Blue Cross Blue Shield Credentialing Services in New Jersey

To provide credentialing requirements for identifying qualified physicians and healthcare professionals who can join in the Network.

To establish and maintain a community of participating doctors and healthcare professionals that reflects Horizon’s dedication to provide accessibility to the initial credentialing and re-credentialing procedures and to assess such requests in accordance with international Specifications for Participation.

Our experts will immediately help you get credentials

We will review your educational history, career experience, credentials, and registration to practice in the healthcare industry during the credentialing process. Throughout the credentialing process, we will monitor your progress to determine your education, training, credentials, and registration to practice in a health care setting. We will examine all of your documents to ensure that you have been certified by one of the world’s most prominent healthcare providers. As a team, we are devoted to long-term growth. We will help you obtain the services you desire. This is how we show our appreciation to our customers and demonstrate our commitment to providing great customer service.

Policy:

The Credentials Commission (the “Committee”), a group of Horizon’s Quality Improvement Committee, is the Horizon council in charge of examining physicians and healthcare professionals for initial and re-credentialing in the Network. The Executive Medical Director, Quality Management, or his/her designee, chairs the Committee, which oversees the credentialing programme. A separate policy named “Credentials Committee” describes the Committee, its makeup, and operational processes in detail. The Panel has final approval or disapproval authority over candidates for first credentialing and re-credentialing. All applicants for participation are evaluated by the Committee in accordance with the Standards for Participating in Attachment A.

• The procedure of credentialing and re-credentialing physicians and healthcare professionals is nondiscriminatory:

• Because of their race, age, religion, gender, sexual orientation, or country origin;

• In participation, compensation, or compensation, against any medical or healthcare professional acting fully within the boundaries of his or her license or qualification under state law; and

• Against any physician or healthcare practitioner who works with high-risk groups or specializes in the treatment of expensive disorders. This section applies to doctors that handle Medicare Advantage patients. The ban does not stop a Medicare Advantage company from engaging in any of the following activities.

Procedure:

Initial Credentialing
Confidential information received throughout the credentialing and re-credentialing process must be utilized and released in line with Horizon’s rules or as legally required.

A completed application for Network participation in a version authorized by the Credentials Council or the New Jersey Universal Physician Application must be completed and must meet the following minimum criteria:

• The form must be filled out completely, legibly, signed, and dated.

• The proposal must be signed and dated within 180 days of the decision on credentialing.

• It is necessary to submit a completed credentials verification release form.

• All necessary supporting documentation must be included.

The application contains notice to the physician or healthcare professional that they have the opportunity to examine the information supplied in support of their credentialing application. The physician or healthcare professional has the right to know of the progress of their credentialing applications upon request.

The Physician Data Management (PDM) Department reviews the application for validity.

If applying to the Managed Care Network and/or the PPO Network, the applicant must be notified in writing that their application is complete within 45 days of receipt. If a credentialing application is incomplete, the applicant must be advised in writing of the insufficiency no later than 45 days after receipt, with a due date for receipt of additional information provided. If that deadline passes and the application remains incomplete, it will be deemed withdrawn and the applicant will be notified in writing. All applications must be examined by the Credentials Committee or withdrawn within 90 days after receipt.

If submitting to the Medicaid Network solely, or the Medicaid and DSNP Network, the applicant must be informed in advance if the procedure is approved within 60 days of receipt. If a credentialed application is insufficient, the applicant must be advised in writing of the insufficiency no later than 60 days after receipt, with a due date for receipt of extra information provided. If that deadline expires and the application remains unfinished, it will be deemed withdrawn, and the applicant will be notified in writing. All applications must be examined by the Credential Council or withdrawn within 90 days after receipt.

No later than 90 days after receipt of a completed application, applicants will be reviewed and conclusions made. Applicants will be notified in writing within 30 days after the Credentials Committee’s decision, as detailed in Section H below, with effect on January 1, 2014. Applicants may inquire about the status of their application at any time during the process. Horizon NJ Health applicants will be notified in writing of the Credentials Committee’s decision within 10 business days.

The Committee may:

• Approve the application for network participation and provide the applicant a participating provider contract, which, following completion and receipt by Horizon, will make the applicant a participating physician or healthcare professional.

• Before making a decision, request further information and/or an interview.

• Determine that the applicant does not meet the Network Participation Standards and deny the applicant.

• Take any additional actions that may be required.

• All applicants approved for Network participation shall be advised of Horizon’s policy regarding the removal of a physician or healthcare professional from the Networks at the time of contracting and at each renewal thereof. (For a. Professional Competency and b. Administrative Matters, see Physician and Health Care Professional Counseling and Termination Policy.)

• If the Credentials Committee requires further information during its evaluation, the applicant will be notified in writing within 15 days of the Credentials Committee’s request for such material. The applicant will have 15 days to provide this information. If the requested information is not received within 15 days of the request, and the PDM staff has attempted to contact the applicant for the information or documentation without success, the applicant will be presented at the next scheduled Credentials Committee meeting.

• An applicant for initial credentialing who has had their application withdrawn because they did not respond to a request for information or provide a document may reapply at any time.

• Following the Credentials Committee meeting, a report detailing all approved physicians or healthcare professionals must be created and delivered to Network Operations. The credentialing database is used to pull information for the paper directory and the online directory, such as education, training, certification, and specialty. A quality control method is in place to assure the accuracy of the credentialing data in the directory.

Re-credentialing

A completed re-credentialing application in an approved format must be submitted, together with notification to the physician or healthcare professional of their right to examine information submitted in support of their re-credentialing application, and must meet the following basic review requirements:

• The amended form must be completely filled out, legibly signed, and dated.

• The application must be signed and dated within 180 days of the decision on re-credentialing.

• It is necessary to submit a signed credentials verification release form.

• All necessary supporting documentation must be included.

BlueCross BlueShield of New Jersey Phone Number

Call at 1-833-876-3825 number to furnish your queries as soon as possible.

BlueCross BlueShield of New Jersey Email Address

Send us an email for your answering the questions Thomas_Vincz@horizonblue.com

BlueCross BlueShield of New Jersey Enrollment Form