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

EFFECTIVE DATE:
September 27, 1996

LAST REVISED DATE:
March 9, 2018

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:

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.

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

  • Adult Family Care Providers
  • Adult Medical Day Care
  • Ambulance/Medical Transport Providers
  • Ambulatory Surgical Centers
  • Assisted Living Program
  • Assisted Living Residence
  • Behavioral Health Facilities (Inpatient, Residential, Ambulatory)
  • Birthing Centers
  • Chore Services
  • Clinical Laboratories
  • Community Residential Homes
  • Comprehensive Outpatient Rehabilitation Facilities
  • Comprehensive Personal Care Home Service Providers
  • Dialysis Centers
  • Durable Medical Equipment Providers (DME)
  • Family Planning
  • FQHC
  • Healthcare Services Firms
  • Home Delivered Meals
  • Home Health/Private Duty Nursing Providers (PDN)
  • Home Infusion
  • Hospice Providers
  • Independent Diagnostic Testing Facilities (IDTF)
  • Inpatient Acute Rehabilitation Facilities
  • Medication Dispensing Device Service Providers
  • Non-Medical Transport Providers
  • Non-Traditional Service Providers
  • Outpatient Rehabilitation Providers
  • Pediatric Medical Day Care Providers
  • Personal Care Assistant Providers (PCA)
  • Personal Emergency Response Services
  • Prosthetics and Orthotics
  • Radiology/Imaging Centers including Mobile X-ray/Imaging Service Providers
  • Retail Health Clinics
  • Skilled Nursing/Sub acute/Long Term Care Facility Providers
  • Sleep Disorder Laboratories
  • Social Adult Day Care Providers
  • Specialty Pharmacy Providers
  • Temporary Help Agencies
  • Urgent Care Centers
  • Vaccine Network for Pharmacies

Horizon BCBSNJ commercial network
Ancillary/MLTSS providers that participation in Horizon BCBSNJ’s commercial network may provide care and services on an in-network basis to members enrolled in Horizon managed care plans/products (OMNIA Health Plans, Horizon Direct Access, Horizon EPO, Horizon HMO, Horizon POS, NJ DIRECT, Horizon Medicare Advantage plans) and members enrolled in Horizon PPO/Indemnity plans/products.

Horizon NJ Health network
Ancillary/MLTSS providers that participation in the Horizon NJ Health network may provide care and services on an in-network basis to members enrolled in the following plans/products/programs: Horizon NJ Health (Medicaid managed Care), NJ Family Care, Managed Long-Term Services & Supports (MLTSS) and Horizon NJ TotalCare (HMO SNP).

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

Initial Credentialing:

  1. To be considered for participation in a Horizon BCBSNJ network, an ancillary and/or MLTSS provider must:
    • Complete and submit an application (in a format approved by the Credentials Committee)
    • Provide the following supporting documentation (as applicable):
      • Licensure
      • Accreditation
      • Certification with Medicare for facilities Professional Liability Coverage
      • Business Liability Coverage
      • Dates of Health and Safety Inspections and findings
      • Ongoing State Board Monitoring or Investigations
  2. The Horizon BCBSNJ Ancillary Account Executive screens the application for completeness.
    • Complete applications are forwarded to the Physician Data Management (PDM) Department for processing and uploaded to the Ancillary SharePoint site.
  3. The Horizon BCBSNJ Physician Data Management (PDM) Department validates/verifies the supporting documentation through primary source verification.
    • If the credentialing information obtained from other sources varies substantially from the information obtained from the ancillary/MLTSS provider, the PDM staff will notify the ancillary/MLTSS provider in writing within 30 days of receipt of the application.

      The notification informs the ancillary/MLTSS provider of any discrepancies and their right to seek to have erroneous information obtained via another source corrected or to correct their own submitted information to Horizon BCBSNJ.
    • Ancillary/MLTSS providers must respond within 15 days by submitting a response and correction(s) to the PDM Department.

      If the ancillary/MLTSS provider fails to respond within the 15-day period, the application shall be considered withdrawn and the applicant shall be notified as such in writing.
  4. Applicants meeting the Standards for Participation (“clean files”) are presented for review by the Credentials Committee (or the Credentials Subcommittee) no more than ninety (90) days of our receipt of the application/required supporting documentation.

