Applied Behavior Analysis Service Are Information - Horizon BCBSNJ
APPLIED BEHAVIOR ANALYSIS (ABA) SERVICE AREA INFORMATION
Behavioral health practitioners should complete this form to help us understand the availability of Applied Behavior
Analysis (ABA) Services throughout our local service area. Horizon will use this information to help us provide accurate
referrals for ABA services to our members in their preferred setting and geographic area.
FORM SUBMISSION
Submit this form, along with other credentialing documentation, through our online Application (which can be accessed
through the Join Our Networks webpage), or mail it to:
Horizon BCBSNJ Credentialing & Recredentialing Department
3 Penn Plaza East, PP-14C
Newark NJ 07105-2200
Practitioner Name
Practitioner (Type 1) NPI
Group Practice Name (if applicable)
Tax Identification #
1
Are you able to accept new patients (who would begin services within 30 days of an initial assessment)?
Yes
No
2
Do you offer Center-Based Programs?
Yes
No
If you answered ¡°Yes¡± above, please list the location(s) of your center-based programs. Include a separate sheet to
list additional location information.
?
Please include the location street address, city, state, ZIP code, as well as the phone number that members
would call to schedule appointments. Do not include administrative locations.
?
For initial credentialing: these addresses/phone numbers must be included in CAQH or on your universal
application. We will only load addresses listed on your application.
Location 1 Address:
Location 1 Telephone
Location 2 Address:
Location 2 Telephone
Location 3 Address:
Location 3 Telephone
40096-08142023
Products are provided by Horizon Blue Cross Blue Shield of New Jersey, Horizon Insurance Company, Horizon NJ Health and/or Braven Health. Each
company is an independent licensee of the Blue Cross? Blue Shield? Association. Communications may be issued by Horizon Blue Cross Blue Shield
of New Jersey in its capacity as administrator of programs and provider relations for all its companies. ?2023 Horizon Blue Cross Blue Shield of New
Jersey, Three Penn Plaza East, Newark, New Jersey 07105-2200.
Please complete question 3 below based on the individual practitioner listed on page 1.
3
Does the practitioner listed on page 1 offer in-home ABA Services?
Yes
No
If you answered ¡°Yes¡± above, please select the counties in which you would provide in-home services.
New Jersey
New York
Pennsylvania
Delaware
Atlantic
Bronx
Bucks
Kent
Bergen
Kings
Chester
New Castle
Burlington
Nassau
Delaware
Sussex
Camden
New York
Lehigh
Cape May
Orange
Monroe
Cumberland
Putnam
Montgomery
Essex
Queens
Northampton
Gloucester
Richmond
Philadelphia
Hudson
Rockland
Pike
Hunterdon
Suffolk
Mercer
Westchester
Middlesex
Monmouth
Morris
Ocean
Passaic
Salem
Somerset
Sussex
Union
Warren
Completed by (Name)
Completed on (Date)
................
................
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