director's
    • Name
    • Specialty
    • NPI
    • Proof of License

  • Health Services Firms

    The following requirements apply to Healthcare Services Firms in regard to participation in the Horizon NJ Health Network. Healthcare Services Firms are not credentialed for participation in the Horizon BCBSNJ Commercial Network or the Horizon Casualty Network.

    Requirement Documentation
    Licensure Business Registration
    Division of Consumer Affairs License
    General or Commercial Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amount(s) of at least $1M per occurrence and $3M per aggregate
    Professional Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amounts of at least $1M per occurrence and $3M per aggregate
    Worker's Compensation N/A
    Accreditation N/A
    Medicare Participation Current documentation of Medicare participation
    ADA Survey N/A

    The following additional requirement applies to Healthcare Services Firms, if one or more of the following subservices are provided:

    • Caregiver Participant Training
    • Home Based Supportive Care
    • Respite
    • Supported Day
    • Community Transitions
    • Cleaning or Maintenance
    Requirement Documentation
    Business Documentation A copy of the current:
    • Business Entity Information (New Jersey Tax Certification or Trade Name Registration)
    • State of NJ Business Registration

  • Home Delivered Meals

    The following requirements apply to Home Delivered Meals providers in regard to participation in the Horizon NJ Health Network. Home Delivered Meals providers are not credentialed for participation in the Horizon BCBSNJ Commercial Network or the Horizon Casualty Network.

    Requirement Documentation
    Licensure Verification from the appropriate State Licensing Board/Agency in which the facility operates indicating:
    • License number
    • License expiration date
    • Restrictions placed on the license if applicable
    • Business Registration
    General or Commercial Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amount(s) of at least $1M per occurrence and $3M per aggregate
    Professional Liability N/A
    Worker's Compensation N/A
    Accreditation N/A
    Medicare Participation N/A
    ADA Survey N/A

  • Home Health/Private Duty Nursing Providers (PDN)

    The following requirements apply to Home Health/Private Duty Nursing Providers in regard to participation in the Horizon BCBSNJ Commercial Network, the Horizon Casualty Network, and/or the Horizon NJ Health Network.

    Requirement Documentation
    Licensure Verification from the appropriate State Licensing Board/Agency in which the facility operates indicating:
    • License number
    • License expiration date
    • Restrictions placed on the license if applicable
    General or Commercial Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amount(s) of at least $1M per occurrence and $3M per aggregate
    Professional Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amounts of at least $1M per occurrence and $3M per aggregate
    Worker's Compensation N/A
    Accreditation Current verification of accreditation from one of the following:
    • The Joint Commission
    • Community Health Accreditation Program (CHAP)
    • The Compliance Team (TCT)
    • Accreditation Commission for Health Care (ACHC)
    • Commission on Accreditation of Rehabilitation Facilities (CARF)
    • Commission on Accredtiation for Health Care New Jersey (CAHC)
    Medicare Participation Current documentation of Medicare participation for Home Health Agency only
    ADA Survey N/A

    The following additional requirement applies to Home Health/Private Duty Nursing, if one or more of the following subservices are provided:

    • Caregiver Participant Training
    • Home-based Supportive Care
    • Respite
    • PT/OT/Speech/Cognitive
    Requirement Documentation
    Business Documentation A copy of one of the following:
    • Business Entity Information (New Jersey Tax Certification or Trade Name Registration)
    • State of NJ Business Registration

  • Home Infusion

    The following requirements apply to Home Infusion in regard to participation in the Horizon NJ Health Network and/or the Horizon Casualty Network

    The credentialing/recredentialing of Home Infusion for participation in the Horizon BCBSNJ commercial network is delegated to CareCentrix, Inc. through the Horizon Care@Home program. Durable Medical Equipment (DME) Providers interested in participating in the Horizon Care@Home program may call CareCentrix at 1-855-243-3324 for information about participation, credentialing and recredentialing

