Credentialing Frequently Asked Questions
Credentialing is required for all practitioners affiliated with an office based practice to participate in our networks and prior to treating Horizon members. We follow industry standards for credentialing and recredentialing of health care professionals. Credentialing standards are set by the National Committee on Quality Assurance (NCQA) and state and federal regulations.
We work with the Council for Affordable Quality Healthcare (CAQH) to collect the credentialing and recredentialing application data, and with a Credentialing Verification Organization to verify required elements of the credentialing application and process.
If you have questions about our credentialing process, please call Horizon BCBSNJ at 1-800-624-1110 or call Horizon NJ Health at 1-800-682-9091 between 8 a.m. and 5 p.m. Eastern Time, Monday through Friday.
Below are answers to questions you may have about credentialing to participate in the Horizon BCBSNJ and/or Horizon NJ Health network(s).
This content was last revised on April 23, 2021 and may be subject to change.
CREDENTIALING AND RECREDENTIALING BASICS
Q1. What is credentialing?
A1. Credentialing assesses qualifications, relevant training, licensure, certification and/or registration to practice for each practitioner who participates in Horizon’s network(s).
Q2. When must I be credentialed?
A2. Credentialing occurs before a practitioner is considered eligible to participate in Horizon’s network(s).
Horizon conducts recredentialing of all participating practitioners three years after an initial credentialing date (and at three-year intervals thereafter) to verify that a practitioner’s professional qualifications remain valid and current.
Q3. Who sets the credentialing standards and criteria that Horizon uses?
A3. Our credentialing standards are set by the National Committee on Quality Assurance (NCQA), and state and federal regulations. Horizon BCBSNJ’s credentialing process complies with these standards.
Q4. What information do I need to provide to complete Horizon’s credentialing process?
A4. You can use our Application Checklists/forms to determine which information is required to apply for participation in our network(s).
- Physician Application Checklist
- Other Health Care Professional Application Checklist
- Hospital-Based Practitioners
- Telemedicine-Only Practitioner Application Checklist
Please ensure that all documentation is current and valid.
Q5. Why does NaviNet need my email information?
A5. Horizon BCBSNJ Email Share allows NaviNet to share your email address with Horizon BCBSNJ. Your email will be used solely to facilitate communication between your organization and Horizon BCBSNJ. Horizon BCBSNJ values your privacy and will not sell or license your email address to its agents, affiliates, or subsidiaries. Note that new email addresses or changes to existing email addresses will not be reflected in NaviNet.
It is recommended that you also provide email addresses on your credentialing application. You can update your practice’s/facility’s email addresses as well as other demographic information, using our online Provider Data Maintenance tool. Sharing your email address with Horizon will not impact your email status with NaviNet.
Q6. I completed the Horizon BCBSNJ Email Share information on NaviNet but still can’t access the Agreements online. What can I do?
A6. If after completing the Horizon BCBSNJ Email Share information, you still cannot access our Agreements online, please email a request for the appropriate Agreement(s) to EnterprisePDM@HorizonBlue.com.
Q7. What are my rights in credentialing?
A7. Practitioners applying to participate in a Horizon network have the following rights regarding the credentialing process:
- To review the information submitted to support your credentialing application
- To correct erroneous information
- To be informed of your credentialing or recredentialing application status, upon request
Q8. Can a practitioner use CAQH ProView™ to make credentialing information accessible to Horizon?
A8. We encourage you to use CAQH’s provider data-collection service, CAQH ProView to make the majority of required information available to us.
If you don’t already have a CAQH ProView profile, please self-register to obtain your unique CAQH provider ID number. Please ensure that you grant Horizon access to your information on CAQH and that you have recently attested that this information is current and complete.
Q9. How long does the Horizon BCBSNJ credentialing process take?
A9. Please allow 90 days from the date that we receive all required information for us to complete the credentialing process.
The time for the entire process depends upon the application upon receipt. Applications that include all required documentation that is current and signed when applicable will process faster. Primary source verification is performed on each application and then presented to our Credentials Committee for a final review. You will receive written notification of the Committee’s determination.
We will notify you if there are missing elements from your application. Documentation must be provided by the stated deadline or the application will be withdrawn and a new one must be submitted.
Q10. How do I check the status of a credentialing application?
A10. If you have not received a written response about your Application after 90 days, you may call 1-800-624-1110 for the status of Horizon BCBSNJ Applications or call 1-800-682-9091 for the status of Horizon NJ Health Applications.
Q11. Once my application is approved, what are the next steps?
A11. Once your application has been approved by the Horizon BCBSNJ Credentialing Committee, we will send a letter that includes:
- Your participation effective date
- Instructions to access a Welcome Kit of important information
- Copies of your fully executed Agreement(s)
Q12. What if my application is not approved?
A12. Horizon BCBSNJ will notify you in writing if your credentialing application is not approved.
Q13. How often will I be recredentialed?
A13. Recredentialing is required at least every three years by the NCQA and state and federal regulatory organizations. If recredentialing is not completed, you will not be eligible to continue to participate in Horizon BCBSNJ networks.
Q14. How do I complete recredentialing with Horizon BCBSNJ?
A14. You must attest to all the data in your CAQH every 120 days and maintain a complete and current application. Horizon BCBSNJ retrieves your information from CAQH ProView to perform the recredentialing process. If CAQH is not up to date, Horizon BCBSNJ’s Credentialing Verification Organization will contact you for additional information and/or ask you to submit a paper application.
Q15. Is there anything that might delay recredentialing?
A15. It is important your CAQH ProView is complete and that you attest every 120 days to keep the application and information current. In some instances, additional documentation such as a current Statement of Collaboration or Continuity of Care Coverage Arrangement may need to be completed. Horizon BCBSNJ’s Credentialing Verification Organization will contact you if additional information is needed.
Q16. How do I update my demographic information?
A16. Review our information on how to initiate demographic updates for details about submitting requests to update your demographic information.