Credentialing and Recredentialing Policy for Participating Physicians and Healthcare Professionals

Administrative Policy:
Credentialing and Recredentialing Policy for Participating Physicians and Healthcare Professionals

Effective Date:
March 13, 2012

Last Revised Date:
March 31, 2017

Scope:

This policy applies to the Managed Care and PPO Networks (the "Network") as they apply to the following products: HMO, Medicare Advantage, POS, Direct Access, PPO, Managed Medicaid and Managed Workers Compensation products. These products are issued by either: Horizon Healthcare Services, Inc., (Horizon Blue Cross Blue Shield of New Jersey), Horizon Healthcare of New Jersey, Inc., or, Horizon NJ Health (hereinafter collectively “Horizon BCBSNJ”), and Horizon Casualty Services, Inc. (HCS).

Purpose:

To develop credentialing standards for identifying competent physicians and healthcare professionals who are eligible to participate in the Network.

To document a process for managing the applicants’ initial credentialing and recredentialing applications in the initial credentialing and recredentialing processes and to evaluate such applications in accordance with the Standards for Participation to develop and maintain a network of participating physicians and healthcare professionals that demonstrates Horizon’s commitment to provide access to a quality Network for its members.

Policy:

The Credentials Committee (the "Committee"), a committee of Horizon's Quality Improvement Committee, is the committee within Horizon charged with the responsibility of reviewing the physicians and healthcare professionals for initial credentialing and recredentialing in the Network. The Committee is chaired by the Executive Medical Director, Quality Management or his/her designee who provides oversight for the credentialing program. The Committee, its composition and operating procedures are described in detail in a separate policy entitled “Credentials Committee.” The Committee has final authority to approve or disapprove applicants for initial credentialing and recredentialing. The Committee evaluates all applicants for participation against the Standards for Participation in Attachment A.

The credentialing and recredentialing process of physicians and healthcare professionals does not discriminate:

  1. On the basis of race, age, religion, gender, sexual orientation, or national origin;
  1. In terms of participation, reimbursement, or indemnification, against any physician or healthcare professional who is acting within the scope of his/her license or certification under state law solely on the basis of the license or certification; and
  1. Against any physician or healthcare professional who serves high-risk populations or who specializes in the treatment of costly conditions. This paragraph pertains to physicians treating Medicare Advantage members. The prohibition does not preclude any of the following actions by a Medicare Advantage organization:
  • Refusal to grant participation to health care professionals in excess of the number necessary to meet the needs of the plans enrollees.
  • Use of different reimbursement amounts for different specialties or for different practitioners in the same specialty.
  • Implementation of measures designed to maintain quality and control costs consistent with its responsibilities.

Note: This paragraph pertains to physicians and healthcare professionals participating in the Medicare Advantage product.

  1. Horizon's procedure for monitoring and preventing discriminatory practices include the following:
  • Credentials Committee members are required to sign annually a conflict of interest/confidentiality/anti-discrimination agreement “Confidentiality and nondisclosure statement.
  • Horizon BCBSNJ monitors to assure that discrimination practices do not occur and investigates every complaint alleging provider discrimination. The Credentialing Department reports semi-annually to the Credentials Committee the number of provider complaints made to Horizon BCBSNJ alleging provider discrimination.

Procedure:

  1. INITIAL CREDENTIALING
    NOTE: Confidential information obtained in the credentialing and recredentialing process shall be used and disclosed in accordance with Horizon's policies or as otherwise required by law.
  1. A completed application for participation in the Network, in a format approved by the Credentials Committee or the New Jersey Universal Physician Application should be submitted and meet these basic requirements:
  • -The application must be complete, legible, signed and dated.
  • -The application must be signed and dated within 180 days prior to the credentialing decision.
  • -A signed credentials verification release form must be submitted.
  • -All required supporting documentation must be attached
  1. The application includes notification to the physician or healthcare professional of their right to review the information submitted in support of their credentialing application. Upon request, the physician or healthcare professional has the right to be informed of the status of their credentialing application.
  1. The application is screened for completeness by the Physician Data Management (PDM) Department. The applicant shall be notified in writing the application is complete no later than 45 days following receipt. In the event that a credentialing application is incomplete, the applicant shall be notified in writing of the deficiency no later than 45 days following receipt. He/she shall have 45 additional days to complete the application. If the 45-day period expires and the application remains incomplete, the application shall be considered withdrawn and the applicant so notified in writing effective January 1, 2014.
  1. The documentation submitted or obtained in support of the credentialing process is validated and verified through primary sources as indicated in Attachment A.

    Medicare Participation:
    Physicians and healthcare professionals who have opted out of Medicare may not participate in the Horizon Managed Care Network. Therefore, the validation and verification process includes the review of the Medicare Opt-out list. The Medicare Opt-out list must be reviewed using the current local Medicare Part B Carrier website. This must be done to determine whether the physician or healthcare professional has chosen to opt-out of the Medicare program. The Medicare Opt-out list must be checked at the time of initial credentialing and quarterly thereafter. Results will be reported to the Credentials Committee. Physicians and healthcare professionals who have opted out of Medicare may not be credentialed for that line of business nor can he/she prescribe to Medicare Advantage members.
  1. If the credentialing information obtained from other sources varies substantially from the information obtained from the physician or healthcare professional, the physician or healthcare professional will be notified in writing by the PDM Department. The notification will inform the physician or healthcare professional that he/she has the right to respond to the information submitted by another party or to correct his/her own information that was submitted incorrectly, as applicable. The physician or healthcare professional shall have 15 days to submit his/her response and/or correction(s) to the PDM Department.  If the 15-day period expires and the physician or healthcare professional has failed to respond, the application shall be considered withdrawn and the applicant so notified in writing.
  1. After the primary source verification process is completed, the PDM Department will review any files that appear not to meet one or more of the Standards For Participation (Appendix A) This includes, but is not limited to, files of physicians and healthcare professionals with actions on their licenses or professional liability cases exceeding the thresholds adopted by the Credentials Committee. PDM will request additional information as warranted, and prepare a summary of the issue for Committee review. The Executive Medical Director for Quality Management or his/her designee and other medical directors may review files if there are clinical questions. Any files determined to meet the Standards after review will be returned to the Credentialing Department for inclusion with the “clean files.”

