Federally Qualified Health Center (FQHC) Resource Guide

We want to make sure you have the information you need to do business with us. This guide includes important details about enrollment, credentialing and claim submission guidelines.

Provider Enrollment/Credentialing

To join the Horizon NJ Health Network — Primary Care Physician (PCP), Specialist, Physician Extender (Nurse Practitioner) or health care professional — you will need:

  • CAQH or NJ Universal Application (less than 180 days old)
  • FQHC Credentialing Checklist (Attachment A)
    • The credentialing checklist is considered complete without a DEA, CDS and New Jersey Medicaid ID if those have not yet been obtained.
  • If not attached, automatic withdraw (not processed)
    • Signed agreement(s)
  • Group agreement (with current roster) or link letter from group authorizing link

Credentialing applications should be submitted to:

  • Horizon BCBSNJ
    3 Penn Plaza East
    Mail Station PP 14 C
    Newark, NJ 07105

During the public health emergency, credentialing applications may be submitted to the following email address: EnterprisePDM@HorizonBlue.com

Processing

It takes up to 90 days for the credentialing process to be completed. The provider’s credentialing application will be processed while the Medicaid Provider ID is pending.

If the application is incomplete, a processor will contact you a maximum of three times within 15 days. The application status will pend during this time. If the missing information is not received, the application will be withdrawn.

Once the application is complete, a provider ID will be issued to the credentialing application submitter. The effective date of the assigned provider ID will be consistent with the date of the completed application and is not based on the submission date of the credentialing application. The provider ID will enable the provider to begin to submit any claims for services that were rendered prior to the provider’s completion of credentialing.

Quantity Limits Per Coverage Year

Horizon NJ Health may limit the quantity of certain services eligible for coverage per year. A claim denied by an MCO for exceeding the benefit limit indicates that the MCO has already paid up to the quantity of services eligible for coverage per year for the NJFamilyCare/Medicaid enrollee. If the service was not previously provided by the billing FQHC, the claim will be paid. However, if the service was previously provided by the FQHC, the claim will be denied.

Claim Filing Deadlines

Horizon NJ Health must receive all claims within 180 calendar days from the initial date when services were rendered. If claims are received beyond 180 calendar days from the initial date of service, claims will be denied for untimely filing. Coordination of Benefit (COB) claims must be submitted within 60 days from the date of the primary insurer’s Explanation of Benefits (EOB) statement.

Horizon NJ Health’s Appeals Department uses specific criteria when reviewing valid proof of timely filing:

  • Member's name
  • Horizon NJ Health or Medicaid member ID number
  • Billed amount
  • Date of service
  • Billed/mailed date
  • Address where the claim form was sent (Horizon NJ Health or insurance code)
  • For EDI submissions, a 999 report indicating submission to the correct insurance code is required for consideration of timely submission

For claims submitted electronically:

  • Submit an electronic data interchange (EDI) acceptance report. This must show that Horizon NJ Health received, accepted and/or acknowledged the claim submission.

Note: A submission report alone is not considered proof of timely filing for electronic claims. It must be accompanied by an acceptance report.

  • The acceptance report must:
    1. Include the actual wording that indicates the claim was either “accepted,” “received” and/or “acknowledged.” (Abbreviations of those words are also acceptable.)
    2. Show the claim was accepted, received and/or acknowledged within the timely filing period.

Procedures for Claim Submission

Horizon NJ Health is required by state and federal regulations to capture and report specific data regarding services rendered to its members. All services rendered, including capitated encounters and fee-for-service claims, must be submitted on the CMS 1500 (HCFA1500) version 02/12 or UB-04 claims form, or via electronic submission in a HIPAA-compliant 837 or NCPDP format.

Horizon NJ Health does not accept handwritten or stamped claims. Claims forms and electronic submissions must be consistent with the instructions provided by CMS requirements, as stated in the CMS Claims Manual, available at cms.gov/Manuals/IOM/list.asp.

The hospital, physician and health care professional, to appropriately account for services rendered and to ensure timely processing of claims, must adhere to all billing requirements.

Horizon NJ Health cannot process the claims if data is missing, incomplete, invalid or coded incorrectly.

National Practitioner Identifier (NPI)

Horizon NJ Health requires all practitioners use their NPI numbers for all claim submissions. To ensure our systems properly identify you as an individual, group or facility, Horizon NJ Health requires you register the NPI with your taxonomy and tax identification numbers.

