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:
March 10, 2019

SCOPE:
This policy applies to the Horizon Healthcare of New Jersey, Inc. Managed Care Network, the Horizon Healthcare Services, Inc. d/b/a Horizon Blue Cross Blue Shield of New Jersey PPO Network, the Horizon Casualty Services, Inc. Managed Workers’ Compensation Network and Horizon NJ Health’s Medicaid Network. For the purpose of this policy, all of these Horizon entities shall be collectively defined as “Horizon”. For the purpose of this policy, all of the above – referenced networks shall be defined as “Network(s)”.

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:
Ancillary and MLTSS providers include the following:

  1. Acute Rehabilitation Facilities
  2. Adult Family Care Providers
  3. Adult Medical Day Care
  4. Ambulance/Medical Transport Providers
  5. Ambulatory Surgical Centers
  6. Assisted Living Services, Program, Residence or Comprehensive Personal Care Home Service Providers
  7. Behavioral Health Facilities (Inpatient, Residential, Ambulatory)
  8. Centers for Independent Living
  9. Chore Services
  10. Clinical Laboratories
  11. Community Residential Homes
  12. Comprehensive Outpatient Rehabilitation Facilities
  13. Dental Sleep Medicine Providers (Oral Appliances)
  14. Dialysis Centers
  15. Durable Medical Equipment Providers (DME)
  16. Employer Based Groups
  17. Essential Community Providers
  18. Healthcare Services Firms
  19. Home Delivered Meals
  20. Home Health/Private Duty Nursing Providers (PDN)
  21. Home Infusion/Specialty Pharmacy Providers
  22. Hospice Providers
  23. Independent Diagnostic Testing Facilities (IDTF)
  24. Lithotripsy Providers
  25. Mastectomy Prosthetic Providers
  26. Medication Dispensing Device Service Providers
  27. Non-Medical Transport Providers
  28. Non-Traditional Service Providers
  29. Ocular Prosthetic Providers
  30. Outpatient Rehabilitation Providers
  31. Pediatric Medical Day Care Providers
  32. Personal Care Assistant Providers (PCA)
  33. Personal Emergency Response Services
  34. Prosthetics and Orthotics
  35. Radiology/Imaging Centers including Mobile X-ray/Imaging Service Providers
  36. Retail Health Clinics
  37. Skilled Nursing/Sub acute/Long Term Care Facility Providers
  38. Sleep Disorder Laboratories
  39. Social Adult Day Care Providers
  40. Temporary Help Agencies
  41. Urgent Care Centers
  42. Vaccine Network for Pharmacies

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.

PROCEDURE:

  1. Initial Credentialing:

    Note: Confidential information obtained in the credentialing process shall be used and disclosed in accordance with Horizon's privacy policies or as otherwise required by law.
    1. A completed application for participation in the specified network, in a format approved by the Credentials Committee and all required supporting documentation must be submitted. Note: 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.com or by calling eviCore at 1-800-467-6424.

    2. The application is screened for completeness by the Ancillary Account Executive and forwarded to the Physician Data Management (PDM) Department for processing.

    3. The documentation submitted or obtained in support of the credentialing process is validated and verified through primary source verification.

    4. Each provider must provide documentation of:

      • Licensure (if applicable)
      • Accreditation (if applicable)
      • Certification with Medicare or Medicaid for facilities if the hospital participates in either of these respective programs (if applicable)
      • Professional Liability Coverage
      • Dates of Health and Safety Inspections and findings
      • Ongoing State Board Monitoring or Investigations (if applicable)
    5. If the credentialing information obtained from other sources varies substantially from the information obtained from the ancillary or MLTSS provider, the ancillary or MLTSS provider will be notified in writing by the PDM staff within 30 days of receipt of the application. The notification will inform the ancillary or MLTSS provider of their right to correct erroneous information submitted by another party or to correct their own information that was submitted incorrectly. The ancillary or MLTSS provider shall have 15 days to submit a response and correction(s) to the PDM Department. If the 15 day period expires, and the ancillary or MLTSS provider has failed to respond, the application shall be considered withdrawn and the applicant notified in writing.

    6. The applicant is presented and reviewed by the Credentials Committee within no more than ninety (90) days of receipt of the application.

    7. Applicants meeting the Standards for Participation (“clean files”) are presented to the Credentials Committee on a spreadsheet. These “clean files” can also be reviewed and approved by the Credentials Subcommittee.

    8. The Committee may:

      1. Approve the applicant and the offering of a contract to the ancillary or MLTSS provider, upon which execution and receipt by Horizon shall render the ancillary or MLTSS provider a participating provider;
      2. Request more information and/or an interview before making a decision;
      3. Find that the applicant does not meet the Standards for Participation in the network and decline the applicant; or
      4. Take other action as may be required.
    9. In the event that the Committee, in its review, requires additional information, an email communication will be sent to the Ancillary Account Executive. The ancillary or MLTSS provider will be notified of the information needed in writing within 15 days of receipt of the Committee's request for such information. If the required information is not received within 15 days of the request, the application will still be presented at the next scheduled Committee meeting.

    10. Following the Credentials Committee meeting, the Credentialing/Recredentialing Committee Report is completed, copied and forwarded to the Ancillary Account Executives specifying the ancillary or MLTSS providers marked as approved or denied.

    11. Ancillary or MLTSS providers will be advised of the decision of the Committee on their application in writing within 60 days of the decision. Horizon NJ Health providers will be notified in writing within 10 business days of the Credentials Committee’s decision.

  2. Recredentialing:

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

    1. Frequency: All participating ancillary or MLTSS providers shall undergo recredentialing every three years. Horizon and Horizon NJ Health Ancillary and MLTSS providers due for recredentialing shall be deemed in compliance with the three year cycle requirement if the recredentialing decision is made within the month that is 36 months from the month of the prior recredentialing decision.

    2. In order to be recredentialed, each ancillary or MLTSS provider shall submit a completed, legible update form for recredentialing, along with the required supporting documentation. The ancillary or MLTSS provider must attest whether the information provided on the recredentialing form has changed since last being credentialed. The ancillary or MLTSS provider shall demonstrate they continue to meet all requirements for credentialing and the satisfaction of the requirements that are primary source verified.