    In order to ensure accuracy of all collected information, PDM will conduct peer review  on all files prior to the Credentials Committee Meeting.
  1. Once the application is complete, the applicant is presented to and reviewed by the Credentials Committee. Applicants meeting the Standards For Participation (“clean files”) are presented on a spreadsheet. These “clean files” can also be reviewed and approved by the chair of Credentials Committee in conjunction with three (3) standing voting members through a “clean files meeting”. Applicants requiring a more detailed review are presented individually to the Credentials Committee with supporting information pertaining to the review. In an effort to expeditiously approve applicants who meet Horizon’s standards, prior to the next scheduled Credentials Committee meeting, a review of completed initial credentialing applications that meet the Standards For Participation (Attachment A) may occur. See the policy entitled “Credentials Committee” for further details.

    Review and decisions on applicants shall be made no later than 90 days from receipt of a completed application. Applicants will be advised in writing within no more than 30 days of the Credentials Committee's decision as set forth in Section H below effective January 1, 2014. Applicants may request the status of their application during the process. Horizon NJ Health applicants will be notified in writing within 10 business days of the Credentials Committee’s decision.
  1. The Committee may:
  • Approve the application for participation in the network and the offering of a participating provider contract to the applicant, which upon execution and receipt by Horizon shall render the applicant a participating physician or healthcare professional.
  • Request more information and/or an interview before making a decision.
  • Find that the applicant does not meet the Standards For Participation in the Network and decline the applicant.
  • Take other action as may be required.
     
  • All applicants approved for participation in the Network shall be informed at the time of contracting, and at each renewal thereof, of the policy that Horizon follows with respect to the removal of a physician or healthcare professional from the Networks. (See Physician and Health Care Professional Counseling and Termination Policy for: a. Professional Competency and, b. Administrative Matters)
  1. In the event that the Credentials Committee, in its review, requires additional information, the applicant will be notified of the information needed in writing within 15 days of the Credentials Committee's request for such information. The applicant will be given 15 days to produce such information. If the required information is not received within 15 days of the request and the PDM staff has reached out to the applicant for the information or documentation with no success, the applicant will be presented at the next scheduled Credentials Committee meeting.
  1. If a new application is received from a physician or healthcare professional whose application for initial credentialing was previously denied because they did not meet the Standards For Participation, it will not be reviewed by the Credentials Committee if the applicant still does not meet the Standards For Participation. This applicant’s new application will be considered incomplete. It shall be withdrawn and the applicant will be notified in writing that they cannot reapply until they meet the Standards For Participation.

    An applicant for initial credentialing whose application has been withdrawn due to the fact that they did not respond to a request for information or submission of a document, may reapply at any time.
  1. Following the Credentials Committee meeting, a report must be generated and forwarded to Network Operations listing all approved physicians or healthcare professionals. Information for the paper directory and the on-line directory is pulled from the credentialing database, including education, training, certification, and specialty. There is a quality process in place to ensure the accuracy of credentialing data included in the directory.
  1. RECREDENTIALING
    NOTE: Confidential information obtained during the recredentialing process shall be used and disclosed in accordance with Horizon's privacy policies or otherwise required by law.
  1. Frequency: All participating physicians and healthcare professionals shall undergo recredentialing every three years. Horizon and Horizon NJ Health physicians and other healthcare professionals due for recredentialing shall be deemed in compliance with the three-year cycle requirement if the recredentialing decision is made by the month that is 36 months from the month of the prior credentialing decision. An early off-cycle recredentialing review may be performed for physicians and healthcare professionals who have had a quality of care issue with a severity rating of two, as determined by the Quality Case Review Committee, since the last credentialing event. Horizon also reserves the right to perform an early off-cycle recredentialing review of a physician or healthcare professional if requested by the Credentials Committee or if requested by an adhoc appeal hearing committee.
  1. Standard: In order to be recredentialed, each physician or healthcare professional shall submit a completed, legible, recredentialing application in an approved format. The physician or healthcare professional must attest as to whether the information provided has changed since the last credentialing event. The physician or healthcare professional shall demonstrate that he/she continues to meet all requirements for credentialing, and the satisfaction of the requirements are primary source verified as outlined in Attachment A.

    In addition, the physician or healthcare professional must be judged to be a member in good standing in the Network.

    Standing in the Network shall be determined by a review of the physician's or healthcare professional's compliance with Horizon policies and procedures.