    Requirement Documentation
    Licensure Verification from the appropriate State Licensing Board/Agency in which the facility operates indicating:
    • License number
    • License expiration date
    • List of any restrictions placed on the license
    • DEA license
    • Pharmacy license to dispense in the State where they pharmacy is located
    General or Commercial Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amount(s) of at least $1M per occurrence and $3M per aggregate
    Professional Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amounts of at least $1M per occurrence and $3M per aggregate
    Worker's Compensation N/A
    Accreditation Current verification of accreditation from one of the following:
    • The Joint Commission
    • Community Health Accreditation Program (CHAP)
    • The Compliance Team (TCT)
    • Accreditation Commission for Health Care (ACHC)
    • Commission on Accreditation of Rehabilitation Facilities (CARF)
    • Healthcare Quality Association on Accreditation (HQAA)
    Medicare Participation Current documentation of Medicare participation
    ADA Survey N/A

  • Hospice Providers

    The following requirements apply to Hospice Providers in regard to participation in the Horizon BCBSNJ Commercial Network, the Horizon Casualty Network, and/or the Horizon NJ Health Network

    Requirement Documentation
    Licensure Verification from the appropriate State Licensing Board/Agency in which the facility operates indicating:
    • License number
    • License expiration date
    • List of any restrictions placed on the license
    General or Commercial Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amount(s) of at least $1M per occurrence and $3M per aggregate
    Professional Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amounts of at least $1M per occurrence and $3M per aggregate
    Worker's Compensation N/A
    Accreditation Current verification of accreditation from one of the following:
    • The Joint Commission
    • Community Health Accreditation Program (CHAP)
    • The Compliance Team (TCT)
    • Accreditation Commission for Health Care (ACHC)
    • Commission on Accreditation of Rehabilitation Facilities (CARF)
    • Other equivalent accreditation agency/body
    Medicare Participation Current documentation of Medicare participation
    ADA Survey ADA per location, if applicable

    The following additional requirements apply to Hospice Providers for participation in the Horizon NJ Health Network if the subservice Home Based Supportive Care is provided:

    Requirement Documentation
    Business Documentation A copy of:
    • Business Entity Information (New Jersey Tax Certification or Trade Name Registration)
    • State of NJ Business Registration

    If radiology/imaging services are provided, the requirements within the Radiology/Imaging Centers including Mobile X-Ray/Imaging Service Providers section of this policy must also be met.

  • Independent Diagnostic Testing Facilities (IDTF)

    The following requirements apply to Independent Diagnostic Testing Facilities in regard to participation in the Horizon BCBSNJ Commercial Network, the Horizon Casualty Network, and/or the Horizon NJ Health Network

    Requirement Documentation
    Licensure N/A
    General or Commercial Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amount(s) of at least $1M per occurrence and $3M per aggregate
    Professional Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amounts of at least $1M per occurrence and $3M per aggregate
    Worker's Compensation N/A
    Accreditation N/A
    Medicare Participation Current documentation of Medicare participation
    ADA Survey ADA per location

  • Inpatient Acute Rehabilitation Facilities

    The following requirements apply to Acute Rehabilitation Facilities in regard to participation in the Horizon BCBSNJ Commercial Network, the Horizon Casualty Network and/or the Horizon NJ Health Network.

    Requirement Documentation
    Licensure Verification from the appropriate State Licensing Board/Agency in which the facility operates indicating:
    • License number
    • License expiration date
    • List of any restrictions placed on the license
    General or Commercial Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amount(s) of at least $1M per occurrence and $3M per aggregate
    Professional Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amounts of at least $1M per occurrence and $3M per aggregate
    Worker's Compensation N/A
    Accreditation Verification from the Joint Commission or completion of a site visit resulting in satisfactory scores
    Medicare Participation Current documentation of Medicare participation
    ADA Survey ADA per location

    If radiology/imaging services are provided, the requirements within the Radiology/Imaging Centers including Mobile X-Ray/Imaging Service Providers section of this policy must also be met.