      In addition, the ancillary or MLTSS provider must be judged to be a member in good standing in the network(s) in which they participate.

    3. Each provider must provide documentation of:

      • Licensure (if applicable)
      • Accreditation (if applicable)
      • Certification with Medicare or Medicaid for facilities if the hospital participates in either of these respective programs (if applicable)
      • Professional Liability Coverage
      • Dates of Health and Safety Inspections and findings
      • Ongoing State Board Monitoring or Investigations (if applicable).
    4. A completed recredentialing form in a format approved by the Credentials Committee, and all required supporting document should be submitted.

    5. 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.

    6. The recredentialing application is screened for completeness by PDM. In the event that a recredentialing application is incomplete, the ancillary or 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 or MLTSS provider notified in writing.

    7. The documentation submitted in support of the recredentialing application is validated and verified through primary source verification.

    8. In the event the recredentialing information obtained from other sources varies substantially from the information obtained by the ancillary or MLTSS provider, the ancillary or MLTSS provider will be notified in writing by the PDM Department. The ancillary or MLTSS provider shall have 15 days to submit a response. If the 15 day period expires, and the ancillary or MLTSS provider has failed to respond, the application shall be considered withdrawn and the applicant notified of termination in writing.

    9. Any quality information obtained through the complaint or quality case review process is included in the recredentialing file.

    10. Applicants meeting the Standards for Participation (“clean files”) are presented to the Credentials Committee on a spreadsheet. These “clean files” can also be reviewed and approved by the Credentials Subcommittee.

    11. In the event the Committee, in its review, requires additional information, the ancillary or MLTSS provider will be notified of the information needed in writing and will be given 15 days to produce such information. If the required information is not received within 15 days, the application will be considered withdrawn and the ancillary or MLTSS provider notified in writing.

    12. Ancillary or MLTSS providers will be advised of the decision of the Committee on their application in writing within 30 days of the decision. Horizon NJ Health providers will be notified in writing within 10 business days of the Credentials Committee’s decision.

ATTACHMENT A

Standards for Participation:

The basic credentialing requirements for the ancillary or MLTSS provider categories are as set forth below:

NOTES:

If an ancillary or MLTSS provider participates in either Medicare Advantage and/or Horizon NJ, their respective participating provider numbers are required. Medicare certification is required for participation in the Medicare Advantage Network, as applicable. Medicaid certification is required for participation in the Horizon New Jersey Health Network. Ancillary or MLTSS providers who are not eligible to treat Medicare members (including mammography facilities that are not FDA-approved) will not be credentialed for these products. Horizon may credential providers without Medicare or Medicaid certification for other products.

Regarding accreditation: All ancillary or MLTSS providers applying for initial credentialing or recredentialing in Horizon's networks must meet the Standards for Participation, attached hereto as Attachment A.

Should an ancillary provider be required to be accredited by an appropriate accrediting body and not have such accreditation, a site visit by a Horizon clinician is required in lieu of such accreditation. A CMS or DOHSS site review may be substituted for a Horizon site visit, but Horizon must obtain a copy of the review of the facility to verify that the facility was reviewed and passed inspection.

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

Please note that 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)
  1. Acute Rehabilitation Facilities
    • State licensure by state in which facility is located, current malpractice coverage of at least $1 million per occurrence and $3 million in the aggregate, and, Joint Commission accreditation, Medicaid and/or Medicare certification (see note above):
    • If this ancillary provider performs any radiology/imaging services they must meet the requirements in #35 below.

    Documentation: Verification from the State Licensing Board/Agency in which the ancillary facility operates indicating the ancillary provider has a license, the number, expiration date and any restrictions placed on its license. A copy of the certificate of insurance displaying the period covered and the coverage amounts. Verification from the Joint Commission. Documentation of Medicaid and/or Medicare certification status, as applicable. Verifications must be done within 180 calendar days prior to the credentialing/recredentialing decision.

  2. Adult Family Care Providers

    MLTSS Requirement: Licensed Adult Family Care (AFC) Agency Licensed by (HEFL) Health Facilities Evaluation and Licensing; Business license required. Criminal Background check attestation dated within 180 days prior to credentialing/recredentialing decision.

    MLTSS Documentation: A copy of business license. A copy of the certificate of insurance displaying the period covered and the coverage amount of 1 million per service. A copy of a completed Criminal Background check attestation dated within 180 days prior to credentialing/recredentialing decision.

    Additional MLTSS: Subservices provided by can include Caregiver Participant Training and/or Respite Care. Those subservices should have, Business Entity Information (New Jersey Tax Certification or Trade Name Registration), State of NJ Business Registration.

  3. Adult Medical Day Care

    Requirement: State licensure by the state in which the facility is located, current malpractice, coverage of at least $1 million per occurrence and $3 million in the aggregate.

    Documentation: Verification from the appropriate State Licensing Board/Agency indicating the ancillary or MLTSS provider has a license, the number, expiration date and any restrictions placed on its license. A copy of the certificate of insurance displaying the period covered and the coverage amounts. Verifications must be done within 180 calendar days prior to the credentialing/recredentialing decision.

    Additional MLTSS Requirements: For Social Adult Day Criminal Background check attestation dated within 180 days prior to credentialing/recredentialing decision. A copy of the certificate of insurance displaying the period covered and the coverage amount of 1 million per service.

  4. Ambulance/Medical Transport Providers

    Requirement: State licensure by state in provider’s service area is located indicating type of transport services (i.e. Basic Life Support (BLS), Specialty Care Transport (SCT), Mobile assistance Vehicle (MAV)) and current malpractice coverage of at least $1 million per occurrence and $3 million in the aggregate, Medicaid and/or Medicare certification (see note above).

    Documentation: Verification from the appropriate State Licensing Board/Agency indicating the ancillary provider has a license, the number, expiration date and any restrictions placed on it. A copy of the certificate of insurance displaying the period covered and the coverage amounts. Documentation of Medicaid and/or Medicare certification status, as applicable. Verifications must be done within 180 calendar days prior to the credentialing/recredentialing decision.