    The physician's or other healthcare professional's file shall include an attestation of the accuracy and completeness of the performance information verification signed by the Credentialing Coordinator responsible for the file.
  1. A completed recredentialing application, in an approved format, which includes notification to the physician or healthcare professional of their right to review information submitted in support of their recredentialing application, must be submitted and meet these basic review requirements:
  • The updated form must be complete, legible, signed and dated.
  • The application must be signed and dated within 180 days prior to recredentialing decision.
  • A signed credentials verification release form must be submitted.
  • All required supporting documentation must be attached.
  1. In the event that the recredentialing application is not returned by the applicant at least 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 shall be notified in writing of the termination.
  1. The recredentialing application is screened for completeness by the PDM Department. In the event that a recredentialing application is incomplete, the applicant shall be notified in writing of the deficiency no later than 60 days following receipt. He/she shall have60 days to complete the application. If the 60 day period expires and the application remains incomplete, the application shall be considered withdrawn and the applicant so notified in writing of his/her termination.
  1. The documentation submitted in support of the recredentialing application is validated and verified through primary sources as indicated in Attachment A.
  1. Medicare Participation physicians and healthcare professionals who have opted out of Medicare may not participate in the Horizon Managed Care Network. Therefore, the validation and verification process includes the review of the Medicare Opt-out list. The Medicare Opt-out list must be reviewed using the current local Medicare Part B Carrier website. This must be done to determine whether the physician or healthcare professional has chosen to opt-out of the Medicare program. The Medicare Opt-out list must be checked quarterly. Results will be reported to the Credentials Committee. Physicians and healthcare professionals who have opted out of Medicare may not be recredentialed for that line of business nor can he/she prescribe to Medicare Advantage members
  1. At the time of recredentialing the following performance indicators are monitored: quality of care and administrative complaints, and fraud events. The complaints report must include data from the entire 36 month recredentialing period. The performance indicators are submitted to the Credentialing Department by Quality Management and Executive & Regulatory Complaints Departments. Fraud data is obtained through the review of the Special Investigations fraud database. All indicators are documented in the PNO system.
  1. In the event the recredentialing information obtained from other sources varies substantially from the information obtained from the applicant, the applicant will be notified in writing by the PDM. The notification will inform the applicant that he/she has the right to respond to the information submitted by another party or to correct his/her own information that was submitted incorrectly. The applicant shall have 15 days to submit his/her response and correction(s) to the PDM Department. If the 15-day period expires, and the physician or healthcare professional has failed to respond, the application shall be considered withdrawn and the applicant notified of termination in writing.
  1. After the primary source verification process is completed, the PDM Department will review any files that appear not to meet one or more of the Standards For Participation (Appendix A). This includes, but is not limited to, files of physicians and healthcare professionals with actions on their licenses or professional liability cases exceeding the thresholds adopted by the Credentials Committee. PDM will request additional information as warranted, and prepare a summary of the issue for Committee review. The Executive Medical Director for Quality Management or his/her designee and other medical directors may review files if there are clinical questions. Any files determined to meet the Standards after review will be returned to the Credentialing Department for inclusion with the remaining “clean files.”
  1. The applicant is presented to and reviewed by the Credentials Committee. Applicants meeting the Standards For Participation (“clean files”) are presented on a spreadsheet. These “clean files” can also be reviewed and approved by the chair of Credentials Committee in conjunction with three (3) standing voting members through a “clean files meeting”. Applicants requiring more detailed review are presented with the supporting information. See the Credentials Committee policy for further details.
  1. The Committee may:
  • Approve the application for recredentialing.
  • Request more information and/or an interview before making a decision.
  • Find that the applicant does not meet the Standards For Participation and/or other requirements set forth herein and terminate the applicant’s participation agreement and the applicant from the applicable network.
  • Take other action as may be required.
  1. In the event that the Credentials Committee, in its review, requires additional information, the applicant 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 applicant will be presented at the next scheduled Credential Committee meeting.
  1. Applicants will be advised in writing of the decision of the Committee on their application for recredentialing within 30 days of the decision. Horizon NJ Health applicants will be notified in writing within 10 business days of the Credentials Committee’s decision.
  1. A physician or healthcare professional whose application has been terminated for not meeting the Standards for Participation cannot reapply until they meet the Standards For Participation.
  1. An applicant whose application has been terminated due to incomplete information may re-apply at any time. Also refer to section 2E.
  1. DISCUSSION BETWEEN RECREDENTIALING CYCLES
    A participating physician or healthcare professional may be brought to the Credentials Committee for discussion even though it may not be their time for recredentialing, if the PDM Department or any other source determines that there is a question as to whether the participating physician or healthcare professional continues to meet the Standards For Participation.
  1. DELEGATED GROUPS (see Delegation of Credentialing/Recredentialing Policy)
  1. The Credentials Committee may delegate all or certain portions of the credentialing and recredentialing processes to another entity pursuant to the terms of a written agreement, provided however, that the right to formally approve credentialing and recredentialing of physicians and healthcare professionals as well as the right to suspend and/or terminate physicians and healthcare professionals be retained by the Horizon BCBSNJ Credentials Committee.
  2. The Credentials Committee, through its Delegated Credentialing/Recredentialing Policy maintains the responsibility to oversee any such delegated credentialing activity through periodic audits of the credentialing process, Committee minutes and reports.
  3. Groups to whom credentialing responsibility has been delegated must adhere to the same standards outlined in Attachment A, agree to periodic audits and provide corrective action plans as necessary.
  4. Prior to delegation a site visit is conducted, including review of policies and procedures and a credentialing file review. The Credentials Committee must approve any delegated arrangement. Monitoring occurs as per the Delegate and Vendor Oversight Policy. This includes a yearly credentialing file review.
  5. Quality information maintained by Horizon will be included in the recredentialing information submitted to the Credentials Committee for physicians and healthcare professionals in the delegated groups.

ATTACHMENT A

STANDARDS FOR PARTICIPATION

  1. Applicability:
    These standards shall apply to all applicants, regardless of race, age, religion, sex or national origin. The standards outlined below shall apply to all applicants in the following categories, and shall be available for review by all applicants upon request:
  1. Acupuncturists
  2. Advanced Practice Nurses (APNs) formerly known as Certified Nurse Practitioners (CNPs)
  3. Anesthesiologists
  4. Applied Behavioral Analyst (ABA)
  5. Audiologists
  6. Behavioral Healthcare Professionals
  7. Certified Nurse Midwives (CNM's)
  8. Certified Registered Nurse Anesthetists (CRNA’s)
  9. Chiropractors (DC’s)
  10. Occupational Therapists (OT’s)
  11. Optometrists (OD’s)
  12. Oral Surgeons (DDS’s & DMD’s)
  13. Physical Therapists (PT’s)
  14. Physicians (MD’s & DO’s)
  15. Physicians Assistants (PA’s)
  16. Physical Therapists (PT’s)
  17. Podiatrists (DPM’s)
  18. Registered Dieticians (RD)
  19. Registered Nurse First Assistants
  20. Speech Pathologists

Note: Physicians and healthcare professionals shall only be approved for credentialing and recredentialing in the area of practice for which they are applying if they have supporting documentation indicating that they have completed a residency in that area of practice.