    The Credentials Committee (or Credentials Subcommittee) may:

    • Approve the applicant and the offering of a contract to the ancillary/MLTSS provider.

      Upon which execution and receipt (by Horizon BCBSNJ shall render the ancillary/MLTSS provider a participating provider.
    • Request more information and/or an interview before making a decision.

      If the Committee requires additional information, an email will be sent to the Ancillary Account Executive.The Ancillary Account Executive will request (in writing) that the ancillary/MLTSS provider provide the requested information within 15 days of the Committee's request.

      If the requested information is not received within 15 days, the application will still be presented at the next scheduled Committee meeting.
    • Find that the applicant does not meet the Standards for Participation in the network and decline the applicant.
    • Take other action as appropriate.
  5. Following the Credentials Committee meeting, a Credentialing/Recredentialing Committee Report indicating the ancillary/MLTSS status (i.e., approved or denied) is completed, copied and forwarded to the appropriate Ancillary Account Executive(s).
  6. The Ancillary Account Executive notifies the ancillary/MLTSS provider in writing of the decision of the Committee in regard to their application:
    • Applicants to Horizon NJ Health will be notified within 10 business days of the Credentials Committee’s decision.
    • All other applicants will be notified within 60 days of the Credentials Committee’s decision.

Recredentialing:

Recredentialing Frequency:
All participating ancillary/MLTSS providers shall undergo recredentialing every three (3) years.

  • An Ancillary/MLTSS provider due for recredentialing shall be deemed in compliance with the three-year cycle if the recredentialing decision is made within the month that is 36 months from the month of the previous credentialing or recredentialing decision.
  • In the event that the recredentialing application is not returned by the applicant by 30 days prior to the end of the 36 month recredentialing cycle (to the end of the 36 month recredentialing cycle for Horizon NJ Health physicians and other health care professionals), the application shall be considered withdrawn, and the applicant will be notified in writing of termination.
  1. To be considered for continued participation in a Horizon BCBSNJ network, an ancillary and/or MLTSS provider must:
    • Legibly complete and submit a recredentialing application (in a format approved by the Credentials Committee).

      If information included on the recredentialing application has not changed since the ancillary/MLTSS provider was last credentialed/recredentialed, the ancillary/MLTSS provider must attest that this is the case.
    • Provide the following supporting documentation (as applicable):
      • Licensure
      • Accreditation
      • Certification with Medicare for facilities if the hospital participates in either of these respective programs
      • Professional Liability Coverage
      • Business Liability Coverage
      • Dates of Health and Safety Inspections and findings
      • Ongoing State Board Monitoring or Investigations
        • Demonstrate they continue to meet all requirements for credentialing and the satisfaction of the requirements that are primary source verified.
        • Be judged to be a member in good standing in the network(s) in which they participate.

          Any quality information obtained through the complaint or quality case review process is included in the recredentialing file.
  2. The Physician Data Management (PDM) Department screens the recredentialing application for completeness.

    If a recredentialing application is incomplete, the ancillary/MLTSS provider shall be notified in writing of the deficiency no later than 60 days following receipt. The ancillary or MLTSS provider shall have 60 additional days to complete the application. If the 60 day period expires and the application remains incomplete, the application shall be considered withdrawn and the ancillary/MLTSS provider notified in writing.
  3. The Physician Data Management (PDM) Department validates/verifies the documentation submitted in support of the recredentialing application through primary source verification.

    In the event the recredentialing information obtained from other sources varies substantially from the information obtained by the ancillary/MLTSS provider, the ancillary/MLTSS provider will be notified in writing by the PDM Department. The ancillary/MLTSS provider shall have 15 days to submit a response. If the 15 day period expires, and the ancillary/MLTSS provider has failed to respond, the application shall be considered withdrawn and the applicant notified of termination in writing.
  4. Applicants meeting the Standards for Participation (“clean files”) are presented to the Credentials Committee. These “clean files” can also be reviewed and approved by the Credentials Subcommittee.

    If the Committee requires additional information, the ancillary/MLTSS provider will be notified of the information needed in writing and will be given 15 days to produce such information. If the requested information is not received within 15 days, the ancillary/MLTSS provider will be notified in writing that the application is considered withdrawn.
  5. Following the Credentials Committee meeting, the ancillary/MLTSS status will be advised in writing of the decision of the Committee:
    • Applicants to Horizon NJ Health will be notified within 10 business days of the Credentials Committee’s decision.
    • All other applicants will be notified within 30 days of the Credentials Committee’s decision.

