Practice Locations Limit
Administrative Policy:
Practice Locations Limit
Effective Date:
July 6, 2018
Last Revised Date:
December 15, 2020
Scope:
This policy applies to all physicians, healthcare professionals and behavioral healthcare professionals (collectively referred to as “Practitioner(s)”) who participate in the Managed Care Network, PPO Network, Braven Health Network, Horizon New Jersey Health Medicaid Network and FIDE-SNP. For the purpose of this policy, all of these Horizon entities shall be collectively defined as “Horizon BCBSNJ”. For the purpose of this policy, all of the above-referenced networks shall be defined as “Network(s)”.
Purpose:
This policy establishes guidelines for the display of practice locations in our online Doctor & Hospital Finder and printed directories to help ensure that only locations where appointments can be scheduled are shown. This policy also outlines the procedures for adding practice locations during initial credentialing and maintenance of locations and identifies when validation of practice locations is required.
Definitions:
Validation – Electronic, written, or verbal responses to questions regarding practitioner demographics including but not limited to practice locations, practice limitations, availability to see new patients, ability to schedule and treat patients at a location and knowledge about participating with Horizon BCBSNJ products.
Doctor & Hospital Finder (DHF) – Horizon BCBSNJ’s online provider directory, which lists participating doctors, other health care professionals, dentists, ancillary providers and facilities.
Practice Limitation – A service that is not performed even though that service may normally be performed by most other practices within a specialty, or, when services are only offered to a subset of patients such as students, adults or children.
Practice Location – The location in which a practitioner schedules patient appointments.
Print-on-demand Directory – Printed directory that is created at the time of the request based on the most currently available information for doctors, other health care professionals, ancillary providers and facilities.
Policy:
Horizon BCBSNJ will display up to five practice locations in the Doctor & Hospital Finder without requiring validation of each location. If the display of six or more practice locations are requested, the first five locations provided will be displayed. The remainder of practice locations will be suppressed (i.e., not displayed) until all currently displayed and suppressed practice locations have been validated by the practitioner. Exceptions may be granted if any of the practice locations requested to be displayed have a documented business need or practice limitation. Exceptions must be approved by the Director of Physician Operations and Data Management or designee.
Demographic information stored in Horizon BCBSNJ’s systems is transmitted to the Doctor & Hospital Finder daily. The practice locations that meet Horizon BCBSNJ’s business rules for display at the time of transmission will be visible and/or searchable.
The practice locations included in the annual printing of the directories are determined by the display status at the time information is accessed for printing. If a practice location is suppressed at the time information is accessed for printing and then later approved to be displayed, those locations will be included in the next annual version of the printed directory.
Print-on-demand directories will display all unsuppressed locations at the time of printing.
Procedure:
INITIAL CREDENTIALING
Horizon BCBSNJ will enter the first seven contiguous practice locations when one tax-id number included on the CAQH or Universal Application into our data management system. If the practitioner has multiple tax-id numbers, at least one location associated with each of the tax-id numbers will be displayed. Only five locations will display in the Doctor & Hospital Finder and printed directories regardless of the number of tax-id numbers the practitioner is affiliated with. The credentialing process will continue as documented in the Credentialing and Recredentialing Policy for Participating Physicians and Healthcare Professionals Policy. Electronic, written or verbal requests to display additional practice locations may be made upon acceptance into one or more networks as outlined in the Validation Section of this policy.
MAINTENANCE
Horizon BCBSNJ will update valid requests for practice locations to be displayed in the Doctor & Hospital Finder and printed directories as long as the maximum number of practice locations remains at five or fewer. Practitioners requesting to display six or more practice locations must follow the process noted in this Validation Section of this policy. Additional practice locations may be suppressed from the Doctor & Hospital Finder and printed directories until completed.
Practitioners are required to immediately notify Horizon BCBSNJ of any practice location or practice limitation changes in accordance with the Provider Directory Management Policy, which can be found in the Policies and Procedures section of the Providers Tab on the Horizon BCBSNJ web site. Practitioners may change the practice locations to be displayed or advise of practice limitations at any time by logging into CAQH. Electronic or written requests may also be accepted following current protocols for requesting changes to demographic information as long as responses to all of the eight validation questions are provided for every practice location requested to be displayed.
Practitioners that do not maintain accurate information regarding their practice locations may be subject to restriction of network participation and/or termination.
VALIDATION
All locations that are displayed in the Doctor & Hospital Finder and Printed Directories will be validated. Electronic, written or verbal validation to the questions below will be required for all locations for practitioners who request to have six or more practice locations displayed in the Doctor & Hospital Finder and printed directories. The practitioner must schedule and treat patients at each of the locations to be published. Once validation is received for all practice locations by the practitioner, the Director of Physician Operations and Data Management or designee will review and determine if the request is approved. If the request to display one or more of the practice locations is denied, the practitioner will be notified.
- What is the practitioner’s full name, including degree?
- What is the practitioner’s full address?
- What is the practice name at this location?
- What phone number should patients call to schedule appointments?
- What is the practitioner’s specialty?
- Is this practitioner scheduling and seeing existing patients at this location?
- Is the practitioner accepting new patients at this location?
- Does the practitioner have any limitations at this location (i.e. students only, hospitalist, reads/performs tests only, age restrictions, etc.)?
- Does the practitioner participate in Horizon BCBSNJ’s Medicare Network?
- Does the practitioner participate in the Managed Medicaid or FIDE-SNP Network?
SURVEY
Horizon BCBSNJ may periodically survey practitioners asking the eight (8) questions below, which may also be used by CMS in their Audit.
- Does the provider see patients at this location?
- Does the provider accept the MA-PD plan at this location?
- Does the provider accept (or not accept) new patients who have this MA-PD plan? (The provider directory is considered accurate if it correctly indicates if the provider is or is not accepting new patients)
- Is the provider a PCP, cardiologist, oncologist or ophthalmologist?
- Is the address correct?
- Is the telephone number correct? (Usually confirmed by dialing the phone number)
- Is the provider’s name correct?
- Is the practice name correct?
References:
HPMS Memo dated January 17, 2017, Provider Directory Policy Updates
HCM-PP-PDM-032-1220