Exception: Physicians or healthcare professionals who are full time employees of a network participating hospital (including pediatric specialists), who do not maintain private practices and are routinely assigned to service patients without being selected by members are not subject to this policy, unless such physicians and healthcare professionals may be selected by members or are listed as participating physicians and healthcare professionals in literature provided to members.

If physicians or healthcare professionals who fall under the exception also maintain solo practices or work in a group practice or an outpatient ambulatory surgicenter, they must apply for credentialing and recredentialing in accordance with this policy to participate in those alternate settings.

Those physicians or healthcare professionals who are referred to as Locum Tenens, will not be credentialed.

Applicants must meet the standards listed below and documentation of their satisfaction of the requirements must be primary source verified as detailed below.

B.    Standards:
Applicants must meet the standards listed below and documentation of their satisfaction of the requirements must be primary source verified as detailed below.

  1. License
    Requirement: The physician or healthcare professional must possess a current, unrestricted license and/or certification needed to meet the minimal requirements in clinical practice in the State of New Jersey and/or in such other state as applicable to the applicant’s care of Horizon members.

    Documentation: Verification from the appropriate State Board indicating that the physician or healthcare professional has a license, including a number, expiration date and any restrictions placed on it. Verification must be within 180 calendar days prior to the credentialing/recredentialing decision, and the license must be active at the time of the credentialing/recredentialing decision.
  1. DEA certification
    Requirement: The physician (MD, DO) or healthcare professional as applicable (DPM, DMD, DDS, APN who prescribes CDS) must possess a current, unrestricted certificate from the Drug Enforcement Agency (DEA) in the State of New Jersey and/or in such other State as applicable to the applicant’s care of Horizon members. If a qualified practitioner does not have a valid DEA certificate, the organization notes in the credentialing file and the practitioner must arrange for another practitioner to fill prescriptions.

    NOTE: This requirement is waived for radiologists and pathologists and other healthcare professional specialties identified by Horizon whose practice does not require that they prescribe controlled substances, provided there is no history of loss, restriction, suspension or denial of such a certificate for cause.

    Documentation: Verification from the Drug Enforcement Agency or copy of the DEA certification indicating that the physician or healthcare professional has a certificate, including a number, expiration date and any restrictions placed on it. DEA certificate must be active at the time of the credentialing/recredentialing decision.
  1. CDS certification
    Requirement: The physician (MD, DO) or healthcare professional as applicable (DPM, DMD, DDS, APN who prescribes CDS) must possess a current, unrestricted New Jersey Controlled Dangerous Substances (CDS) certificate. If a qualified practitioner does not have a valid CDS certificate, the organization notes in the credentialing file and the practitioner must arrange for another practitioner to fill prescriptions. NOTE: This requirement is waived for radiologists and pathologists and other healthcare professional specialties identified by Horizon whose practice does not require that they prescribe controlled substances, provided there is no history of loss, restriction, suspension or denial of such a certificate for cause.

    Documentation: Verification from the Controlled Dangerous Substances Agency indicating that the physician or healthcare professional has a certificate, a number, expiration date and any restrictions placed on it. CDS certificate must be active at the time of the credentialing/recredentialing decision.
  1. Board certification status
    Requirement: The physician or healthcare professional, as applicable, must meet one of the following requirements:
     
  1. The physician or healthcare professional must currently be board certified in a specialty recognized by one of the following:
  • The American Association of Nurse Practitioners (CNP),,
  • The American Association of Pediatric Nurse Practitioners (CNP) or the National Commission on Certification for Physician Assistants (PA),
  • The American Board of Medical Specialties (MD’s, DO’s),
  • The American Board of Oral and Maxillofacial Surgery (DMD, DDS)
  • The American Board of Podiatric Orthopedics and Primary Medicine (DPM),
  • The American Certification of Nurse Midwives (CNM),
  • The American Nurses Credentialing Center (ANCC),
  • The American Osteopathic Association (DO), the American Board of Podiatric Surgery (DPM)
  • The American Osteopathic Board of Neurology and Psychiatry
  • The Behavioral Analyst Certification Board (BACB),
  • The National Board of Certification & Recertification for Nurse Anesthetists (CRNA)
  • The National Certification Board of Pediatric Nurse Practitioners (CNP)
  1. The physician or healthcare professional must be eligible to sit for board certification and be within five years of the completion of his/her formal training, or
  1. The physician or healthcare professional may be eligible for inclusion in the provider network without board certification or eligibility for board certification when there is a recognized network need (as set forth in the criteria developed pursuant to section 15 of the Standards hereafter) for physicians or healthcare professionals of that specialty in a geographic area and the physician or healthcare professional has completed an approved residency program or
  1. For Advanced Practice Nurses, CRNA's and Nurse Midwives, BCBSNJ will confirm their certifications through confirmation of nurse licensure.
  1. The physician or healthcare professional may be eligible for inclusion in the provider network without board certification or eligibility for board certification when they are joining a group that has board certified participating physicians or healthcare professionals in > 2 to 1 ratio to those who are not board certified, including the applicant. This ratio is to be met by specialty. For the purpose of counting board certified members of a group practice, all those physicians and healthcare professionals who are board certified should be counted. For example, if a group of urologists has 12 physicians, 8 participating and board certified and 4 participating and non-board certified, adding another non-board certified urologist would not meet the Standards of Participation since the ratio of board certified urologists to non-board certified urologists would be less than the acceptable ratio. As another example, if a mixed group of 12 physicians and healthcare professionals has 2 board certified APNs, 2 board certified pediatricians 2 board certified internists and 2 board certified OB/GYNs and the remaining providers are not board certified, the ratio of board certified physicians and healthcare professionals to non-board certified physicians and healthcare professionals would be satisfied (2:1) within each specialty.
  1. For recredentialing, if the physician or healthcare professional is not board certified, the physician or healthcare professional may meet network participation requirements  if one or more of the following is met:
  • Seven (7) or more years of practice in the local medical community and a letter of recommendation from the Chairperson of one of the hospitals in which he/she practices that includes information about the physician or healthcare professional’s performance;
  • Teaching in a medical school program within the past ten (10) years;
  • Chairperson of a hospital department or section within the past five (5) years;
  • The physician or healthcare professional has provided documentation proving that he or she has initiated the process of retaking the boards (for example application, any prerequisite courses and clinical requirements);
  • Two or more notable publications in respected peer-reviewed medical journals within the past ten (10) years;
  • Volunteer clinical activities serving underprivileged populations within the past 5 years and a written recommendation from the medical director of the program addressing the physician’s responsibilities and performance; or
  • Previously credentialed for network need and meets all other credentialing criteria.
  • The Physician or Healthcare Professional was initially credentialed before July 1, 2012, and at the time, was not board certified.
  1. Board certification is not applicable for acupuncturists.
  1. Physicians or healthcare professionals (i.e.- physical therapist, social workers) who are not board certified must be able to provide proof of the highest level of education they have completed (initial credentialing only). Highest level of education is to include fellowship in the specialty being credentialed or residency, as applicable.

