Horizon Ancillary Re-credential Application

Section II: Billing Information
Ancillary Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Billing Telephone Number

Area CodePhone Number
Billing Fax Number

Area CodePhone Number
Credentialing Contact

First NameLast Name
Contact Email Address*
example@example.com
Credentialing Contact Phone Number

Area CodePhone Number

Section III: Documentation
Attach copy of w-9

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Ancillary/Organization is accredited?*

YesNo
If "Yes" which accrediting body?
Effective Date

MonthDayYear
Date
Expiration Date

MonthDayYear
Date
Attach copy of accreditation form below

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If NOT ACCREDITED, please submit a copy of a full CMS or State Audit Report, Plan of Correction and Post-Certification Revisit Report

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License Number*
Effective Date*

MonthDayYear
Date
Expiration Date*

MonthDayYear
Date
Attach copy of licensure with notice of reviews or disciplinary actions taken in the past 5 (five) years

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Type of Insurance (select all that apply)*

Professional Liability (minimums $1m occurrence/ $3m aggregate)Business Liability (minimums $1m occurrence/ $3m aggregate)Excess (Umbrella)
Policy Number*
Policy Amount ($)*
Minimum/Aggregate
Effective Date*

MonthDayYear
Date
Expiration Date*

MonthDayYear
Date
Attach Copy of Professional Liability

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Attach Copy of Business Liability

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Attach copy of CLIA

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Please find an attached copy of the Americans with Disabilities Act (ADA) Survey below. Please complete and return survey if a new service location is being reported. Upload survey below.

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Horizon ADA Survey Form
Please find an attached copy of the Ownership and Disclosure Form below. Please complete and return form below.

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Horizon Ownership and Disclosure Form

Section IV: General Disclosure Questions

Please complete the required general disclosure questions below. Incomplete disclosures may result in a delay in the re-credentialing process.
Does your organization have any pending, settled, dropped or dismissed liability cases? If “yes”, please attach an explanation of each case. Explanation must include date of incident and final outcome.*

YesNo
If you answered "Yes" to the above question please include a copy of the sanction notice(s)

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Has your organization (or any party owner or controlling 10% or more of your company) ever been subjected to or currently undergoing any of the following (Check all that apply):*

a. Government disciplinary action such as, but not limited to revocation, suspension or restriction of license or Medicare/Medicaid provider status?b. Criminal or ethical investigation or convictionsc. Bankruptcy, insolvency or assignment for the benefit or creditor proceedings?d. Medicare and/or Medicaid sanctions within the last five years?e. Received any member complaints in the past 12 months?f. None of the above
If you answered “yes” to any of the above questions, please attach a brief explanation of each incident below. Explanation must include date of the incident and the outcome.

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Languages, other than English, spoken by staff:

Section V: Affirmation of Information

Attestation
All information submitted by me on behalf of First Name* Last Name* an ancillary provider (the “provider”) is true and correct to the best of my knowledge and belief. I understand that as an authorized representative of the provider, I have the right to review the information submitted in support of the provider’s application. I understand that if any of this information is subsequently found to be false, misleading or incomplete, it could result in denial of the provider’s application or termination of participation in the Horizon Blue Cross
Blue Shield of New Jersey provider network, or any of its subsidiary or affiliate provider networks (hereafter collectively referred to as "Horizon BCBSNJ").

I understand and agree that I have the responsibility for producing adequate and accurate information for proper evaluation of the qualifications of the provider and for resolving any doubts about such qualifications. I also agree to provide information on an ongoing basis as requested and in accordance with any specific future request that is relevant to Horizon BCBSNJ's evaluation of the provider’s application, credentials or qualifications, and that this statement in its entirety shall also apply then.

I hereby authorize and consent to Horizon BCBSNJ's acquisition of information from any person or organization, as long as such acquisition is done in good faith and without malice in connection with Horizon BCBSNJ's evaluation of the provider’s application, credentials and qualifications.

I hereby release from liability Horizon BCBSNJ, its agents or designees, and any and all persons or organizations that provide information to Horizon BCBSNJ, its agents or designees, for any and all actions taken in good faith and without malice in connection with Horizon BCBSNJ's review of the provider’s application, credentials and qualifications.

I attest that to the best of my knowledge the information provided in response to the questions on the Re-credentialing Update Form have been answered correctly.
Ful Name*

First NameLast Name
Title*
Entity
Date of Signature*

MonthDayYear
Date
Sign Below*

Clear
Should be Empty:

Horizon Ancillary Re-credentialing Application

Section I: Provider Information

Section II: Billing Information

Section III: Documentation

Section IV: General Disclosure Questions

Section V: Affirmation of Information