ATTACHMENT A

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 (e.g., mammography facilities that are not FDA-approved) 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.

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 BCBSNJ site visit. Copies of all such site reviews must be provided to Horizon BCBSNJ 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. (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)

Verifications:
Please note that ALL verifications must have been performed no more than 180 calendar days prior to the credentialing/recredentialing decision.

Standing in the Medical Community Requirements
In addition to the following requirements, 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.

PROVIDER TYPES:
Specific Standards for Participation apply to the following Ancillary/MLTSS provider types. Click a selection below to review the 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 Copy of the:
  • Adult Family Care (AFC) Agency license
  • Health Facilities Evaluation and Licensing (HEFL) license
  • Business License
Business Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Professional Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Worker’s Compensation N/A
Accreditation N/A
Medicare Participation N/A
ADA N/A

The following additional requirements apply to Community Residential Homes, 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

return to top

Adult Medical Day Care
The following requirements apply to Adult Medical 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
  • List of any restrictions placed on the license
Business Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Professional Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Worker’s Compensation N/A
Accreditation N/A
Medicare Participation Current documentation of Medicare participation.
ADA N/A

return to top

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
  • List of any restrictions placed on the license
  • Type of transport services [i.e. Basic Life Support (BLS), Specialty Care Transport (SCT), Mobile assistance Vehicle (MAV)]
Business Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Professional Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Worker’s Compensation N/A
Accreditation N/A
Medicare Participation Current documentation of Medicare participation.
ADA N/A

return to top

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
  • List of any restrictions placed on the license
Business Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Professional Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Worker’s Compensation N/A
Accreditation Current verification of accreditation from one of the following:
  • AAAHC (Accreditation Association for Ambulatory Health Care)
  • AAAASF (American Association for Accreditation of Ambulatory Surgery Facilities)
  • The Joint Commission
Medicare Participation Current documentation of Medicare participation.
ADA ADA survey per location

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


*In lieu of a License, a surgical practice that maintains a single ambulatory surgical suite within their office may submit documentation describing their compliance with the following requirements qualifying the ambulatory surgical suite for exemption from state licensing/certificate of need requirements:

  • Only one room within the private practice offices is utilized as an ambulatory surgical suite , and
  • Only the physician or physicians comprising and engaged in the practice's private practice may use the ambulatory surgical suite, 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 ambulatory surgical suite.

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

return to top

Assisted Living Program
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 Copy of the Department of Health license indicating:
  • License number
  • License expiration date
  • List of any restrictions placed on the license
Business Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Professional Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Worker’s Compensation N/A
Accreditation N/A
Medicare Participation Current documentation of Medicare participation.
ADA 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

return to top

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 Copy of the Department of Health license indicating:
  • License number
  • License expiration date
  • List of any restrictions placed on the license
Business Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Professional Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Worker’s Compensation N/A
Accreditation N/A
Medicare Participation Current documentation of Medicare participation.
ADA 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

return to top

Behavioral Health Facilities (Inpatient Residential, Ambulatory)
The following requirements apply to Behavioral Health Facilities (Inpatient Residential, 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 State Licensing Board/Agency in which the facility operates indicating:
  • License number
  • License expiration date
  • List of any restrictions placed on the license
Business Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Professional Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the 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
Medicare Participation Current documentation of Medicare participation.
ADA ADA survey per location

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

return to top

Birthing Center
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:
  • License number
  • License expiration date
  • List of any restrictions placed on the license
Business Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Professional Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Worker’s Compensation N/A
Accreditation Accreditation/Certification by American Association of Birthing Centers (AABC)
Medicare Participation Current documentation of Medicare participation.
ADA N/A

return to top

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:
  • Business License
  • NJ Tax Certificate
Business Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy Number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Professional Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy Number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Worker’s Compensation A copy of the Worker’s Compensation Insurance certificate
Accreditation N/A
Medicare Participation N/A
ADA N/A

