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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