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
    • 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 If the missing information is not received, the application will be withdrawn.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.

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 form.

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 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.

Tikka Attach

Federally Qualified Health Center (FQHC)
Resource Guide Appendix
Attachment A (Credentialing Checklist)

FQHC Information:

Name of FQHC:
Billing Address of FQHC:
Billing Phone Number (with area code):
Fax (with area code):
Name and Site Addresses of Provider:

FQHC Contact Staff Person (Medical):

Name:
Phone Number (with area code):
Fax (with area code):
Email Address:
Alternate Contact Name:
Alternate Phone Number (with area code):
Fax (with area code):
Email Address:

FQHC Contact Staff Person (Dental):

Name:
Phone Number (with area code):
Fax (with area code):
Email Address:
Alternate Contact Name:
Alternate Phone Number (with area code):
Fax (with area code):
Email Address:



Date of Completed Application Submission:
This tool has been developed to assist the FCHCs with the NJ Medicaid MCO provider/
practitioner credentialing process. Please complete the checklist below and ensure that
all applicable information is included. A package with missing or inaccurate applicable
information constitutes an incomplete application and may result in delays in processing.

1. Completion of current MCO application(s): q Aetna q Amerigroup q Horizon NJ Health
q United Healthcare Community Plan q Wellcare

2. Items submitted to the Council for Affordable Quality Healthcare (CAQH) may be submitted
by providing the applicable CAQH ID. If an FQHC does not utilize CAQH, or the provider?s
CAQH profile is incomplete or out-of-date, it must provide these items in an alternative
manner, made available by the MCO.

a. Current attestation

b. National Provider Identification Number (NPI)

c. Medicare Number

d. Tax ID

e. Specialties

f. Taxonomy Code(s)

g. Patient ages seen

h. Languages spoken

i. Provider Office Hours

j. Any revocation or suspension of a state license or Drug Enforcement Administration/
Bureau of Narcotics and Dangerous Drugs (DEA/BNDD) number. Any ?yes? answer
requires explanation.

k. Any sanctions imposed by Medicare and/or any Medicaid program (e.g. suspensions,
debarment, or recovery action). Any ?yes? answer requires explanation.

l. Any censure by any state or county medical association. Any ?yes? answer requires
explanation.

m. Any revocations, suspensions, or denials of hospital clinical privileges and/or other
affiliations (includes restrictions, denied renewals, and other disciplinary/ probationary
action). Any ?yes? answer requires explanation.

n. Application includes statements from the practitioner regarding fitness to perform
function, such as physical and mental health problems, history of chemical
dependency/ substance abuse, history of loss of license and/or felony convictions,
history of loss and/or limitation of hospital privileges or disciplinary action.

o. CLIA (Laboratory Services).

3. q Copy of NJ State medical license.
4. q Valid Drug Enforcement Adminstation (DEA), as applicable, with the NJ office in which the

provider is practicing.



5. q Valid NJ Controlled Dangerous Substance (CDS) certificate, as applicable.
6. q Proof of federal torts coverage (i.e. the ?Deeming letter?) or current adequate malpractice

insurance ? copy of malpractice insurance certificate face sheet. Minimum of $1 million dollars
and $3 million dollars aggregate is required.

7. If requested, previous five (5) years of malpractice claims or settlements from the malpractice
carrier. Include explanations of any gaps in coverage (including being a new provider with no
history of malpractice insurance).

8. q Agreement(s) signed manually or electronically by the Provider, if required by the MCO.
9. q Curriculum Vitae, including addenda explaining gaps in employment of six (6) months or longer.
10. q Board Certification, or documentation showing that the applicant is within 5 years of

completing training, or when the applicant is scheduled to take the test for board certification.
1Pursuant to the Settlement Agreement, the credentialing checklist is considered complete without
a DEA, CDS, and New Jersey Medicaid ID if those have not yet been obtained by the provider. See
Settlement Agreement, at Section 7. The provider will send the Medicaid application concurrently
with the MCO credentialing application. Once they are obtained by the provider, it will promptly
report that information to the MCO and Medicaid fee-for-service.

11. q Hospital Admitting Privileges , as reflected by either:
a. letter from Medical Office Staff or Department Chairman of the network hospital in which

the applicant has admitting privileges stating that the applicant has full, active, unrestricted
clinical privileges and is in good standing; or

b. Evidence of an acceptable coverage arrangement at a network hospital if the practitioner?s
scope of practice does not include hospital privileges.

12. q Educational Commission for Foreign Medical Graduates (ECFMG) Certificate for foreign-born
foreign medical school graduates, if applicable.

13. q W-9 Form.
14. q Site specific Americans with Disabilities Act (ADA) provider survey.
15. q Special Needs survey/ Aged, Blind, and Disable (ABD) form.
16. q Collaboration Practice Agreement (Nurse Midwife/ Nurse Practitioner).
17. For Physician Assistants & Nurse Practitioners:

a. q Name of certifying entity. (E.g., American Academy of Nurse Practitioners; National
Commission on Certifcation of Physician Assistants; etc.).

b. q Certification number.
18. Healthstart certification, if applicable.



19. Proof of 21st Century Cures Act Compliance: (The 21st Century Cures Act requires all Medicaid
Managed Care and Children?s Health Insurance Program network providers to be enrolled with
State Medicaid programs)

a. q NJ Medicaid ID or,
b. q Documentation from NJ Medicaid Fiscal Agent of successful ?21st Century provider?

registration or,

c. q Proof of NJ State FFS application submission including date of submission.
Note: Provider must successfully complete NJ FFS enrollment or 21st Century provider registration
in order to participate with a MCO

20. q NJ CBC Attestation Form (Criminal Background Check).
21. q Disclosure of Ownership and Control Interest Statement.
22. q Explanation Statement for Missing Info:

1 Please include all hospitals where provider is privileged.



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