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

return to top

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
Business Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy Number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Professional Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy Number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Worker’s Compensation N/A
Accreditation accreditation by the College of American Pathologist (CAP)
Medicare Participation Current documentation of Medicare participation.
ADA ADA survey per location
Certification of the Clinical Laboratory Improvement Agency (CLIA) Certification from the CLIA

return to top

Community Residential Homes
The following requirements apply Community Residential Homes in regard to participation in the Horizon NJ Health Network. Community Residential Homes 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 indicating:
  • License number
  • License expiration date
  • List of any restrictions placed on the license
Business Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy Number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Professional Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy Number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Worker’s Compensation N/A
Accreditation N/A
Medicare Participation N/A
ADA N/A

The following additional requirements apply to Community Residential Homes, if the subservice Community Residential Services 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

return to top

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 State Licensing Board/Agency in which the facility operates indicating:
  • license number
  • License expiration date
  • List of any restrictions placed on the license
Business Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy Number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Professional Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy Number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Worker’s Compensation N/A
Accreditation The Joint
Medicare Participation Current documentation of Medicare participation.
ADA ADA survey per location

return to top

Comprehensive Personal Care Home Service Providers
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 Copy of the Department of Health license indicating:
  • license number
  • License expiration date
  • List of any restrictions placed on the license
Business Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy Number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Professional Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy Number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Worker’s Compensation N/A
Accreditation N/A
Medicare Participation Current documentation of Medicare participation.
ADA N/A
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

return to top

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 State Licensing Board/Agency in which the facility operates indicating:
  • License number
  • License expiration date
  • List of any restrictions placed on the license
Business Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy Number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Professional Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy Number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Worker’s Compensation N/A
Accreditation N/A
Certification of the Clinical Laboratory Improvement Agency (CLIA) Current verification of certification from the CLIA.
Medicare Participation Current documentation of Medicare participation.
ADA ADA survey per location

return to top

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
Business Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy Number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Professional Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy Number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
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)
For DME suppliers of sleep medicine devices (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:
  • Central Station Alarm Association (CSAA) certification
  • Horizon BCBSNJ Architecture Review Committee (ARC) approval
Medicare Participation Current documentation of Medicare participation.
ADA N/A

The following additional requirements apply to Durable Medical Equipment (DME) Providers if the subservices, Medication 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

return to top

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 State Licensing Board/Agency in which the facility operates indicating:
  • License number
  • License expiration date
  • List of any restrictions placed on the license
Business Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy Number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Professional Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy Number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the 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 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

return to top

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 State Licensing Board/Agency in which the facility operates indicating:
  • License number
  • License expiration date
  • List of any restrictions placed on the license
Business Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy Number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Professional Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy Number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Worker’s Compensation N/A
Accreditation N/A
Medicare Participation Current documentation of Medicare participation.
ADA 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

return to top

Healthcare 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 Copy of the Business License
Copy of Division of Consumer Affairs License
Business Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy Number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Professional Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy Number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Worker’s Compensation N/A
Accreditation N/A
Medicare Participation Current documentation of Medicare participation.
ADA 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 (dated within 180 days prior to credentialing/recredentialing decision):
  • Business Entity Information (New Jersey Tax Certification or Trade Name Registration)
  • State of NJ Business Registration

return to top

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 Copy of the Business License
Copy of DOH License
Business Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy Number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Professional Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy Number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Worker’s Compensation N/A
Accreditation N/A
Medicare Participation N/A
ADA N/A

return to top

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 State Licensing Board/Agency in which the facility operates indicating:
  • License number
  • License expiration date
  • List of any restrictions placed on the license
Business Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy Number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Professional Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy Number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the 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 Accreditation for Health Care New Jersey (CAHC)
  • The Joint Commission,
Medicare Participation N/A
ADA Current documentation of Medicare participation.
ADA N/A
Certificate of Need A copy of the certificate of need.

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
Requirement Documentation
Business Documentation A copy of the current (dated within 180 days prior to credentialing/recredentialing decision):
  • Business Entity Information (New Jersey Tax Certification or Trade Name Registration)
  • State of NJ Business Registration

return to top

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.

