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Practice Location Reinstatements

Administrative Policy:
Practice Location Reinstatements

Original Effective Date:
1/20/2019

Last Revised Date:
12/15/2020

Scope:
This policy applies to all physicians, healthcare professionals and behavioral healthcare professionals (collectively referred to as “Practitioner(s)”) who participate in the Managed Care Network, PPO Network, Braven Health Network, Horizon New Jersey Health Medicaid Network and FIDE-SNP. For the purpose of this policy, all of these Horizon entities shall be collectively defined as “Horizon BCBSNJ”. For the purpose of this policy, all of the above – referenced networks shall be defined as “Network(s)”.

Purpose:
This policy establishes guidelines and timeframes for the reinstatement of practice locations to display in the Doctor & Hospital Finder (DHF) and printed directories. This policy also outlines the procedures and timeframes for adding these previously existing practice locations during maintenance of locations and/or the credentialing/recredentialing review process and identifies when validation of practice locations is required.

Definitions:
Validation – Electronic, written, faxed or verbal responses to questions regarding practitioner demographics including but not limited to practice locations, practice limitations, availability to see new patients, ability to schedule and treat patients at a location and knowledge about participating with Horizon Blue Cross of Blue Shield of New Jersey’s (Horizon BCBSNJ) products.

Doctor & Hospital Finder (DHF) – Horizon BCBSNJ’s online provider directory, which lists participating doctors, other health care professionals, dentists, ancillary providers and facilities.

Practice Location – The location in which a practitioner schedules patient appointments.

Print-on-demand Directory – Printed directory that is created at the time of the request based on the most currently available information for doctors, other health care professionals, ancillary providers and facilities.

Policy:
Horizon BCBSNJ will not reinstate a practice location unless it has been validated via telephonic outreach by the Provider Data Management Department. Locations that meet Horizon BCBSNJ’s requirements as a hospital-based practice location, can be reinstated without telephonic outreach. However, the location will be suppressed from display in the Doctor & Hospital Finder. Exceptions must be approved by the Director of Physician Operations and Data Management or designee. In all instances electronic, written, and verbal validation to the questions listed in this policy must be received before reinstatement can be reconsidered or processed.

Demographic information stored in Horizon BCBSNJ’s systems is transmitted to the Doctor & Hospital Finder daily. The practice locations that meet Horizon BCBSNJ’s business rules for display at the time of transmission will be visible and/or searchable.

The practice locations included in the annual printing of the directories are determined by the display status at the time information is accessed for printing. If a practice location is inactive or terminated on a practitioner record at the time information is accessed for printing and then later approved to be displayed, those locations will be included in the next annual version of the printed directory.

Print-on-demand directories will display all active unsuppressed locations at the time of printing.

Procedure:
Practitioners will be notified of our policy via an announcement in the News and Legal Notices section of the Providers Tab on the Horizon BCBSNJ web site.

MAINTENANCE
Horizon BCBSNJ will update valid requests for practice location reinstatements to be displayed in the Doctor & Hospital Finder and printed directories as long as the practice location(s) are validated via telephonic outreach by the Provider Data Management Department. Practitioners requesting to reinstate a location(s) must follow the process noted in this Validation Section of this policy. Additional practice locations may be reinstated but suppressed from the Doctor & Hospital Finder and printed directories if the location is identified as possessing a practice limitation preventing Horizon members from making an appointment with the practitioner.

Practitioners are required to immediately notify Horizon BCBSNJ of any practice location or practice limitation changes in accordance with the Provider Directory Management Policy. Practitioners may change the practice locations to be displayed at any time by logging into CAQH or other Horizon BCBSNJ online self-service portal applications. Self-Service portal applications may also be used to update practice limitations. Electronic or written requests may also be accepted following current protocols for requesting changes to demographic information as long as responses to all of the eight validation questions outlined by CMS are provided for every practice location requested to be displayed.

Practitioners that do not maintain accurate information regarding their practice locations may be subject to practice location suppression, restriction of network participation, and/or termination.

CREDENTIALING AND RECREDENTIALING
Horizon BCBSNJ will update practice locations included on the CAQH or Universal Application into our data management system. The process will continue as documented in the Credentialing and Recredentialing Policy for Participating Physicians and Healthcare Professionals Policy. Electronic, written or verbal requests to display previously terminated practice locations that do not appear on CAQH or the Universal Application will be accepted and reviewed by Provider Data Management. Practitioners will be asked to update their CAQH application for data accuracy purposes. Failure to update CAQH can lead to continued location termination.

VALIDATION
Practitioners who request to reinstate practice locations for display in the Doctor & Hospital Finder and printed directories must provide electronic, written, or verbal validation to the questions below for all locations. The practitioner must schedule and treat patients at each of the locations to be published. Locations deemed to fulfill practice limitation requirements can be reinstated to the practitioner’s record but may be suppressed from publication. Once validation is received for all practice locations by the practitioner, the Director of Physician Operations and Data Management or designee will review and determine if the request is approved. If the request to reinstate one or more of the practice locations is denied, the practitioner will be notified.

  1. What is the practitioner’s full name, including degree?

  2. What is the practitioner’s full address?

  3. What is the practice name at this location?

  4. What phone number should patients call to schedule appointments?

  5. What is the practitioner’s specialty?

  6. Is this practitioner scheduling and seeing existing patients at this location?

  7. Is the practitioner accepting new patients at this location?

  8. Does the practitioner have any limitations at this location (i.e. students only, hospitalist, reads/performs tests only, age restrictions, etc.)?

  9. Does the practitioner participate in the Horizon BCBSNJ’s Medicare Network?

  10. Does the practitioner participate in the Horizon New Jersey Health’s Medicaid or FIDE-SNP Network?

SURVEY
Horizon BCBSNJ may periodically survey practitioners asking the below questions, which may also be used by CMS in their Audit.

  1. Does the provider see patients at this location?

  2. Does the provider accept the MA-PD plan at this location?

  3. Does the provider accept (or not accept) new patients who have this MA-PD plan? (The provider directory is considered accurate if it correctly indicates if the provider is or is not accepting new patients)

  4. Is the provider a PCP, cardiologist, oncologist or ophthalmologist?

  5. Is the address correct?

  6. Is the telephone number correct? (Usually confirmed by dialing the phone number)

  7. Is the provider’s name correct?

  8. Is the practice name correct?

References:
HPMS Memo dated January 17, 2017, Provider Directory Policy Updates

HCM-PP-PDM-001-1220