  5. Ambulatory Surgical Centers

    Requirement: State licensure by state in which center is located, if center is not a single surgical suite located within the private practice office of a physician or physician group practice (*please refer to SPECIAL REQUIREMENTS section below on page 26), current malpractice coverage of at least $1 million per occurrence and $3 million in the aggregate, AAAHC (Accreditation Association for Ambulatory Health Care), accreditation or AAAASF (American Association for Accreditation of Ambulatory Surgery Facilities) or Joint Commission accreditation and Medicaid and/or Medicare certification (see NOTE above).

    If center is a single surgical suite located within the private practice office of a physician or physician group practice, the requirements are as follows: malpractice coverage of at least $1 million per occurrence and $3 million in the aggregate, AAAHC (Accreditation Associations for Ambulatory Health Care), AAAASF (American Association for Accreditation of Ambulatory Surgery Facilities) or Joint Commission accreditation and Medicaid and/or Medicare certification:

    • If this ancillary provider performs any radiology/imaging services they must meet the requirements in #35 below.

    Documentation: Verification from the appropriate State Licensing Board/Agency indicating the ancillary provider has a license, the number, expiration date and any restrictions placed on it (as applicable). A copy of the certificate of insurance displaying the period covered and the coverage amounts. Verification from accreditation from AAAHC or, AAAASF or Joint Commission. Documentation of Medicaid and/or Medicare certification status, as applicable. Verifications must be done within 180 calendar days prior to the credentialing/recredentialing decision.

    Please see the Special Requirements section below for additional information.

  6. Assisted Living Services, Program, Residence or Comprehensive Personal Care Home Service Providers

    MLTSS Requirements: Assisted Living Facility Licensed By Department of Health. A copy of the certificate of insurance displaying the period covered and the coverage amount of 1 million per service. A copy of a completed Criminal Background check attestation dated within 180 days prior to credentialing/ recredentialing decision.

    MLTSS Documentation: A copy of DOH license. A copy of the certificate of insurance displaying the period covered and the coverage amounts. A copy of a completed Criminal Background Attestation.

    Additional MLTSS: Subservice provided by can include Respite Care. This subservices should have, Business Entity Information (New Jersey Tax Certification or Trade Name Registration), State of NJ Business Registration.

  7. Behavioral Health Facilities (Inpatient Residential, Ambulatory)

    Requirement: State licensure by state in which facility is located, current malpractice coverage of at least $1 million per occurrence and $3 million in the aggregate, Joint Commission, Community Health Accreditation Program (CHAP), or Commission on Accreditation of Rehabilitation Facilities (CARF) accreditation, and Medicaid and/or Medicare certification, as applicable (see NOTE above):

    • If this ancillary provider performs any radiology/imaging services they must meet the requirements in #35 below.

    Documentation: Verification from the appropriate State Licensing Board/Agency indicating the ancillary provider has a license, the number, expiration date and any restrictions placed on it. A copy of the certificate of insurance displaying the period covered and the coverage amounts. Verification from the appropriate accrediting agency. Documentation of Medicaid/Medicare certification status. Verifications must be done within 180 calendar days prior to the credentialing/recredentialing decision.

  8. Centers for Independent Living

    MLTSS Requirement: State licensure by state in which facility is located, current malpractice coverage of at least $1 million per occurrence and is a Certified Center for Independent Living. A copy of the certificate of insurance displaying the period covered and the coverage amount of 1 million per service. A copy of a completed Criminal Background check attestation dated within 180 days prior to credentialing/recredentialing decision.

    MLTSS Documentation: Verification from the appropriate State Licensing Board/Agency indicating the provider has a license, the number, expiration date and any restrictions placed on it. A copy of the certificate of insurance displaying the period covered and the coverage amounts. A copy of a completed Criminal Background Attestation.

    Additional MLTSS: Subservice can include Caregiver Participant Training. This subservices should have, Business Entity Information (New Jersey Tax Certification or Trade Name Registration), State of NJ Business Registration.

  9. Chore Services

    MLTSS Requirements: Business entity with evidence of authority to conduct such business in New Jersey, (i.e. New Jersey Tax Certificate or Trade Name Registration). Has any license required by law to engage in the service, provide furnishings, appliances, equipment. A copy of the certificate of insurance displaying the period covered and the coverage amount of 1 million per service. A copy of Worker’s Compensation Insurance Certificate. A copy of a completed Criminal Background check attestation dated within 180 days prior to credentialing/ recredentialing decision.

    MLTSS Documentation: A copy of the certificate of insurance displaying the period covered and the coverage amount of 1 million per service. A copy of a completed Criminal Background check attestation dated within 180 days prior to credentialing/recredentialing decision. Copy of License and NJ Tax Certificate. A copy of the Worker’s Compensation Insurance certificate.

    Additional MLTSS: Subservice can include Cleaning and or Maintenance Services. These subservices should have, Business Entity Information (New Jersey Tax Certification or Trade Name Registration), State of NJ Business Registration.

  10. Clinical Laboratories

    Requirement: State licensure by the state in which the facility is located, current malpractice, coverage of at least $1 million per occurrence and $3 million in the aggregate, Clinical Laboratory Improvement Agency (CLIA) certification, or College of American Pathologist (CAP) accreditation and Medicaid and/or Medicare certification (see NOTE above).

    Documentation: Verification from the appropriate State Licensing Board/Agency indicating the ancillary provider has a license, the number, expiration date and any restrictions placed on its license. A copy of the certificate of insurance displaying the period covered and the coverage amounts. Verification from CLIA or CAP. Documentation of Medicaid and/or Medicare certification status. Verifications must be done within 180 calendar days prior to the credentialing/recredentialing decision.

  11. Community Residential Homes

    MLTSS Requirement: A copy of the certificate of insurance displaying the period covered and the coverage amount of 1 million per service. A copy of a completed Criminal Background check attestation dated within 180 days prior to credentialing/recredentialing decision, State License.

    MLTSS Documentation: Verification from the appropriate State Licensing Board/Agency indicating the provider has a license, the number, expiration date and any restrictions placed on its license. A copy of the certificate of insurance displaying the period covered and the coverage amounts, a copy of a completed Criminal Background Attestation.