  • Medication Dispensing Device Service Providers

    The following requirements apply to Medication Dispensing Device Service Providers in regard to participation in the Horizon NJ Health Network. Medication Dispensing Device Service Providers are not credentialed for participation in the Horizon BCBSNJ Commercial Network or the Horizon Casualty Network.

    Requirement Documentation
    Licensure Business Registration
    General or Commercial Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amount(s) of at least $1M per occurrence and $3M per aggregate
    Professional Liability N/A
    Worker's Compensation N/A
    Accreditation N/A
    Medicare Participation N/A
    ADA Survey ADA per location

  • Non-Medical Transport Providers

    The following requirements apply to Non-Medical Transport Providers in regard to participation in the Horizon NJ Health Network. Non- Medical Transport Providers are not credentialed for participation in the Horizon BCBSNJ Commercial Network or the Horizon Casualty Network

    Requirement Documentation
    Licensure Business Registration
    General or Commercial Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amount(s) of at least $1M per occurrence and $3M per aggregate
    Professional Liability N/A
    Worker's Compensation N/A
    Accreditation N/A
    Medicare Participation N/A
    ADA Survey N/A
    New Jersey Business Authority Proof of New Jersey Business Authority, i.e. tax certificate or trade name registration

    Note: If the Non Traditional service provider uses sub-contractors for the provision of non-traditional services, then the provider must submit an Attestation Form verifying that the subcontractors have active Worker's Compensation insurance. An NPI number for this provider type is not required per section 45 CFR 106.103 by the Department of Health and Human Services/Centers for Medicare and Medicaid Services (https://www.cms.gov).

  • Non-Traditional Service: Community Transition Services

    The following requirements apply to Non-Traditional Service: Community Transition Services in regard to participation in the Horizon NJ Health Network. Non-Traditional: Service Community Transition Services are not credentialed for participation in the Horizon BCBSNJ Commercial Network or the Horizon Casualty Network

    Requirement Documentation
    Licensure Business Registration
    General or Commercial Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amount(s) of at least $1M per occurrence and $3M per aggregate
    Professional Liability N/A
    Worker's Compensation A copy of the Worker's Compensation Insurance certificate
    Accreditation N/A
    Medicare Participation N/A
    ADA Survey N/A

    Note: If the Non Traditional service provider uses sub-contractors for the provision of non-traditional services, then the provider must submit an Attestation Form verifying that the subcontractors have active Worker's Compensation insurance. An NPI number for this provider type is not required per section 45 CFR 106.103 by the Department of Health and Human Services/Centers for Medicare and Medicaid Services (https://www.cms.gov).

  • Non-Traditional Service: Residential Modifications

    The following requirements apply to Non-Traditional Service: Residential Modifications in regard to participation in the Horizon NJ Health Network. Non-Traditional: Residential Modifications are not credentialed for participation in the Horizon BCBSNJ Commercial Network or the Horizon Casualty Network

    Requirement Documentation
    Licensure Business Registration
    General or Commercial Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amount(s) of at least $1M per occurrence and $3M per aggregate
    Professional Liability N/A
    Worker's Compensation A copy of the Worker's Compensation Insurance certificate
    Accreditation N/A
    Medicare Participation N/A
    ADA Survey N/A

    Note: If the Non Traditional service provider uses sub-contractors for the provision of non-traditional services, then the provider must submit an Attestation Form verifying that the subcontractors have active Worker's Compensation insurance. An NPI number for this provider type is not required per section 45 CFR 106.103 by the Department of Health and Human Services/Centers for Medicare and Medicaid Services (https://www.cms.gov).

  • Non-Traditional Service: Vehicle Modifications

    The following requirements apply to Non-Traditional Service: Vehicle Modifications in regard to participation in the Horizon NJ Health Network. Non-Traditional: Vehicle Modifications are not credentialed for participation in the Horizon BCBSNJ Commercial Network or the Horizon Casualty Network

    Requirement Documentation
    Licensure Business Registration
    General or Commercial Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amount(s) of at least $1M per occurrence and $3M per aggregate
    Professional Liability N/A
    Worker's Compensation A copy of the Worker's Compensation Insurance certificate
    Accreditation N/A
    Medicare Participation N/A
    ADA Survey N/A

    Note: If the Non Traditional service provider uses sub-contractors for the provision of non-traditional services, then the provider must submit an Attestation Form verifying that the subcontractors have active Worker's Compensation insurance. An NPI number for this provider type is not required per section 45 CFR 106.103 by the Department of Health and Human Services/Centers for Medicare and Medicaid Services (https://www.cms.gov).

