Provider Specialty Change Request Form - Horizon BCBSNJ

PROVIDER SPECIALTY CHANGE REQUEST FORM

Practitioners may use this form to request that we update our files to: change a provider specialty type; add an additional

provider specialty type for certain networks; or add a subspecialty or specialized service type.

Requests may take up to thirty days to process. Please provide at least thirty days in advance of the effective date of a

requested change. We are not responsible for the implementation of changes without proper advance notice. Requests

received without complete information or an authorized signature will not be processed.

Please submit this form as an attachment along with a completed copy of our Horizon Data Submission Template. For

details and instructions, visit DemographicUpdates.

Practitioner Name

Practitioner Date of Birth

Gender (Male/Female)

Practitioner Type1 NPI

Practitioner Degree

Currently Contracted Specialty

Group Practice Name

Group Practice Type 2 NPI

CHANGE MY PRACTITIONER SPECIALTY

For the network(s) checked below, change the above-noted specialty to

Horizon Managed Care Network and/or Horizon PPO Network

Horizon NJ Health Network

ADD A PRACTITIONER SPECIALTY

For the Horizon NJ Health Network, add specialty type

ADD A SUBSPECIALTY OR SPECIALIZED SERVICE TYPE

For the network(s) checked below, add subspecialty/specialized service type

Horizon Managed Care Network and/or Horizon PPO Network

Horizon NJ Health Network

List the name of certifying board for the above-noted specialty type, subspecialty/specialized service type.

Attestation

By signing and dating below, I authorize the above noted change/addition to my Horizon provider file.

Signature

Date of Signature

32263 - 02022023

Products are provided by Horizon Healthcare Services, Inc. d/b/a Horizon BCBSNJ, Horizon Healthcare of New Jersey, Inc. (d/b/a Horizon NJ Health for Medicaid

line of business), Horizon Insurance Company and Healthier New Jersey Insurance Company d/b/a Braven Health. Communications may be issued by Horizon

Healthcare Services, Inc. d/b/a Horizon BCBSNJ in its capacity as administrator of programs and provider relations for its companies.

Horizon Healthcare of New Jersey, Inc. d/b/a Horizon NJ Health, Horizon Insurance Company, Healthier New Jersey Insurance Company d/b/a Braven Health and

Horizon Healthcare Services, Inc. d/b/a Horizon BCBSNJ are independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross? and Blue

Shield? names and symbols are registered marks of the Blue Cross and Blue Shield Association. The Horizon? name and symbols are registered marks of Horizon

Blue Cross Blue Shield of New Jersey. ?2023 Horizon Blue Cross Blue Shield of New Jersey, Three Penn Plaza East, Newark, New Jersey 07105.

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download