Horizon NJ Health also continues to accept the use of your provider identification numbers (legacy ID). The continued use of the legacy ID is recommended, as the claims processing system uses this number for adjudication and payment activities.

Please make sure your name matches the name used on your W-9.

Claims Disputes/Appeals

You have a right to a written appeal of disputes relating to payment of claims, as defined below. As always, Horizon NJ Health’s procedures are intended to provide our physicians and health care professionals with a prompt, fair and full investigation and resolution of claim issues.

Common Appeal Reasons

No Authorization: Authorization was provided by PCP or Horizon NJ Health prior to providing the service to the member.

Untimely Filing: Claim was filed within the required 180 days from the date of service.

Payment Discrepancy: The amount paid was inconsistent with the contracted rate or the established Horizon NJ Health fee schedule.

Member Not Enrolled: The member was enrolled in medical assistance on the date of service, as evidenced by valid source documentation.

Lack of Explanation of Benefit (EOB): Third-party liability information has been provided to show the member is not eligible for other coverage or has reached their benefit limit.

Claims Editing Discrepancy: Physician, facility or other health care practitioner disagrees with the edits applied to the claim.

Incorrect Denial: The denial code on the claim is not accurate. No physician, facility or health care professional who exercises the right to file an appeal under this procedure shall be terminated or otherwise penalized for filing and pursuing such an appeal.
When a physician, facility or health care professional is dissatisfied with a claim payment, including determinations, prompt payment or no payment made by Horizon NJ Health, he/she may file a claim appeal, as described below:
All claim appeals must be initiated on the applicable appeal application form created by the New Jersey Department of Banking and Insurance. The appeal must be received by Horizon NJ Health within 90 calendar days following receipt by the physician or health care professional of the payer’s claim determination.
To file a claim appeal, a physician or health care professional must send the appeal application form and any supporting documentation to Horizon NJ Health using one of the following methods:

Mail:
Horizon NJ Health Claim Appeals – Medicaid
PO Box 63000
Newark, NJ 07101-8064

Fax:
1-973-522-4678

Horizon NJ TotalCare (HMO D-SNP) Appeals and Grievances
PO Box 24079
Newark, NJ 07101-0406

IMPORTANT – Supporting documentation, e.g., proof of timely filing, may be submitted. Please follow all appropriate procedures as defined in the Medicaid Provider Administrative Manual before submitting an appeal.

Corrected claims should be sent to:
Horizon NJ Health
Claim Processing Department
PO Box 24078
Newark, NJ 07101-0406

These claims should not be submitted through the appeals process.

A Horizon NJ Health appeal resolution analyst will review all claim appeals. Appeals resolution analysts are personnel of Horizon NJ Health who are not responsible on a day-to-day basis for the payment of claims. The appeal resolution analyst will review all submitted documentation and confer with all necessary Horizon NJ Health departments, given the nature of the claim appeal.

A decision will be made once the resolution analyst reviews the information and provides a final written determination and notification that will be sent to the physician, facility or health care professional within 30 calendar days of the date of Horizon NJ Health’s receipt of the claim appeal request. An FQHC provider is only required to complete only the first level appeal process.

Providers can check the status of appeals by going to NaviNet.net or by calling Provider Services at 1-800-682-9091, weekdays, 8 a.m. to 5 p.m., Eastern Time.

For paper claims

  1. The submission date must be within the timely filing period.
  2. Certified mail receipts are valid proof of timely filing.
  3. Only red and white paper claims can be processed.

Other valid proof of timely filing documentation

Valid when incorrect insurance information was provided by the patient at the time the service was rendered:

  • A denial/rejection letter from another insurance carrier
  • Another insurance carrier’s explanation of benefits
  • Letter from another insurance carrier or employer group indicating coverage termination prior to the date of service of the claim
  • Letter from another insurance carrier or employer group indicating no coverage for the patient on the date of service of the claim

All of the above must include documentation that the claim is for the correct patient and the correct date of service. The date on the other carrier’s payment correspondence starts the timely filing period for submission to Horizon NJ Health. In order to be considered timely, the claim must be received by Horizon NJ Health within 60 days from the date on the other carrier’s correspondence. Not including all of the information requested will result in a rejected inquiry or a delay in response. If the claim is received after the timely filing period, it will not meet timely filing criteria.