  • Outpatient Rehabilitation Providers

    The following requirements apply to Outpatient Rehabilitation Providers in regard to participation in the Horizon BCBSNJ Commercial Network, the Horizon Casualty Network, and/or the Horizon NJ Health Network

    Requirement Documentation
    Licensure N/A
    General or Commercial Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amount(s) of at least $1M per occurrence and $3M per aggregate
    Professional Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amounts of at least $1M per occurrence and $3M per aggregate
    Worker's Compensation N/A
    Accreditation N/A
    Medicare Participation Current documentation of Medicare participation
    ADA Survey ADA survey per location

    In instances where there are multi-specialties present at a facility, physical therapist(s) and occupational or speech therapist(s) will be credentialed/recredentialed as individual practitioners. Please refer to the Credentialing and Recredentialing Policy for Participating Physicians and Healthcare Professionals.

    A physical therapist or occupational or speech therapist cannot have dual credentialing status as an individual provider and as part of an Outpatient Rehabilitation Provider or other group

    The following additional requirements apply to Outpatient Rehabilitation Providers for participation in the Horizon NJ Health Network if the subservices Community Residential Service, Cognitive therapy, Supported Day and or Structured Day are provided:

    Requirement Documentation
    Business Documentation A copy of one of the following:
    • Business Entity Information (New Jersey Tax Certification or Trade Name Registration)
    • State of NJ Business Registration

    If radiology/imaging services are provided, the requirements within the Radiology/Imaging Centers including Mobile X-Ray/Imaging Service Providers section of this policy must also be met.

  • Pediatric Medical Day Care Providers

    The following requirements apply to Pediatric Medical Day Care Providers in regard to participation in the Horizon BCBSNJ Commercial Network, the Horizon Casualty Network, and/or the Horizon NJ Health Network.

    Requirement Documentation
    Licensure Verification from the appropriate State Licensing Board/Agency in which the facility operates indicating:
    • License number
    • License expiration date
    • Restrictions placed on the license if applicable
    General or Commercial Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amount(s) of at least $1M per occurrence and $3M per aggregate
    Professional Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amounts of at least $1M per occurrence and $3M per aggregate
    Worker's Compensation N/A
    Accreditation N/A
    Medicare Participation N/A
    ADA Survey ADA survey per location

  • Personal Care Assistant Providers (PCA)

    The following requirements apply to Personal Care Assistant Providers in regard to participation in the Horizon BCBSNJ Commercial Network, the Horizon Casualty Network, and/or the Horizon NJ Health Network.

    Requirement Documentation
    Licensure Verification from the appropriate State Licensing Board/Agency in which the facility operates indicating:
    • License number
    • License expiration date
    • Restrictions placed on the license if applicable
    General or Commercial Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amount(s) of at least $1M per occurrence and $3M per aggregate
    Professional Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amounts of at least $1M per occurrence and $3M per aggregate
    Worker's Compensation N/A
    Accreditation Current Verification of accreditation from one of the following:
    • The Joint Commission
    • Community Health Accreditation Program (CHAP)
    • The Compliance Team (TCT)
    • Commission on Accreditation for Health Care New Jersey (CAHC)
    • National Association for Home Care and Hospice (NAHC)
    • The National Institute for Home Care Accreditation
    • Accreditation Commission for Health Care (ACHC)
    Medicare Participation N/A
    ADA Survey N/A

    The following additional requirements apply to Personal Care Assistant Providers for participation in the Horizon NJ Health Network if the subservices Caregiver Support Training, Home Based Supportive Care, and/or Respite are provided:

    Requirement Documentation
    Business Documentation Copy of one of the following:
    • Business Entity Information (New Jersey Tax Certification or Trade Name Registration)
    • State of NJ Business Registration

  • Personal Emergency Response Services

    The following requirements apply to Personal Emergency Response Services providers in regard to participation in the Horizon NJ Health Network. Personal Emergency Response Services providers are not credentialed for participation in the Horizon BCBSNJ commercial network or the Horizon Casualty Network

    Requirement Documentation
    Licensure A copy of one of the following:
    • Business Entity Information (New Jersey Tax Certification or Trade Name Registration)
    • State of NJ Business Registration
    General or Commercial Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amount(s) of at least $1M per occurrence and $3M per aggregate
    Professional Liability N/A
    Worker's Compensation N/A
    Accreditation N/A
    Medicare Participation N/A
    ADA Survey N/A

  • Prosthetic and Orthotic Providers

    The following requirements apply to Prosthetic and Orthotic Providers in regard to participation in the Horizon BCBSNJ Commercial Network, the Horizon Casualty Network, and/or the Horizon NJ Health Network.

    Please note: the credentialing/recredentialing of Prosthetic and Orthotic Providers for participation in the Horizon BCBSNJ Commercial Network is delegated to CareCentrix, Inc. through the Horizon Care@Home program. Prosthetic and Orthotic Providers interested in participating in the Horizon Care@Home program may call CareCentrix at 1-855-243-3324 for information about participation, credentialing and recredentialing

    Requirement Documentation
    Licensure N/A
    General or Commercial Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amount(s) of at least $1M per occurrence and $3M per aggregate
    Professional Liability N/A
    Worker's Compensation N/A
    Accreditation Current Verification of accreditation from:
    • The American Board Certification (ABC)
    • The Board of Certification/Accreditation (BOC)
    • The Healthcare Quality Association on Accreditation (HQAA)
    Medicare Participation Current documentation of Medicare participation
    ADA Survey ADA survey per location

  • Radiology/Imaging Centers including Mobile X-Ray/Imaging Service Providers

    The following requirements apply to Radiology/Imaging Centers including Mobile X-Ray/Imaging Service Providers in regard to participation in the Horizon BCBSNJ Commercial Network. Radiology/Imaging Centers including Mobile X-Ray/Imaging Service Providers are not credentialed for participation in the Horizon Casualty Network, and/or the Horizon NJ Health Network.

    Please refer to the Credentialing and Recredentialing Policy for Participating Physicians and Healthcare Professionals for credentialing/recredentialing requirements for individual radiologists in all networks.

    Note: eviCore collects the application and supporting documents for radiology facilities for the Commercial Networks only.

    • Please note that Radiology/Imaging Providers (including Mobile X-ray/Imaging Service Providers) must contact eviCore Healthcare, our business partner in the management of radiology/imaging services, to obtain an application for participation with Horizon BCBSNJ. A request for an application may be made by e-mailing credentialing@evicore.comor call: 1-800-918-8924 ext. 20824. Currently participating Radiology/Imaging Providers who add new locations, new modalities or undergo change in ownership, must contact eviCore Healthcare to initiate the review process.
    Requirement Documentation
    Licensure Verification from the appropriate State Licensing Board/Agency in which the facility operates indicating:
    • License number
    • License expiration date
    • Restrictions placed on the license if applicable
    General or Commercial Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amount(s) of at least $1M per occurrence and $3M per aggregate
    Professional Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amounts of at least $1M per occurrence and $3M per aggregate
    Worker's Compensation N/A
    Accreditation Current verification of accreditation by the appropriate accreditation/certification/licensing agency for each applicable modality performed (see table below)
    Site Visit Documentation of a recent Horizon BCBSNJ site visit conducted by eviCore within the past three years. All radiology/imaging centers must undergo a site visit by eviCore prior to approval of participation and for recredentialing. Mobile Diagnostic providers are not required to have a site visit.
    Medicare Participation N/A
    ADA Survey N/A