Please note: 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 State Licensing Board/Agency in which the facility operates indicating:
  • License number
  • License expiration date
  • List of any restrictions placed on the license
  • Copy of DEA license
  • Copy of the pharmacy license to dispense in the state where the pharmacy is located
Business Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Professional Liability A current copy of the certificate of insurance showing
  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the 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 N/A

return to top

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 State Licensing Board/Agency in which the facility operates indicating:
  • License number
  • License expiration date
  • List of any restrictions placed on the license
Business Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Professional Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the 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 N/A

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 for Radiology/Imaging Centers including Mobile X-Ray/Imaging Service Providers must also be met.

return to top

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 Verification from the State Licensing Board/Agency in which the facility operates indicating:
  • License number
  • License expiration date
  • List of any restrictions placed on the license
Professional Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Business Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Worker’s Compensation N/A
Accreditation N/A
Medicare Participation Current documentation of Medicare participation.
ADA ADA survey per location

return to top

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 State Licensing Board/Agency in which the facility operates indicating:
  • License number
  • License expiration date
  • List of any restrictions placed on the license
Business Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Professional Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the 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 ADA survey per location

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

return to top

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 Copy of the Business License
Professional Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Business Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Worker’s Compensation N/A
Accreditation N/A
Medicare Participation N/A
ADA ADA survey per location

return to top

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 Copy of the Business License
Professional Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Business Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Worker’s Compensation N/A
Accreditation N/A
Medicare Participation N/A
ADA N/A
New Jersey Business Authority Proof of New Jersey Business Authority, i.e. tax certificate or trade name registration.

return to top

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

Requirement Documentation
Licensure Copy of the Business License
Professional Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Business Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Worker’s Compensation A copy of the Worker’s Compensation Insurance certificate
Accreditation N/A
Medicare Participation N/A
ADA N/A

return to top

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

Requirement Documentation
Licensure Copy of the Business License
Professional Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Business Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Worker’s Compensation A copy of the Worker’s Compensation Insurance certificate
Accreditation N/A
Medicare Participation N/A
ADA N/A

return to top

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

Requirement Documentation
Licensure Copy of the Business License
Professional Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Business Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Worker’s Compensation A copy of the Worker’s Compensation Insurance certificate
Accreditation N/A
Medicare Participation N/A
ADA N/A

return to top

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
Business Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Professional Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Worker’s Compensation N/A
Accreditation N/A
Medicare Participation Current documentation of Medicare participation.
ADA ADA survey per location
Established Credentialing Program* Current documentation that this provider has an established credentialing program with primary source verification of all employed practitioners.

*In instances where there are multi-specialties present at a facility (physical therapist, ortho, primary care, etc.), physical therapist(s) and occupational or speech therapist(s) will be credentialed/recredentialed as individual providers. 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 for Radiology/Imaging Centers including Mobile X-Ray/Imaging Service Providers must also be met.

return to top

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 State Licensing Board/Agency in which the facility operates indicating:
  • License number
  • License expiration date
  • List of any restrictions placed on the license
Business Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Professional Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Worker’s Compensation N/A
Accreditation N/A
Medicare Participation N/A
ADA ADA survey per location

return to top

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 State Licensing Board/Agency in which the facility operates indicating:
  • License number
  • License expiration date
  • List of any restrictions placed on the license
Business Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Professional Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the 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 N/A
ADA ADA survey per location

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

return to top

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 Copy of the Business License, orBusiness entity with evidence of authority to conduct such business in New Jersey, (i.e. New Jersey Tax Certificate or Trade Name Registration).
Professional Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Business Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Worker’s Compensation N/A
Accreditation N/A
Medicare Participation N/A
ADA N/A

return to top

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: add effective date for CCX
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. 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
Business Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
Professional Liability A current copy of the certificate of insurance showing:
  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate
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 per service location

return to top

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, the Horizon Casualty Network, and/or the Horizon NJ Health Network.

Notation: eviCore handles commercial networks only. HNJH and HCS are handled by Horizon

  • 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.com or call : 1-800-918-8924 extension 20824

Requirement

Documentation

License

Verification from the State Licensing Board/Agency in which the facility operates indicating:

  • License number
  • License expiration date
  • List of any restrictions placed on the license

Staff Licensure

Current copies of licenses of all staff members (as appropriate).

Malpractice Insurance---split out to professional liability and business liability

A current copy of the certificate of insurance showing:

  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate

Accreditation/certification/license

Current verification of accreditation by the appropriate accreditation/certification/licensing agency for each modality performed.
(See below.)

Horizon BCBSNJ Site Visit
All radiology/ imaging centers must undergo a site visit by EviCore prior to approval of participation and for recredentialing.

Documentation of recent Horizon BCBSNJ site visit

Medicare participation

Current documentation of Medicare participation.