Documentation: Verification of board certification from one of the organizations listed in Section 4 (a) of Attachment A through certi-facts or from a Specialty Board. Verification must be obtained within 180 calendar days prior to the credentialing or recredentialing decision. For physicians or healthcare professionals who are not board certified, verification from the appropriate residency program, medical/professional school, or the AMA/AOA Physician Profile is required.

  1. Verification of the Highest Level of Education and Training (Initial Credentialing)
    Requirement: The physician or healthcare professional must indicate the highest of the following three levels of education completed:
  1. Graduation from medical or professional school,
  2. Residency, if appropriate. Fellowship is not acceptable for verification of residency.
  3. Board certification, if appropriate

Documentation: Verification from school or other organization through certificates, hard copy from certifying organization, or a specialty board website approved by Horizon. For physicians or healthcare professionals who are not board certified, verification from the appropriate residency program, medical/professional school, or the AMA or AOA Physician Profile. Horizon BCBSNJ verifies with the NJ Board of Medical Examiners annually that they verify education for each licensed practitioner and maintains a copy of the correspondence within the Credentialing Department

  1. Professional liability coverage
    Requirement: The physician or healthcare professional must possess current professional liability insurance, with minimum coverage of $1 million/$3 million and customary retentions and deductibles for physicians and healthcare professionals.  Such coverage shall be provided by a carrier authorized to write such policies in the State of New Jersey or the state in which the practice(s) are located if other than New Jersey.

    Note: In instances where Pennsylvania physicians and healthcare professionals participate in the Medical Care Availability and Reductions of Error Fund (MCARE), which is a state subsidized liability coverage of $0.5 million/$1.5million, Horizon will apply the MCARE amount to the amount of coverage that the physicians and healthcare professionals also carry in determining whether the physicians and healthcare professionals meets the professional liability coverage standard.

    Documentation: A copy of the certificate of insurance or the attested to Professional Liability Insurance section of the application, displaying the period covered and the coverage amounts. Verification of coverage must be obtained within 180 calendar days prior to the credentialing/recredentialing decision.
  1. Professional liability history
    Requirement: Physicians or healthcare professionals who exceed the following threshold number of liability claims, open and closed, settlements and verdicts during the past five years shall be reviewed by the Credentials Committee. A Medical Director may review the file prior to presentation to the Credentials Committee. This review shall include a review of the severity of any claim or action. In addition, the credentialing staff may forward any file for a Medical Director review when there is a history of malpractice claims not exceeding the threshold levels set forth below, but there are one or more large verdicts or settlements (>$1,000,000) or facts of the claims suggest a quality of care issue. When there is a history of malpractice claims, whether exceeding the levels set forth below, or not, the Committee reserves the right to determine whether such history is indicative of a current or continuing quality of care matter that precludes credentialing or recredentialing.

Specialty

Threshold number of cases

Primary Care

3

Specialists

5

Other Healthcare Professionals

3

Documentation: History is obtained from the applicant and verified by query of the National Practitioner Data Bank. Verification must be within 180 days of the credentialing/recredentialing decision.

  1. Work History
    Requirement: For initial credentialing, the physician or healthcare professional must supply, at a minimum, five years of work history showing no unjustified gaps greater than six months. Participating physicians and healthcare professionals, may not take a planned leave of absence without reasonable notification to Horizon BCBSNJ. When a leave of absence must be taken on short notice, proper notice to Horizon BCBSNJ must be given as soon as reasonably possible.

Documentation: The work history section of the application or a copy of the curriculum vitae for initial credentialing is required. If there is a gap in the work history greater than six months, the physician or healthcare professional must provide a letter of explanation.  For participating physicians and healthcare professionals, a letter is required from the physician or healthcare professional when a leave of absence from practice is planned or as soon as reasonably possible when a leave of absence must be taken on short notice.

  1. Participating Horizon Physician Collaboration Requirement specific to certain categories of healthcare professionals as described
    Requirement: The Certified Nurse Midwife (CNM), Advanced Practice Nurse (APN), Certified Registered Nurse Anesthetist (CRNA) and Physician Assistant (PA) shall have an established, consultative, collaborative management and referral relationship with an appropriate Horizon participating physician 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.

Documentation:

  1. A statement from the CNM, APN or PA that indicates the participating physician with whom the CNM, APN or PA has an established collaborative management and referral relationship.
  2. A statement from the participating physician with whom the CNM, APN, CRNA or PA is attesting to be working with, that verifies to Horizon’s satisfaction, that the CNM, APN, CRNA or PA meets this requirement.

The statement must be dated within 180 days of the credentialing/recredentialing decision.

Exception: Advanced Practice Nurse (APN) specializing in Behavioral Health secures a collaborative practice agreement only for prescribing nurses.