    Additional MLTSS: Subservice can be Community Residential Services. This subservices should have, Business Entity Information (New Jersey Tax Certification or Trade Name Registration), State of NJ Business Registration.

  12. Comprehensive Outpatient Rehabilitation Facilities

    Requirement: State licensure by state in which facility is located, current malpractice coverage of at least $1 million per occurrence and $3 million in the aggregate, Joint Commission accreditation, and Medicaid and/or Medicare certification (see NOTE above).

    • If this ancillary provider performs any radiology/imaging services they must meet the requirements in #35 below.

    Documentation: Verification from the State Licensing Board/Agency in which the ancillary facility operates indicating the ancillary provider has a license, the number, expiration date, any restrictions placed on its license. A copy of the certificate of insurance displaying the period covered and the coverage amounts. Verification from Joint Commission. Documentation of Medicaid and/or Medicare certification status. Verifications must be done within 180 calendar days prior to the credentialing/recredentialing decision.

  13. Dental Sleep Medicine Providers (Oral Appliances)

    Requirement: Current malpractice coverage of at least $1 million per occurrence and $3 million in the aggregate; Accreditation/Certification, as applicable, by one of the following organizations: Joint Commission, CHAP (Community Health Accreditation Program), TCT (The Compliance Team), ACHC (Accreditation Commission for Health Care), NABP (National Association of Board of Pharmacy), Healthcare Quality Association on Accreditation (HQAA), Commission on Accreditation of Rehabilitation Facilities (CARF), or American Board for Certification (ABC)American Academy of Dental Sleep Medicine (AADSM), and Medicaid/Medicare supplier certification.

    Documentation: A copy of the certificate of insurance displaying the period covered and the coverage amounts. Verification of accreditation. Documentation of Medicaid/Medicare certification status, verification from the American Board for Certification. Verifications must be done within 180 calendar days prior to the credentialing/re-credentialing decision.

  14. Dialysis Centers

    Requirement: State licensure by state in which center is located, current malpractice coverage of at least $1 million per occurrence and $3 million in the aggregate, Clinical Laboratory Improvement Amendments (CLIA) certification mandatory for outpatient renal dialysis provider, Medicaid and/or Medicare certification (see NOTE above).

    • If this ancillary provider performs any radiology/imaging services they must meet the requirements in #35 below.

    Documentation: Verification from the appropriate State Licensing Board/Agency indicating the ancillary provider has a license, the number, expiration date and any restrictions placed on its license. A copy of the certificate of insurance displaying the period covered and the coverage amounts. Documentation of CLIA certification. Documentation of Medicaid/Medicare certification status. Verifications must be done within 180 calendar days prior to the credentialing/recredentialing decision.

  15. Durable Medical Equipment Providers (DME)

    Requirement: Current malpractice Current malpractice coverage of at least $1 million per occurrence and $3 million in the aggregate; Accreditation/Certification, as applicable, by one of the following organizations: Joint Commission, CHAP (Community Health Accreditation Program), TCT (The Compliance Team), ACHC (Accreditation Commission for Health Care), NABP (National Association of Board of Pharmacy), Healthcare Quality Association on Accreditation (HQAA), Commission on Accreditation of Rehabilitation Facilities (CARF), or American Board for Certification (ABC), and Medicaid/Medicare supplier certification (see NOTE above).

    For DME suppliers of electronic devises only (equipment without clinical monitoring) the requirements are as follows: current malpractice coverage of at least $1 million per occurrence and $3 million in the aggregate, Medicare/Medicaid supplier certification when applicable, certification by CSAA (Central Station Alarm Association) and Horizon’s ARC (Architecture Review Committee) approval documentation.

    Documentation: A copy of the certificate of insurance displaying the period covered and the coverage amounts. Verification of accreditation. Documentation of Medicaid/Medicare certification status, Verification from the American Board for Certification. Verifications must be done within 180 calendar days prior to the credentialing/recredentialing decision.

    For DME suppliers of electronic devises only (equipment without clinical monitoring): a copy of the certificate of insurance displaying the period covered and the coverage amounts, Medicare/Medicaid supplier certificate (when applicable), CSAA certificate and ARC approval documentation.

    Additional MLTSS Requirement: Subservice could include Medication Dispensing Devices and or Personal Emergency Response System. These subservices should have, Business Entity Information (New Jersey Tax Certification or Trade Name Registration), State of NJ Business Registration Criminal Background check attestation dated within 180 days prior to credentialing/recredentialing decision.

  16. Employer Based Groups

    Requirement: Current Malpractice coverage of at least $1 million per occurrence and $3 million in the aggregate. A valid Clinical Laboratory Improvement Agency (CLIA) certificate. The Medical Director must be located in the State of NJ and be participating with Horizon.

    Documentation: A copy of certificate of insurance displaying the period covered and the coverage amounts. Clinical Laboratory Improvement Agency (CLIA) certificate. The name, specialty, and NPI of the Medical Director to show proof that he/she is practicing in NJ and Participating with Horizon.

  17. Essential Community Providers

    Federally Qualified Health Centers (FQHC)

    Requirement: Medicate certification, state Licensure and current comprehensive liability insurance policy of at least $1 million per incident and $3 million in the aggregate.

    Documentation: Verification from the appropriate State Licensing Board/Agency indicating the ancillary provider has a license, the number, expiration date and any restrictions placed on its license. A copy of the certificate of insurance displaying the period covered and the coverage amounts. Documentation of Medicare certification status. Verifications must be done within 180 calendar days prior to the credentialing/recredentialing decision. Documentation evidencing that the provider is a Federally Qualified Health Center.

    • Provider must have a licensed physician designated as Medical Director who is responsible for overall clinical quality

    Family Planning Centers

    Requirement: State Licensure and current comprehensive liability insurance policy of at least $1 million per incident and $3 million in the aggregate. Accreditation by JCAHO, Planned Parenthood Federation of America (PPFA), or other applicable accrediting agencies, bodies, or entities.

    Documentation: Verification from the appropriate State Licensing Board/Agency indicating the ancillary provider has a state license, the license number, expiration date and any restrictions placed on the license. A copy of the certificate of insurance displaying current comprehensive liability insurance policy of at least $1 million per incident and $3 million in the aggregate.