Accreditation/Certification/Licensing Agencies per Modality for Radiology/Imaging Centers

Listed below are the accreditation/certification/licensing agencies for each noted modality

Mobile imaging services must meet the standards as noted 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

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)

INTERVENTIONAL 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)

return to top

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

Business Liability

A current copy of the certificate of insurance showing:

  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate

Professional Liability

A current copy of the certificate of insurance showing:

  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the 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

ADA survey per location

return to top

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 State Licensing Board/Agency in which the facility operates indicating:

  • License number
  • License expiration date
  • List of any restrictions placed on the license

Business Liability

A current copy of the certificate of insurance showing:

  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate

Professional Liability

A current copy of the certificate of insurance showing:

  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate

Worker’s Compensation

N/A

Accreditation

Current verification of accreditation by the Joint Commission.

Medicare participation

Current documentation of Medicare participation.

ADA

ADA Survey per location

Health Inspections Star Rating of 3 or higher-Commercial networks only

Current verification of Health Inspections Star Rating.

*If the Health Inspections Star Rating is less than 3, 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.

The following additional requirements apply to Skilled Nursing/Sub Acute/Long Term Care Facility Providers for participation in the Horizon NJ Health Network if the subservice Respite 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

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

return to top

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 State Licensing Board/Agency in which the facility operates indicating:

  • License number
  • License expiration date
  • List of any restrictions placed on the license

Business Liability

A current copy of the certificate of insurance showing:

  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate

Professional Liability

A current copy of the certificate of insurance showing:

  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate

Worker’s Compensation

N/A

Accreditation

Current verification of accreditation one of the following:

  • The Joint Commission
  • American Academy of Sleep Medicine (AASM)

Medicare participation

Current documentation of Medicare participation.

ADA

ADA Survey per location

return to top

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 State Licensing Board/Agency in which the ancillary facility operates indicating:

  • License number
  • License expiration date
  • List of any restrictions placed on the license

Business Liability

A current copy of the certificate of insurance showing:

  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate

Professional Liability

A current copy of the certificate of insurance showing:

  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate

Worker’s Compensation

N/A

Accreditation

N/A

Medicare Participation

N/A

ADA

N/A

The following additional requirements apply to Community Residential Homes, 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

return to top

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 State Licensing Board/Agency in which the facility operates indicating:

  • License number
  • License expiration date
  • List of any restrictions placed on the license
  • Copy of DEA license
  • Copy of the pharmacy license to dispense in the state where the pharmacy is located

Business Liability

A current copy of the certificate of insurance showing:

  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate

Professional Liability

A current copy of the certificate of insurance showing:

  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the 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

N/A

return to top

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

  • Copy of the Business License
  • Copy of the Temporary Help Agency License through Division of Consumer Affairs

Business Liability

A current copy of the certificate of insurance showing:

  • Coverage period
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate

Professional Liability

A current copy of the certificate of insurance showing:

  • Coverage period
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate

Worker’s Compensation

N/A

Accreditation

N/A

Medicare Participation

N/A

ADA

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

return to top

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

Verification from the all State Licensing Boards/Agencies in the states in which the facility operates indicating:

  • License number(s)
  • License expiration date(s)
  • List of any restrictions placed on the license(s)

Business Liability

A current copy of the certificate of insurance showing:

  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate

Professional Liability

A current copy of the certificate of insurance showing:

  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate

Worker’s Compensation

N/A

Accreditation

Current verification of accreditation one of following:

  • The Joint Commission
  • Urgent Care Association of America (UCAOA)

OR

A copy of a satisfactorily completed Horizon Urgent Care Center Site Visit Form

Medicare Participation

Current documentation of Medicare participation.

ADA

ADA survey per location

return to top

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 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

License

Verification from the State Licensing Board/Agency in which the facility operates indicating:

  • License number
  • License expiration date
  • List of any restrictions placed on the license

Pharmacy license

Verification from the appropriate State/Federal Licensing Boards/Agencies indicating the provider has

  • License number(s)
  • License expiration date(s)
  • List of any restrictions placed on the license(s)

Malpractice Insurance

A current copy of the certificate of insurance showing:

  • Coverage period
  • Policy number
  • Coverage amount(s) of at least $1 million per occurrence and $3 million in the aggregate

Worker’s Compensation

N/A

return to top

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-003-0318