    Radiology/Imaging Accreditation/Certification/Licensing Agencies per Modality

    Modality Accrediting/Certification/Licensing Agencies
    CAT SCAN/CTA/CCTA

    Accrediting Agency:

    • American College of Radiology (ACR)

    Certification/Additional Accrediting Agencies

    • Intersocietal Commission for the Accreditation of Computed Tomographic Laboratories (ICACTL)

    Licensing Agency:

    • NJ Department of Environmental Protection (NJDEP), or
    • Department of Health and Senior Services Standards for Licensure of Ambulatory Care Facilities
    MRI/MRA

    Accrediting Agency:

    • American College of Radiology (ACR)

    Certification/Additional Accrediting Agencies

    • Intersocietal Commission for the Accreditation of Magnetic Resonance Laboratories (ICAMRL)

    Licensing Agency:

    • Federal Drug Administration (FDA) or
    • Department of Health and Senior Services Standards for Licensure of Ambulatory Care Facilities
    NUCLEAR MEDICINE

    Accrediting Agency:

    • American College of Radiology (ACR)

    Licensing Agency:

    • NJ Department of Environmental Protection (NJDEP), or
    • Nuclear Regulatory Commission (NRC)
    NUCLEAR CARDIOLOGY

    Accrediting Agency:

    • American College of Radiology (ACR)

    Certification/Additional Accrediting Agencies:

    • Intersocietal Commission of Accreditation for Nuclear Cardiology Laboratories (ICANL)

    Licensing Agency

    • NJ Department of Environmental Protection (NJDEP) or
    • Nuclear Regulatory Commission (NRC)
    ULTRASOUND

    Accrediting Agency:

    • American College of Radiology (ACR)

    Certification/Additional Accrediting Agencies:

    • American Institute of Ultrasound in Medicine (AIUM)
    • Intersocietal Commission of Accreditation on Vascular Echocardiography Laboratories (ICAVEL)
    PET/CT, PET

    Accrediting Agency:

    • American College of Radiology (ACR)

    Licensing Agency:

    • NJ Department of Environmental Protection (NJDEP) Department of Health and Senior Services Standards for Licensure of Ambulatory Care Facilities, or
    • (For PET) Nuclear Regulatory Commission (NRC)
    GENERAL X-RAY

    Licensing Agency:

    • NJ Department of Environmental Protection (NJDEP)
    INTERNVENTIONAL RADIOLOGY AND FLUOROSCOPY

    Licensing Agency:

    • NJ Department of Environmental Protection (NJDEP)
    MAMMOGRAPHY

    Accrediting Agency:

    • American College of Radiology (ACR)

    Certification/Additional Accrediting Agencies:

    • Mammography Quality Standards Act (MQSA)

    Licensing Agency

    • NJ Department of Environmental Protection (NJDEP), or
    • Federal Drug Administration (FDA)
    DEXA Certification/Additional Accrediting Agencies:
    • NJ Department of Environmental Protection (NJDEP)

  • Retail Health Clinics

    The following requirements apply to Retail Health Clinics in regard to participation in the Horizon BCBSNJ Commercial Network, the Horizon Casualty Network, and/or the Horizon NJ Health Network.

    Requirement Documentation
    Licensure N/A
    General or Commercial Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amount(s) of at least $1M per occurrence and $3M per aggregate
    Professional Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amounts of at least $1M per occurrence and $3M per aggregate
    Worker's Compensation N/A
    Accreditation Current Verification of accreditation from one of the following:
    • The Joint Commission
    • Accreditation Association for Ambulatory Health Care (AAAHC)
    Medicare Participation Current documentation of Medicare participation
    ADA Survey ADA survey per location

  • Skilled Nursing/Sub Acute/Long Term Care Facility Providers

    The following requirements apply to Skilled Nursing/Sub Acute/Long Term Care Facility Providers in regard to participation in the Horizon BCBSNJ Commercial Network, the Horizon Casualty Network, and/or the Horizon NJ Health Network.