    • Provider must have a licensed physician designated as Medical Director who is responsible for overall clinical quality
  18. Healthcare Services Firms

    MLTSS Requirements: Business License Required. Healthcare Service Firm License through Division of Consumer Affairs. A copy of the certificate of insurance displaying the period covered and the coverage amount of 1 million per service. A copy of a completed Criminal Background check attestation dated within 180 days prior to credentialing/recredentialing decision.

    MLTSS Documentation: A Copy of Business license. A copy of Division of Consumer Affairs License. A copy of the certificate of insurance displaying the period covered and the coverage amounts. A copy of a completed Criminal Background Attestation.

    Additional MLTSS Requirement: Subservice could include Caregiver Participant Training, Home-based Supportive Care, Respite, Supported Day, Community Transitions, Cleaning or Maintenance. These subservices should have, Business Entity Information (New Jersey Tax Certification or Trade Name Registration), State of NJ Business Registration Criminal Background check attestation dated within 180 days prior to credentialing/recredentialing decision.

  19. Home Delivered Meals

    MLTSS Requirements: Business License Required. A copy of the certificate of insurance displaying the period covered and the coverage amount of 1 million per service. A copy of a completed Criminal Background check attestation dated within 180 days prior to credentialing/recredentialing decision.

    MLTSS Documentation: A Copy of Business license. A copy of the certificate of insurance displaying the period covered and the coverage amounts. A copy of a completed Criminal Background Attestation.

  20. Home Health/Private Duty Nursing Providers (PDN)

    Requirement: State licensure by state in provider's service area, certificate of need, current malpractice coverage of at least $1 million per occurrence and $3 million in the aggregate, Joint Commission, CHAP (Community Health Accreditation Program), ACHC (Accreditation Commission for Health Care), TCT (The Compliance Team) or CARF (Commission on Accreditation of Rehabilitation Facilities) accreditation, or Commission on Accreditation for Health Care New Jersey (CAHC) and Medicaid and/or Medicare certification (see NOTE above).

    Documentation: Verification from the appropriate State Licensing Board/Agency indicating the ancillary provider has a license, the number, expiration date and any restrictions placed on it. A copy of the certificate of insurance displaying the period covered and the coverage amounts. Verification of accreditation from the appropriate accrediting agency. A copy of the certificate of need. Documentation of Medicaid/Medicaid certification status. Verifications must be done within 180 calendar days prior to the credentialing/recredentialing decision.

    Additional MLTSS Requirements: Subservice can include Caregiver Participant Training, Home Based Supportive Care and or Respite. These subservices should have, Business Entity Information (New Jersey Tax Certification or Trade Name Registration), State of NJ Business Registration. A copy of a completed Criminal Background Attestation.

  21. Home Infusion/Specialty Pharmacy Providers

    Requirement: State licensure, DEA license, pharmacy license to dispense in the state where the pharmacy is located, current malpractice coverage of at least $1 million per occurrence and $3 million in the aggregate, Joint Commission, CHAP (Community Health Accreditation Program), ACHC (Accreditation Commission for Health Care), TCT (The Compliance Team) or CARF (Commission on Accreditation of Rehabilitation Facilities) accreditation and Healthcare Quality Association on Accreditation (HQAA).

    Documentation: Verification from the appropriate State/Federal Licensing Boards/Agencies indicating the ancillary provider has state and DEA licenses, the number, expiration date and any restrictions placed on its license. A copy of the certificate of insurance displaying the period covered and the coverage amounts. Verification from the appropriate accrediting agency. Verifications must be done within 180 calendar days prior to the credentialing/recredentialing decision.

  22. Hospice Providers

    Requirement: State licensure by state in Provider’s service area, current malpractice coverage of at least $1 million per occurrence and $3 million in the aggregate, Joint Commission, CHAP (Community Health Accreditation Program), ACHC (Accreditation Commission for Health Care), TCT (The Compliance Team) or CARF(Commission on Accreditation of Rehabilitation Facilities) accreditation or other equivalent accreditation agency (ies) and Medicaid/Medicare certification as applicable.

    • If this ancillary provider performs any radiology/imaging services they must meet the requirements in #35 below.

    Documentation: Verification from the appropriate State Licensing Board/Agency indicating the ancillary provider has a license, a number, expiration date and any restrictions placed on its license. A copy of the certificate of insurance displaying the period covered and the coverage amounts. Verification of accreditation from the appropriate accrediting agency. Documentation of Medicaid/Medicare certification status. Verifications must be done within 180 calendar days prior to the credentialing/recredentialing decision.

    Additional MLTSS Requirements: Subservice could include home based supportive care. This subservices should have, Business Entity Information (New Jersey Tax Certification or Trade Name Registration), State of NJ Business Registration. A copy of a completed Criminal Background Attestation.

  23. Independent Diagnostic Testing Facilities (IDTF)

    Requirement: Medicare certification, state Licensure and current comprehensive liability insurance policy of at least $1 million per incident and $3 million in the aggregate.

    Documentation: Verification from the appropriate State/Federal Licensing Boards/Agencies indicating the ancillary provider has state licenses, the number, expiration date and any restrictions placed on its license. A copy of the certificate of insurance displaying the period covered and the coverage amounts. A copy of Medicare Certification letter.

  24. Lithotripsy Providers

    Requirement: State licensure by state in which facility is located, current malpractice coverage of at least $1 million per occurrence and $3 million in the aggregate, and Medicaid and/or Medicare supplier certification (see NOTE above).

    • If this ancillary provider performs any radiology/imaging services they must meet the requirements in #19 below.

    Documentation: Verification from the appropriate State Licensing Board/Agency indicating the ancillary provider has a license, the number, expiration date and any restrictions placed on its license. A copy of the certificate of insurance displaying the period covered and the coverage amounts. Documentation of Medicaid/ Medicare certification status. Verifications must be done within 180 calendar days prior to the credentialing/recredentialing decision.

  25. Mastectomy Prosthetic Providers

    Requirement: Current malpractice coverage of at least $1 million per occurrence and $3 million in the aggregate, Fitter Certification, and Medicaid/Medicare supplier certification (see NOTE above).