  1. Scope of Practice requirements specific to certain categories of healthcare professionals.

Requirement:

  1. The CNM, APN CRNA or PA may perform procedures reviewed and approved by the New Jersey State Board of Medical Examiners or other applicable Board. In addition, procedures performed must be within the training and experience of the CNM, APN CRNA or PA, in accordance with his/her agreement with the participating physician and the applicable requirements of the network hospital and/or network birthing center.

    An advanced practice nurse means a person who holds a certification in accordance with section 8 or 9 of P.L. 1991, c.377 (C.45:11-47 or 45:11-48) The title “Nurse Practitioner,” Clinical Nurse Specialist,” or “Nurse Practitioner/Clinical Nurse Specialist” means the same as Advanced Practice Nurse (APN). However, effective November 1, 1999, the certification title became Advanced Practice Nurse. APN's may perform tasks, order medications or devices, and issue prescriptions, as permitted by the New Jersey State Board of Nursing pursuant to N.J.S.A. 45:11-49.

    APN’s certified by the State Board of Nursing pursuant to N.J.S.A. 45:11-45 et. seq. in advanced practice categories comparable to family practice, internal medicine, general practice, obstetrics and gynecology or pediatrics, and working in hospitals or other facilities, may serve as primary care providers.

    Accordingly, those APN’s certified in the following categories pursuant to N.J.A.C. 13:37-7.11 may serve as primary care providers: Adult Health, Family, Pediatric, Women’s Health, OB/GYN, Maternal/Child and Medical Surgical. Proof of such certification is required for credentialing and re-credentialing.

    Advanced Practice Nurses and Certified Registered Nurse Anesthetists must have a collaborative agreement with a participating physician. Must have completed requirements to become an APN or CRNA.
  1. Acupuncturists must practice within the scope of requirements established pursuant to N.J.S.A. 45:2C-1 et seq. (The Acupuncture Act”).

  2. A Certified Registered Nurse Anesthetist (CRNA) who wishes to continue to practice anesthesia after June 16, 2009 is required to have been certified as an Advanced Practice Nurse (APN) by that date, according to N.J.A.C. 13:37-7, adopted effective June 16, 2008. CRNAs with a Master's Degree in Nurse Anesthesia may apply to be certified as an APN any time before June 16, 2009. Those applying after this date must have graduated within two years of application. CRNAs who are not prepared at the Master's level are permitted to apply for APN certification under an alternative certification process, but, under N.J.A.C. 13:37-7, this process is available only to June 16, 2009.
  1. Educational/Clinical Experience requirements specific to certain categories of healthcare professionals

    Requirements:

The Certified Nurse Midwife must have successfully completed and graduated from an educational program in Nurse Midwifery accredited by or with pre-accreditation status from the Division of Accreditation from the ACNM.

The CRNA must have successfully completed and graduated from an approved educational program that is approved by the New Jersey Board of Nursing or the Board in the state in which they practice, and be eligible for certification within the state as a CRNA or within the state in which the healthcare professional practices. Graduation with a minimum of a master’s degree from a nurse anesthesia educational program accredited by the Council on Accreditation of Nurse Anesthesia Educational Programs (COA).

The Advanced Practice Nurse must have successfully completed and graduated from an approved educational program that is approved by the New Jersey Board of Nursing or the Board in the state in which they practice and (for New Jersey programs) includes pharmacology, and be eligible for certification within the state as an APN or within the state in which the healthcare professional practices.

The Physician Assistant must have successfully completed an educational program for Physician Assistants, which is approved by the Committee on Allied Health Education and Accreditation or its successor.

The CNM, APN and PA must complete continuing education credits in accordance with the guidelines of their credentialing bodies.

The Acupuncturist (non-physician) must have a baccalaureate degree and have successfully completed a board approved two-year course of study or a board approved two-year program in a school of acupuncture.

The Registered Nurse First Assistant must receive training as a surgical assistant and be credentialed by the credentialing committee of a hospital or surgical center.

The Chiropractor in order to provide dietary or nutritional counseling must successfully complete a course of study concerning human nutrition consisting of not less than 45 hours from a college or university accredited by a regional or national accrediting agency recognized by the US Department of Education and by the State Board of Chiropractic Examiners.

Speech, Occupational and Physical Therapists:
Requirement: All Physical, Occupational and Speech Therapists must have a Master's degree or higher from a graduate school with a specialty of Physical, Occupational and Speech Therapy Psychologists must hold a license, doctoral degree from a regionally accredited university or professional school and have completed a supervised clinical experience.

Documentation: Documentation of education shall consist of signed attestation of work history via application or CV.

Certified Behavior Analyst:
Requirements: Master's degree or higher from a graduate school with a specialty of behavior analysis, psychology, special education or related field

A minimum of 12 credit hours of graduate level course work in behavioral analysis; courses must have focus on application of behavior analysis, rather than more generic topics in the discipline for which the graduate degree was awarded. The courses should address the following issues in applied behavior analysis: family dynamics, ethical considerations, definition and characteristics, principles, processes and concepts; behavioral assessment and the selection of intervention strategies and outcomes; experimental evaluation of interventions; measurement of behavior and displaying/interpreting behavioral data; behavioral change procedures and systems support (Adapted from the Behavior Analyst Certification Board)

A minimum of six months full-time supervised employment (or internship/Practicum in behavior analysis under the supervision of a behavior analysis) certified as a Behavioral Analyst (BCBA) by the Behavior Analyst Certification Board.

State Licensed to practice at the highest level of independent practice in the state where practice is to occur (if applicable). Clinical Social Workers must hold a master’s degree or doctoral degree in Social Work from a school accredited by the Council on Social Work Education and have had two years post master’s degree experience of at least 3000 hours of direct client contact.

Verification of license is performed through the appropriate NJ licensing board and education verified through the highest level of education.

Documentation: Confirmation from the educational institution and the accrediting agency. Documentation has no verification time limit once verified.

