Compliance with Horizon BCBSNJ’s
credentialing and recredentialing standards is an ongoing contractual responsibility of all participating physicians and other health care professionals. Participating physicians and other health care professionals are also under a continuing contractual obligation to correct any previously provided credentialing
information that is, or becomes, inaccurate. Participating physicians and other health care professionals are also required to report any changes in their credentialing information, including, for example, any disciplinary action by the applicable licensing authority, any criminal conviction and the pendency of any investigation for matters related to their professional practice.
Physicians and other health care professionals who fail, at any time, to meet any of the
standards, as determined by our Credentialing Committee, are subject to loss or restriction of network participation and termination of their Agreement.
Participating physicians and other health care professionals are subject to loss or restriction of network participation and termination of their contract if (among other circumstances): • They are subject to disciplinary action,
including, but not limited to, voluntarily and involuntarily submission to censure,
reprimand, nonroutine supervision,
nonroutine admissions review, monitoring or remedial education or training;
• Their license, accreditation or certification is restricted, conditioned, reclassified, suspended or revoked, whether active or stayed, and whether by the applicable authority, or any federal or state agency, or any hospital, managed care organization or similar entity;
• They are the subject of an investigation for matters related to their professional practice; or
• They are convicted of a criminal offense.
Recredentialing Process
As required by New Jersey state guidelines and accreditation bodies, all practitioners must be recredentialed every 36 months. Our
recredentialing process begins approximately six months prior to the recredentialing date. Physicians and other health care professionals who fail to provide the necessary information in a timely manner are subject to termination of their Agreement.
We work with Medversant, a leader in technology solutions for the management of health care provider information, to help us carry out our recredentialing process, broadly outlined as follows:
• Six months prior to your recredentialing due date, Medversant begins the recredentialing process by searching for current information on the Council for Affordable Quality
Healthcare’s (CAQH) online Universal Provider Datasource®´´´´´(UPD). If your
information is up to date on the UPD, the recredentialing process will continue. • If information is either not on the UPD, or
not updated on the UPD, Medversant will reach out to you by telephone, fax and mail to request that you provide updated and/or missing information.
• If Medversant does not receive a response, Horizon BCBSNJ will mail two requests to your office. Horizon BCBSNJ’s first letter will be mailed 60 days before the
recredentialing cycle ends. The final request will be sent via certified mail, 30 days before the recredentialing cycle ends.
• If Medversant does not receive a response from these multiple attempts, you will be terminated from Horizon BCBSNJ’s networks at the end of that month. No additional requests will be sent and no information will be accepted after the first of that month. If you have questions, please call Medversant at 1-800-508-5799.
Recredentialing Vehicles
There are two ways to carry out your
recredentialing responsibilities with Horizon BCBSNJ.
Universal Provider Datasource We encourage you to use the Universal Provider Datasource (UPD) to carry out your credentialing and recredentialing
responsibilities with us.
Visit www.caqh.organd click Universal
Provider Datasource to access this valuable
resource.
If you’re already registered with CAQH: • Review and/or update your information. • Reattest that your information is true,
accurate and complete.
If you’re not registered with CAQH: • Contact your Professional Relations
Representative and request a CAQH
Registration Request Form.
• Complete the information on the CAQH
Registration Request Form and return it to
your Professional Relations Representative. • Your Professional Relations Representative
will provide you with a CAQH number that allows you to access and complete a CAQH online application.
• Visit www.caqh.organd click Logging in for
the first time?
• Complete an online application (ensure that you select Horizon BCBSNJ so that we can access your information) and then attest that the information provided is true, accurate and complete.
New Jersey Universal Recredentialing Application Form
If you are unable to use the UPD, please complete a copy of the NJ Physician
Recredentialing Application Form. This form is
available on the New Jersey Department of Banking and Insurance website at
<www.state.nj.us/dobi/mccred.htm>. Hard copy recredentialing information and required source documents may be submitted to
Medversant at:
Medversant
355 S. Grand Ave, Suite 1700 Los Angeles, CA 90071
You may also submit information to
Medversant by fax at 1-877-303-4080or by e-mail at <[email protected]>. Recredentialing Tips
To ensure that the recredentialing process runs smoothly for you, please confirm that:
• All questions are answered.
• All information and required source documents are current and included (for example, your proof of malpractice insurance – the item most frequently missing or expired, your Federal Drug Enforcement Agency [DEA] certificate, your Controlled Dangerous Substance [CDS] certificate, etc.). • Information on the application matches the
information on your source documents. • Your Attestation has not expired.