    Requirement Documentation
    Licensure Verification from the appropriate State Licensing Board/Agency in which the facility operates indicating:
    • License number
    • License expiration date
    • List of any restrictions placed on the license
    General or Commercial Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amount(s) of at least $1M per occurrence and $3M per aggregate
    Professional Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amounts of at least $1M per occurrence and $3M per aggregate
    Worker's Compensation N/A
    Accreditation Current verification of accreditation by The Joint Commission
    Medicare Participation Current documentation of Medicare participation
    ADA Survey ADA per location
    Health Inspections Star Rating Current verification of Health Inspections Star Rating
    State Survey State Survey indicating citations

    If the Health Inspections Star Rating is less than 3 or there are 1+ citations, the credentialing/recredentialing application will be referred to the Executive Medical Director, Quality & Care Management (or his/her Director designee) for review. The Clinical team will review deficiencies for potential patient safety issues and determine if additional information/explanation from the facility is recommended prior to a credentialing/recredentialing determination.

    If, for any reason, the Health Inspections Star Rating is not available, not updated or not applicable participation and review will occur on a case by case basis utilizing State Surveys (Citations). The Executive Medical Director, Quality and Care Management or his/her Director designee will review to determine if additional information or explanation from the facility is recommended prior to a credentialing determination.

    If radiology/imaging services are provided, the requirements within the Radiology/Imaging Centers including Mobile X-Ray/Imaging Service Providers section of this policy must also be met.

  • Sleep Disorder Laboratories

    The following requirements apply to Sleep Disorder Laboratories in regard to participation in the Horizon BCBSNJ Commercial Network, the Horizon Casualty Network, and/or the Horizon NJ Health Network.

    Requirement Documentation
    Licensure Verification from the appropriate State Licensing Board/Agency in which the facility operates indicating:
    • License number
    • License expiration date
    • List of any restrictions placed on the license
    General or Commercial Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amount(s) of at least $1M per occurrence and $3M per aggregate
    Professional Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amounts of at least $1M per occurrence and $3M per aggregate
    Worker's Compensation N/A
    Accreditation Current verification of accreditation from one of the following:
    • The Joint Commission
    • American Academy of Sleep Medicine (AASM)
    Medicare Participation Current documentation of Medicare participation
    ADA Survey ADA survey per location

  • Social Adult Day Care

    The following requirements apply to Social Adult Day Care providers in regard to participation in the Horizon NJ Health Network. Social Adult Day Care providers are not credentialed for participation in the Horizon BCBSNJ Commercial Network and the Horizon Casualty Network.

    Requirement Documentation
    Licensure Verification from the appropriate State Licensing Board/Agency indicating:
    • License number
    • License expiration date
    • Restrictions placed on the license if applicable
    General or Commercial Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amount(s) of at least $1M per occurrence and $3M per aggregate
    Professional Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amounts of at least $1M per occurrence and $3M per aggregate
    Worker's Compensation N/A
    Accreditation N/A
    Medicare Participation N/A
    ADA Survey N/A

    The following additional requirements apply to Social Adult Day Care, if the subservice Respite Care is provided.

    Requirement Documentation
    Business Documentation A copy of one of the following:
    • Business Entity Information (New Jersey Tax Certification or Trade Name Registration)
    • State of NJ Business Registration

  • Specialty Pharmacy Providers

    The following requirements apply to Specialty Pharmacy Providers in regard to participation in the Horizon NJ Health Network and/or the Horizon Casualty Network.

    Please note: The credentialing/recredentialing of Specialty Pharmacy Providers for participation in the Horizon BCBSNJ commercial network is delegated to CareCentrix, Inc. through the Horizon Care@Home program. Durable Medical Equipment (DME) Providers interested in participating in the Horizon Care@Home program may call CareCentrix at 1-855-243-3324 for information about participation, credentialing and recredentialing.