  1. Standing in the Medical Community
    Requirement: The physician or healthcare professional must be judged to be in good standing in the medical community as evidenced by:
  • No history of active or stayed reclassification, suspension, revocation or restriction of licensure, DEA or CDS within the past three years;
  • No history of any disciplinary action taken against the physician or healthcare professional by a hospital, managed care or other similar organization, or any State or Federal agency in the past three years. No history of any disciplinary action in progress within the past three years, even if it was related to a disciplinary action taken prior to the past three year period. Disciplinary actions include, but are not limited to, voluntarily and involuntarily submitting to censure, reprimand, non-routine supervision, non-routine admissions review or monitoring, remedial education or training or probation.
  • No history of arrest, criminal conviction, guilty plea or participation in a pretrial intervention program or Board action related to these actions in the past three years;
  • Not currently under investigation for clinical or administrative matters related to their professional practice or recently arrested as a result of an investigation related to clinical or administrative matters (i.e. arrest as a result of an investigation related to alleged inappropriate issuance of prescriptions for narcotics); and
  • No evidence of inappropriate utilization, administrative or billing practices related to managed care and/or non-managed care patients.

Documentation: Copies of:

  • The National Practitioner Data Bank report
  • HIPDB
  • Reports from the NJ State Board of Medical Examiners or other State board as applicable
  • The Office of Inspector General (OIG) Website or System for Award Management (SAM)
  • Information from State Attorney General or any law enforcement agency
  • New Jersey Treasury Website or System for Award Management (SAM)
  • American medical Association (AMA)

Verification from primary sources must be obtained within 180 days prior to the credentialing/recredentialing decision.

NOTE: When there is history of any of the above, the Credentials Committee reserves the right to determine whether such matters are indicative of a current or continuing quality of care matter or other issue that precludes approval of credentialing.

The Committee reserves the right to review disciplinary actions, arrests, convictions, guilty pleas and pre-trial intervention program participation that are not related to patient care.

Special rules for physicians practicing within a group practice setting:

The above Standing in the Medical Community requirements shall be equally applicable to physician group practices and may be applied collectively to the entire group, where appropriate. Horizon's Quality Management and Care Management Department periodically evaluates the collective practice of participating physicians practicing in a group practice setting (i.e., more than three physicians at a single location). In conducting these evaluations, the group's practice may be qualitatively and quantitatively evaluated in various areas, including but not limited to, HEDIS performance, measurement of quality of outcomes, utilization patterns and practices, and compliance with Horizon and industry standard administrative and billing requirements. In the event that a given group practice's performance materially varies from the acceptable standards of group practice that Horizon shall determine and establish by its observation and identification of group practice norms, Horizon may take action under its Counseling and Termination Policy. If despite efforts to improve performance the group fails after a reasonable opportunity to achieve improvement, the Committee may determine that the group practice no longer meets an acceptable level of Standing in the Medical Community, and all participating physicians practicing within such group shall be deemed to be noncompliant with these credentialing Standards For Participation shall be terminated from the network.

  1. Network Hospital Privileges
    Requirement: The physician or healthcare professional as applicable (including Oral Surgeons ) must have unrestricted, active (i.e., other than courtesy or consulting) privileges in good standing with at least one network hospital and be an active member of that hospital’s medical staff. Information provided by Physicians or Healthcare Professional, as applicable on Credentialing/Recredentialing application with attestation of hospital privileges will be acceptable or a letter will be requested from the hospital confirming that the physician or healthcare professional has privileges. Providers treating in a contiguous county outside of New Jersey must have privileges in a participating hospital or Blue Card hospital.

    Anesthesia/Pain Management Physicians utilizing Freestanding Ambulatory Surgical Care Centers (ASC) must maintain privileges with at least one network ASC.

    Notwithstanding the above hospital privileges requirement, Radiologists, Anesthesiologists, Pathologists, Dermatologists, Dermapathologists, Allergists, Immunologists, Physiatrists/Physical Medicine and Rehabilitation, Podiatrists, Chiropractors, Ophthalmologists and Psychiatrists, whose practices are restricted as follows:

  • The area of specialty, practice pattern and concentration is such that the likelihood of the need for hospitalization of patients is extremely remote;
  • With respect to anesthesiologists, anesthesia services are provided at Ambulatory Surgical Centers;
  • The scope of services performed are diagnostic or therapeutic procedures on non-acute patients in free standing facilities (non-acute care hospitals) such that the likelihood of the need for hospitalization of patients is extremely remote; or.
  • Physicians providing telemonitoring services including but not limited to surgical monitoring services during neurosurgical or orthopedic surgical procedures for a neuro-surgeon or orthopedic surgeon do not required hospital privileges.

Physicians and Healthcare Professionals credentialed before July 1, 2012 who are required to have unrestricted, active (e.g. other than courtesy or consulting) Network hospital admitting privileges and are lacking such privileges will be required to obtain such privileges at a Network hospital prior to their next recredentialing date, if that date is greater than 270 days from July 1, 2012. If the recredentialing date is less than 270 days from July 1, 2012, then the Physician or Healthcare Professional will not be required to have Network hospital privileges for that recredentialing date. They will, however, be required to have such privileges for future recredentialing dates.

  1. Continuity of Care Coverage Agreement

Notwithstanding the above hospital privileges requirement, primary care physicians (General Practitioners, Family Practitioners, Pediatricians, Internal Medicine and Preventive Medicine Physicians and Specialists) who elect to limit their practices to providing services in their offices may make arrangements with another qualified and participating acute care physician or physicians who will care for their patients requiring acute care at a network hospital and provide Horizon with an acceptable, written Continuity of Care Coverage Agreement (CCCA) as described below. The CCCA Report is reviewed by Horizon's Credentials Committee, and all files are accessible for Committee review.

Documentation: Documentation of hospital privileges shall consist of a current, signed attestation by the physician or healthcare professional regarding the status of hospital privileges and any history of loss or limitation of privileges or disciplinary activity.