    Documentation: A copy of the certificate of insurance displaying the period covered and the coverage amounts. Verification from Fitter. Documentation of Medicaid/Medicare certification status. Verifications must be done within 180 calendar days prior to the credentialing/recredentialing decision.

  26. Medication Dispensing Device Service Providers

    MLTSS Requirement: Business license required. A copy of the certificate of insurance displaying the period covered and the coverage amount of 1 million per service. A copy of a completed Criminal Background check attestation dated within 180 days prior to credentialing/recredentialing decision.

    MLTSS Documentation: A Copy of Business license. A copy of the certificate of insurance displaying the period covered and the coverage amounts. A copy of a completed Criminal Background Attestation.

  27. Non-Medical Transport Providers

    MLTSS Requirement: Business license required. A copy of the certificate of insurance displaying the period covered and the coverage amount of 1 million per service. A copy of a completed Criminal Background check attestation dated within 180 days prior to credentialing/recredentialing decision. Proof of New Jersey Business Authority, i.e. tax certificate or trade name registration.

    Documentation: A Copy of Business license. A copy of the certificate of insurance displaying the period covered and the coverage amounts. A copy of a completed Criminal Background Attestation.

  28. Non-Traditional Service Providers

    Community Transition Services

    MLTSS Requirement: Business entity with evidence of authority to conduct such business in New Jersey, (i.e. New Jersey Tax Certificate or Trade Name Registration). A copy of the certificate of insurance displaying the period covered and the coverage amount of 1 million per service. A copy of a completed Criminal Background check attestation dated within 180 days prior to credentialing/recredentialing decision. A copy of the Worker’s Compensation Insurance certificate.

    MLTSS Documentation: A Copy of Business license. A copy of the certificate of insurance displaying the period covered and the coverage amounts A copy of a completed Criminal Background Attestation. A copy of the Worker’s Compensation Insurance certificate.

    Residential Modifications

    MLTSS Requirements: Business entity with evidence of authority to conduct such business in New Jersey, (i.e. New Jersey Tax Certificate or Trade Name Registration). Licensed in NJ per the NJ Division of Consumer Affairs, A copy of the certificate of insurance displaying the period covered and the coverage amount of 1 million per service. A copy of a completed Criminal Background check attestation dated within 180 days prior to credentialing/recredentialing decision. A copy of the Worker’s Compensation Insurance certificate.

    MLTSS Documentation: A Copy of Business license. A copy of consumer affairs license. A copy of the certificate of insurance displaying the period covered and the coverage amounts A copy of a completed Criminal Background Attestation. A copy of the Worker’s Compensation Insurance certificate.

    Vehicle Modifications

    MLTSS Requirements: Business license required. State of New Jersey Department of Law & Public Safety Division of Consumer Affairs; a copy of the certificate of insurance displaying the period covered and the coverage amount of 1 million per service; a copy of a completed Criminal Background check attestation dated within 180 days prior to credentialing/recredentialing decision.

    MLTSS Documentation: A Copy of Business license; a copy of the certificate of insurance displaying the period covered and the coverage amounts; a copy of a completed Criminal Background Attestation.

  29. Ocular Prosthetic Providers

    Requirement: Current malpractice coverage of at least $1 million per occurrence and $3 million in the aggregate, National Examining Board of Ocularists (NEBO) certification, and Medicaid/ Medicare supplier certification (see NOTE above).

    Documentation: A copy of the certificate of insurance displaying the period covered and he coverage amounts; verification of accreditation from NEBO. Documentation of Medicaid/Medicare certification status; verifications must be done within 180 calendar days prior to the credentialing/recredentialing decision.

  30. Outpatient Rehabilitation Providers

    Requirement: Current malpractice coverage of at least $1 million per occurrence and $3 million in the aggregate and Medicaid and/or Medicare certification (see NOTE above). Evidence that this provider has an established credentialing program with primary source verification of all employed practitioners.

    • If this ancillary provider performs any radiology/imaging services they must meet the requirements in #35 below.

    Please Note for Physical Therapy:

    • In instances where there are multi-specialties present at a facility (physical therapist, ortho, primary care, etc.), the physical therapist(s) will remain credentialed as individual providers (Refer to Credentialing/Recredentialing Policy).
    • A physical therapist cannot have dual credentialing status as an individual provider and as part of a group.

    Please Note for Occupational and Speech Therapy:

    • In instances where there are multi-specialties present at a facility (physical therapist, ortho, primary care, etc.), the occupational or speech therapist(s) will remain credentialed as individual providers (Refer to Credentialing/Recredentialing Policy).
    • An occupational or speech therapist cannot have dual credentialing status as an individual provider and as part of a group.

    Documentation: Verification and inclusion of a copy of the certificate of insurance displaying the period covered and the coverage amounts and documentation of Medicaid and/or Medicare certification status. Verifications must be done within 180 calendar days prior to the credentialing/recredentialing decision.

    Additional MLTSS Requirement: Subservice could include Community Residential Service, Cognitive therapy, Supported Day and or Structured Day. These subservices should have, Business Entity Information (New Jersey Tax Certification or Trade Name Registration), State of NJ Business Registration. A copy of a completed Criminal Background Attestation.

  31. Pediatric Medical Day Care Providers

    Requirement: State licensure by the state in which the facility is located, current malpractice, coverage of at least $1 million per occurrence and $3 million in the aggregate.

    Documentation: Verification from the appropriate State Licensing Board/Agency indicating the ancillary provider has a license, the number, expiration date and any restrictions placed on its license. A copy of the certificate of insurance displaying the period covered and the coverage amounts. Verifications must be done within 180 calendar days prior to the credentialing/recredentialing decision.

  32. Personal Care Assistant Providers (PCA)

    Requirement: State licensure by the state in which the facility is located, current malpractice coverage of at least $1 million per occurrence and $3 million in the aggregate.

    Documentation: Verification from the appropriate State Licensing Board/Agency indicating the Ancillary provider has a license, the number, expiration date and any restrictions placed on its license. A copy of the certificate of insurance displaying the period covered and the coverage amounts. Verifications must be done within 180 calendar days prior to the credentialing/recredentialing decision. Accreditation from National Association for Home Care and Hospice (NAHC) or Commission on Accreditation for Home Care New Jersey (CAHC) or Joint Commission, or CHAP.