    Requirement Documentation
    Licensure Verification from the appropriate State Licensing Board/Agency indicating:
    • License number
    • License expiration date
    • Restrictions placed on the license if applicable
    • DEA license
    • Pharmacy license to dispense in the state where the pharmacy is located
    General or Commercial Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amount(s) of at least $1M per occurrence and $3M per aggregate
    Professional Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amounts of at least $1M per occurrence and $3M per aggregate
    Worker's Compensation N/A
    Accreditation Current verification of accreditation from one of the following:
    • The Joint Commission
    • Community Health Accreditation Program (CHAP)
    • The Compliance Team (TCT)
    • Accreditation Commission for Health Care (ACHC)
    • Commission on Accreditation of Rehabilitation Facilities (CARF)
    • Commission on Accredtiation for Health Care New Jersey (CAHC)
    • Healthcare Quality Association on Accreditation (HQAA)
    Medicare Participation Current documentation of Medicare participation
    ADA Survey N/A

  • Temporary Help Agencies

    The following requirements apply to Temporary Help Agencies in regard to participation in the Horizon NJ Health Network. Temporary Help Agencies are not credentialed for participation in the Horizon BCBSNJ Commercial Network or the Horizon Casualty Network.

    Requirement Documentation
    Licensure
    • Business Registration
    • Temporary Help Agency License through Division of Consumer Affairs
    General or Commercial Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amount(s) of at least $1M per occurrence and $3M per aggregate
    Professional Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amounts of at least $1M per occurrence and $3M per aggregate
    Worker's Compensation N/A
    Accreditation N/A
    Medicare Participation N/A
    ADA Survey N/A

    The following additional requirements apply to Temporary Help Agencies for participation In the Horizon NJ Health Network if the following subservices are provided:

    • Caregiver Participant Training
    • Home Based Supportive Care
    • Cleaning or Maintenance
    Requirement Documentation
    Business Documentation A copy of one of the following:
    • Business Entity Information (New Jersey Tax Certification or Trade Name Registration)
    • State of NJ Business Registration

  • Urgent Care Centers

    The following requirements apply to Urgent Care Centers in regard to participation in the Horizon BCBSNJ Commercial Network, the Horizon Casualty Network, and/or the Horizon NJ Health Network.

    Requirement Documentation
    Licensure N/A
    General or Commercial Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amount(s) of at least $1M per occurrence and $3M per aggregate
    Professional Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amounts of at least $1M per occurrence and $3M per aggregate
    Worker's Compensation N/A
    Accreditation Current verification of accreditation from one of the following:
    • The Joint Commission
    • Urgent Care Association of America (UCAOA)
    OR

    A copy of a satisfactorily completed Horizon Urgent Care Center Site Visit Form or Reattestation Site Visit Form
    Medicare Participation Current documentation of Medicare participation
    ADA Survey ADA survey per location
    Certification of the Clinical Laboratory Improvement Agency (CLIA)

    Current verification of the certification from the CLIA

    CLIA license is only necessary if the Urgent Care Center is performing laboratory services on site.

  • Vaccine Network for Pharmacies

    The following requirements apply to Vaccine Network for Pharmacies in regard to participation in the Horizon BCBSNJ Commercial Network, the Horizon Casualty Network, and/or the Horizon NJ Health Network.

    Please note: Vaccine Network for Pharmacies will not be credentialed for Medicare Advantage and Braven Health plans/products since Medicare covers these services under its Pharmacy Benefit. However, Vaccine Network for Pharmacies may be credentialed for other (i.e., non-MA) commercial managed care plans/products.

    Requirement Documentation
    Licensure Verification from the appropriate State Licensing Board/Agency indicating:
    • License number
    • License expiration date
    • Restrictions placed on the license if applicable
    Pharmacy License Verification from the appropriate State Licensing Board/Agency indicating the provider has:
    • License number
    • License expiration date
    • Restrictions placed on the license if applicable
    General or Commercial Liability A current copy of the Certificate of Insurance showing:
    • Coverage period
    • Policy Number
    • Coverage amount(s) of at least $1M per occurrence and $3M per aggregate
    Worker's Compensation N/A
    Accreditation N/A
    Medicare Participation N/A
    ADA Survey N/A