Documentation of an acceptable CCCA must include:

  • Valid coverage agreement with an active, network participating physician or physicians’ group, with active privileges at a network hospital in the geographic area of the referring physician, that provides that the referring physician's Horizon patients will be admitted and followed by the covering physician(s) at that network hospital.
  • Information indicating that the covering physician(s) is a network participating provider of the same or similar specialty capable of assuming responsibility for care of the same types of clinical conditions and the complications arising from those conditions, as the physician for whom they are covering.
  • Written confirmation that participating hospital privileges exist for the covering physician.
  • That the covering arrangement assures continuity of care for patients admitted for the referring physician by the covering physician(s) on a 24 hour/7 days a week basis.
  • That the covering physician and the referring physician have signed the agreement*
  • That Horizon must be notified immediately of any material change in the agreement
  • That if the covering physician arrangement is changed, the amendment to the agreement is signed by the referring physician and the new covering physician.

In addition to the documentation requirements set forth above, all applicants shall complete and comply with any forms or other procedural requirements used or adopted by the Credentials Committee relating to this Section 12 requirement.

*Horizon approved Hospitalists shall not be required to execute a CCCA since they sign documentation with Horizon indicating which physicians they have made covering arrangements with. In such cases, the referring physician also executes a form indicating their participation in the hospitalist program, but typically maintain their hospital privileges.

  1. Hospital Terminations
    In the event of a hospital termination, specialty physicians who only have privileges at the terminating hospital will be permitted to secure an acceptable CCCA with another participating, covering physician in the same specialty for the purpose of covering and admitting members to a participating hospital. The physician will have six months from the effective date of the hospital termination to obtain full, admitting privileges at a participating hospital.
  1. Network Need
    Requirement: There is a business need in the local network for a physician or healthcare professional in the applicant’s specialty as set forth in the business standards as determined by the Credentials Committee or the Quality Improvement Committee with respect to this requirement. Such standards shall be business line and network specific and shall be revised from time to time by the Credentials Committee or Quality Improvement Committee consistent with Horizon's membership needs and business objectives.

    In order to serve the needs of Horizon members, individual exceptions will be considered by the Executive Medical Director or Quality Management and/or the Credentials Committee after all other criteria are deemed met through peer review, consistent with the exception documentation. Any such exceptions granted are to be documented, with a copy of the documentation kept in the physician's or healthcare professional's file, and reported to the Credentials Committee.

    Documentation: Analysis of the physician’s or healthcare professional’s specialty, geographic location, hospital affiliation and the membership to be served in that location meets business standards as defined by the Quality Improvement Committee or the Credentials Committee.
  1. Practice Site
    Requirement: The physician or healthcare professional must maintain a practice site and provide Horizon with the address at which the physician or healthcare professional will deliver/delivers health care services to covered persons and the telephone number(s) at which the applicant may be reached. The practice site must be either in the State of New Jersey or in a contiguous county in a state bordering New Jersey. A physician or healthcare professional who takes a leave of absence without giving timely notification to Horizon shall be considered as not having a practice site during their period of leave. Physicians or healthcare professionals must have a plan to ensure covered persons with access to emergent/urgent care services whenever their offices are closed. Home visit physicians or healthcare professionals who do not also see patients in an office setting are exempt from the practice site requirements. Anesthesiologists who are credentialed by a hospital to practice in that setting who do not also have independent practices, but who periodically provide anesthesia services in a dental practice participating in the Horizon NJ Health Network to HNJH dental members, are exempt from the practice site requirements.
  1. Participation in Medicare
    Requirement: Physicians and healthcare professionals must participate in Medicare to participate in the Horizon Managed Care Network.

    Documentation: The Medicare Opt-out list must be reviewed as indicated in the initial credentialing and recredentialing sections of this policy to determine whether the applicant for credentialing or recredentialing participates in Medicare.
  1. Exceptions: Required Procedures
    Individual requests for exceptions to the Standards For Participation, on a case by case basis must be made in writing to the Executive Medical Director Quality Management. 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, a provider affairs representative, a delegate of Horizon or an affiliated organization of Horizon may recommend to the Executive Medical Director Quality Management that a request for an exception be granted provided that such requests include the compelling reason(s) for the exception and all other relevant information, necessary documentation and the completed application.

    The Executive Medical Director Quality Management or designee shall 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.

    The Credentials Committee also has the right to determine that a pended case be granted an exception to the Standards For Participation when the Credentials Committee reviews a case at a Credentials Committee meeting and determines that such is appropriate for the particular matter.
  1. Other Exceptions Prohibited
    Except as specifically set forth above, no exceptions may be made to the Standards For Participation.
  1. Value Options standard list of Behavioral Health Provider types eligible credentialing in New Jersey (excluding Horizon NJ Health)

Process/Policy Focus

Value Options Process for Behavioral Health Providers Under Full Delegation from Horizon

Provider Correspondence

  • Will use Value Options standard appeal language in both credentialing and re-credentialing provider letters
  • Will use the specifically designated legal entity name for each Horizon network

Provider Types

Will use Value Options standard list of behavioral health providers eligible for credentialing in NJ

Medicare Participation & Medicare Opt Out

OMPTs (Other Master-Level Prepared Behavioral Health Therapists) will be exempt from requirement to participate in Medicare

Nurse Collaborative Agreement

Value Options secures a collaborative practice agreement only for CNM, APN’s, and PA

Hospital Admitting Privileges

Behavioral Health MDs and DOs will be exempt from having hospital admitting privileges

1m/3m Malpractice Insurance Requirement

Value Options will not credential any provider who does not maintain the 1m/3m insurance requirement

Board Certification

Value Options requires board certification except in instances where member need and/or geographic access prevails

References:

NCQA - Current Standards and Guidelines for the Accreditation of HP

CMS 42 C.F.R.422.204 (b)

CMS 42 C.F.R. 422.205

NJAC 11:24-3.5 Provider Contract Terminations

NJAC 11:24-3.9 Provider Application for Participation and the Review Panel

NJAC 11:24A-4.7 Provider Application for Participation

 

HCM-PP-CRED-001-1016