    Additional MLTSS Requirements: Subservice can include Caregiver Participant Training, Home Based Supportive Care and or Respite. These subservices should have, Business Entity Information (New Jersey Tax Certification or Trade Name Registration), State of NJ Business Registration. A copy of a completed Criminal Background Attestation.

  33. Personal Emergency Response Services

    MLTSS Requirements: Proof of New Jersey Business Authority, i.e. tax certificate or trade name registration), a copy of the certificate of insurance displaying the period covered and the coverage amount of 1 million per service, a copy of a completed Criminal Background check attestation dated within 180 days prior to credentialing/recredentialing decision.

    MLTSS Documentation: A copy of Business License, a copy of the certificate of insurance displaying the period covered and the coverage amounts; a copy of a completed Criminal Background Attestation.

  34. Prosthetic and Orthotic Providers

    Requirement: Current malpractice coverage of at least $1 million per occurrence and $3 million in the aggregate, facility/individual practitioner ABC accreditation, Board of Certification/Accreditation (BOC), Healthcare Quality Association on Accreditation (HQAA) and Medicaid/Medicare supplier certification (see NOTE above).

    Documentation: A copy of the certificate of insurance displaying the period covered and the coverage amounts. Verification from American Board Certification (ABC), verification from BOC and HQAA. Documentation of Medicaid/Medicare certification status. Verifications must be done within 180 calendar days prior to the credentialing/ recredentialing decision.

  35. Radiology/Imaging Centers including Mobile X-Ray/Imaging Service Providers

    Requirement: State licensure by the state in which the facility is located, current malpractice, coverage of at least $1 million per occurrence and $ 3 million in the aggregate. In addition accreditation/licensed by the accrediting/licensing agencies noted in the following table, as applicable.

     

    Modality Accrediting
    Agency
    Certification/Additional Accrediting Agencies Licensing
    Agency

    CAT SCAN/CTA
    /CCTA

    American College of Radiology (ACR)

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

    NJ Dept of Environmental Protection (NJDEP) or Dept of Health and Senior Services Standards for Licensure of Ambulatory Care Facilities

    MRI/MRA

    ACR

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

    Federal Drug Administration (FDA) or

    Dept of Health and Senior Services Standards for Licensure of Ambulatory Care Facilities

    Nuclear Medicine

    ACR

    NA

    NJDEP) or Nuclear Regulatory Commission (NRC)

    Nuclear Cardiology

    ACR

    Intersocietal Commission of Accreditation for Nuclear Cardiology Laboratories (ICANL)

    NJDEP or NRC

    Ultrasound

    ACR

    American Institute of Ultrasound in Medicine (AIUM)

    Intersocietal Commission of Accreditation on Vascular Echocardiography Laboratories (ICAVEL)

    NA

    PET/CT,PET

    ACR

    NA

    NJDEP, Dept of Health and Senior Services Standards for Licensure of Ambulatory Care Facilities

    For Pet: NJDEP or NRC

    General X-Ray

    NA

    NA

    NJDEP

    Interventional Radiology & Fluoroscopy

    NA

    NA

    NJDEP

    Mammography

    ACR

    Mammography Quality Standards Act (MQSA)

    NJDEP or FDA

    DEXA

    NA

    NA

    NJDEP

    Documentation: A copy of certification or registration by the appropriate State Licensing Boards/Agencies indicating the ancillary provider has a license, the number, expiration date and any restrictions placed on its license; verification of all applicable staff licensure; a copy of the certificate of insurance displaying the period covered and the coverage amounts as well as a copy of certification/ accreditation from one of the above mentioned accrediting agencies. All radiology/ imaging centers must have undergone a site visit by Horizon BCBSNJ prior to approval of participation for the contracted radiology/imaging center and for recredentialing. Documentation of Medicaid and/or Medicare certification status, where applicable (verifications must be done within 180 calendar days prior to the credentialing/recredentialing decision).

    Please Note:

    Mobile imaging services must meet the standards listed above for each applicable modality and are subject to the parameters set forth within the Standards for Diagnostic Radiology/Imaging Facilities/Freestanding-Office including Surgi-Centers and Diagnostic Dental - Radiographic Imaging Policy located on our portal at www.horizonblue.com

  36. Retail Health Clinics

    Requirement: Joint Commission Accreditation or Accreditation Association for Ambulatory Health Care (AAAHC), current malpractice coverage of at least $1 million per occurrence and $3 million in the aggregate, and Medicaid and/or Medicare certification. The supervising physicians in the clinic must be participating with Horizon.

    Documentation: Verification from Joint Commission or AAHAC regarding accreditation. A copy of the certificate of insurance displaying the period covered and the coverage amounts. Documentation of Medicaid and/or Medicare certification status. Verifications must be done within 180 calendar days prior to the credentialing/recredentialing decision.

  37. Skilled Nursing/Sub Acute/Long Term Care Facility Providers

    Requirement: State licensure by state in which facility is located, current malpractice coverage of at least $1 million per occurrence and $3 million in the aggregate, Joint Commission accreditation, and Medicaid and/or Medicare certification (see NOTE above).

    Provider must have a Health Inspections Star Rating of three or higher. If the Health Inspections Star Rating for the facility’s star rating is less than 3, the application will be referred to the Executive Medical Director, Quality and 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 or explanation from the facility is recommended prior to a credentialing determination.

    • If this ancillary provider performs any radiology/imaging services they must meet the requirements in 35 above.

    Documentation: Verification from the appropriate State Licensing Board/Agency indicating the ancillary provider has a license, the number, expiration date and any restrictions placed on its license. A copy of the certificate of insurance displaying the period covered and the coverage amounts. Verification of accreditation from Joint Commission. Documentation of Medicaid/Medicare certification status. Verifications must be done within 180 calendar days prior to the credentialing/recredentialing decision.

    Additional MLTSS Requirement: Subservice could include Respite. This subservices should have, Business Entity Information (New Jersey Tax Certification or Trade Name Registration), State of NJ Business Registration. A copy of a completed Criminal Background Attestation.

