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Thank you for your interest in Horizon NJ Health Manage Care Network. Enclosed is an application and
information for your review and competition. Please use this check list as a guide during this process.

Provider Name: _____________________________________________ Applying as: ?PCP and/or ?Specialist
County: ________________________________ Provider participates with Horizon BCBS of NJ? ? Yes or ? No
Office Manager/Contact: __________________________________ Telephone:___________________________

The following documentation is required to submit an application:

? Fully completed NJ Universal Application (Please review question 26 carefully. If you answer YES, no
documentation is needed) OR CAQH #_________________________________________

? 2 Signed Agreements ? Please DO NOT insert an effective date or alter the agreements. The agreements
will be countersigned and dated with the effective date upon approval. An executed copy will be returned to
you by mail.

? W-9 form

? Copy of Board Certification or proof of Board Eligibility (i.e. NCCPA, ANA, NAPNAP, ACNM).

? Current copy of State Registered Nurse?s License, Physician Assistant License, Midwifery License
and/or EN Practitioner?s License.**

? Hospital and/or Birthing Center Privilege Letter(s) ? Must have a delineation of privileges; be dated within
6 months of request date; stating the provider has active privileges and is in good standing. This item is not
required for Physician Assistant applicants.

? Must have a Statement of Collaboration from managing physician and management plan of care.

? Curriculum Vitae ? please fill in requested information in addition to attaching CV

? Copy of Malpractice Insurance Certificate face sheet policy showing policy period and liability limits.**

? Documentation of continuing Medical Education Credits.

? Special Needs Survey

? American with Disabilities Act (ADA) Provider Survey (one per location)

? For Affordable Care Act eligible providers, please submit a Self or Group ACA Attestation Form



** In order to avoid unnecessary delays please make sure all documentation is dated within the last six
months and is not within 3 month of expiration.



Upon credentialing, the physician/provider is required to attend a brief orientation session with the Professional
Relations Representative assigned to your territory.



THE CREDENTIALING COMMITTEE MEETS ON A MONTHLY BASIS; THEREFORE, ONCE WE RECEIVE
YOUR APPLICATION FOR PROCESSING PLEASE ALLOW 8-10 WEEKS.

Thank you very much for your attention to this matter. We look forward to having your office as part of our select
physician network. Please send applications to:


Horizon NJ Health
210 Silvia Street
West Trenton, NJ 08628