  38. Sleep Disorder Laboratories

    Requirement: State licensure by state in which facility is located, current malpractice coverage of at least $1 million per occurrence and $3 million in the aggregate, American Academy of Sleep Medicine (AASM) or JCAHO accreditation, and Medicaid and/or Medicare certification (see NOTE above).

    Documentation: Verification from the appropriate State Licensing Board/Agency indicating the ancillary provider has a license, the number, expiration date and any restrictions placed on its license. A copy of the certificate of insurance displaying the period covered and the coverage amounts. Verification from the American Academy of Sleep Medicine (AASM) or JCAHO regarding accreditation. Documentation of Medicaid and/or Medicare certification status. Verifications must be done within 180 calendar days prior to the credentialing/recredentialing decision.

  39. Social Adult Day Care Providers

    Requirement: Neither the Department of Human Services nor the Department of Law and Public Safety license Social Adult Day Care centers. However, the centers must meet all local building code requirements (this information can be found on http://www.state.nj.us/humanservices/doas/home/sadcfact.html), current malpractice, coverage of at least $1 million per occurrence and $3 million in the aggregate.

  40. Temporary Help Agencies

    MLTSS Requirements: Business License Required. Temporary Help Agency (services) License through Division of Consumer Affairs. A copy of the certificate of insurance displaying the period covered and the coverage amount of 1 million per service. A copy of a completed Criminal Background check attestation dated within 180 days prior to credentialing/recredentialing decision.

    MLTSS Documentation: A Copy of Business license. A copy of Division of Consumer Affairs License. A copy of the certificate of insurance displaying the period covered and the coverage amounts. A copy of a completed Criminal Background Attestation.

    Additional MLTSS Requirements: Subservice could include Caregiver Participant Training, Home-based Supportive Care, Cleaning or Maintenance. These subservices should have, Business Entity Information (New Jersey Tax Certification or Trade Name Registration), State of NJ Business Registration Criminal Background check attestation dated within 180 days prior to credentialing /recredentialing decision.

  41. Urgent Care Centers

    Requirement: All appropriate required State licenses by state in which facility is located, current malpractice coverage of at least $1 million per occurrence and $3 million in the aggregate, and at least one of the following: accreditation by Joint Commission on Accreditation of Healthcare Organizations (JCAHO), certification by Urgent Care Association of America (UCAOA) or completion of a site visit by Horizon BCBSNJ resulting in satisfactory scores.

    The Urgent Care Center site must meet the following standards:

    • Provider must have a licensed physician (MD/DO) on site during all posted hours of operation.
    • Provider must have a licensed physician designated as Medical Director who is responsible for overall clinical quality.
    • Provider must have a board certified Emergency Medicine physician on staff.
    • Physician Extenders employed by the Urgent Care Center, including, Advanced Practice Nurses (APN), Certified Nurse Midwives (CNM) and Physician Assistants (PA) must have collaborative management agreements with a licensed physician on the medical staff at the Urgent Care Center in accordance with the laws of the State of New Jersey and the regulations of the New Jersey State Board of Medical Examiners or other applicable Board.
    • Provider must accept walk-in patients of all ages for a broad spectrum of illness, injury and disease during hours when facility is open to see patients. Pediatric specialty centers are exempt from age requirement if pediatric-only specialization is included in the name of the center.

    The following must be available during all posted hours of operation for each Urgent Care Center site:

    • X-ray on site
    • Phlebotomy services on site
    • Licensed staff with the appropriate state license and resources to: obtain and read an EKG and x-ray on site; All x-rays to be over read by a radiologist; administer PO, IM & IV medication/fluids on site; perform minor procedures (ex. Sutures, cyst removal, incision& drainage, splinting) on site.
    • The following equipment and staff trained in its use: automated external defibrillator (AED) (or more advanced device); oxygen, ambu-bag/oral airway; drug cart stocked appropriately for patient population (as determined by the facility).
    • At least two exam rooms, separated waiting area, and restricted access patient restrooms. Minimum hours of operation for the facility (must meet all three of the following): 7 days/week (not including national holidays); 4+ hours each day; 1460 hours per year.
    • Provider must have process in place to: notify patients’ primary care physician of visit; notify patients of critical results.

    Documentation: Verification from the appropriate State Licensing Board/Agency indicating the provider has a license (where appropriate), the number, expiration date and any restrictions placed on it. A copy of the certificate of insurance displaying the period covered and the coverage amounts. Verification of accreditation from JCAHO, certification from UCAOA, or a copy of the site visit completed by Horizon. If no JCAHO or UCAOA, a copy of a satisfactorily completed Horizon Urgent Care Center Site Visit Form, which is attached hereto. Verifications must be done within 180 calendar days prior to the credentialing / recredentialing decision.

  42. Vaccine Network for Pharmacies

    Requirement: State licensure, pharmacy license to dispense in the state where the pharmacy is located and current malpractice coverage of at least $1 million per occurrence and $3 million in the aggregate.

    Documentation: Verification from the appropriate State/Federal Licensing Boards/Agencies indicating the ancillary provider has state and DEA licenses, the number, expiration date and any restrictions placed on its license. A copy of the certificate of insurance displaying the period covered and the coverage amounts.

    Please note: Medicare Advantage is excluded from participation as Medicare covers these services under its Pharmacy Benefit.

    Standing in the Medical Community Requirements

    In addition to the basic requirements described above, 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 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.

SPECIAL REQUIREMENTS FOR AMBULATORY SURGICAL CENTERS

In lieu of a state license, a surgeon or surgical practice maintaining a single ambulatory suite within their private practice offices shall submit documentation describing their compliance with the following requirements qualifying the ASC for exemption from state licensing and certificate of need requirements:

  • Only one room within the private practice offices is being utilized as an ASF, and
  • Only a physician or physicians comprising and engaged in the practice's private practice may use the ASF, either as a physician or physicians associated with the practice, partnership or professional corporation or association. No unassociated physicians are permitted access to use the ASF.
  • If this ancillary provider performs any radiology/imaging services they must meet the requirements in #19.

If these requirements are not met, the ASC does not qualify for exemption from state licensure and will not meet the credentialing standards under this Policy without obtaining and submitting proof of proper state licensure.

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

HCM-PP-CRED-003-0317