Provider Enrollment/Credentialing Contracting

To enroll as a network provider with Horizon NJ Health, as a dental health carepProfessional you will need:

To contact SKYGEN USA to request an application for participation with Horizon NJ Health.

• Call: 1-800-508-6965
• Email: networkdevelopment@skygenusa.com

Credentialing

Dental health care providers are required to create an application at https://proview.caqh.org If you have any questions about credentialing please call 1-855-812-9211 or email credentialing@skygenusa.com for assistance.

• CAQH Application must be less than 180 days old
• FQHC Credentialing Checklist
  • The credentialing checklist is considered complete without a DEA, CDS, and New Jersey Medicaid ID.
    • These documents will still be required after approval.
• If the application is incomplete, SKYGEN USA will make 3 weekly outreach attempts, within 90 days. The application status remains as pending during this time. If missing information is not received then the application will be withdrawn.
• If the dental healthcare provider has sanctions on their licenses, certificates or professional liability cases, the provider cannot treat Horizon NJ Members until the credentialing committee reviews and approves the application for participation.
• Once a clean application is deemed complete, the provider will be issued an FQHC Application Completion Notification Letter, with the application completion date. The effective date of the provider will be the approval date of the Horizon NJ Health Dental Credentialing Committee. The FQHC Application Completion Notification Letter will enable the provider to provide treatment and submit any claims for services that are rendered prior to the provider’s completion of credentialing.
  Upon acceptance, the provider will be notified of the credentialing committee’s decision and if approved be added to the Horizon NJ Health Provider Network.

Claim Submissions

Claim Filing Deadlines

Horizon NJ Health must receive all claims within 180 calendar days from the initial date when services were rendered. If claims are not received within 180 calendar days from the initial date of service, claims will be denied for untimely filing.

Procedures for Claim Submission

Horizon NJ Health accepts claims submitted in any of the following formats:

• Provider Web Portal at https://skygenusa.com/user-login/Dentists.htm
• Electronic submission via clearinghouse, Payer ID: 22099
• HIPAA-compliant 837D file
• Paper ADA Dental Claim Form, available from the American Dental Association

National Practitioner Identifier (NPI)

Horizon NJ Health requires all practitioners use their NPI numbers for all claim submissions. To ensure our systems properly identify you as an individual, group or facility, Horizon NJ Health requires you register the NPI with your taxonomy and tax identification numbers. Another requirement that will affect both timeliness and payment is the use of name differential on your W-9. Horizon

NJ Health continues to accept the use of your provider identification numbers (legacy ID). The continued use of the legacy ID is recommended, as the claims processing system uses this number for adjudication and payment activities. Please make sure your name matches the name used on your W-9.

Claim Appeals

This section describes procedures through which participating and nonparticipating dental providers have a right to a written appeal relating to payment of claims, as defined below. As always, Horizon NJ Health’s procedures are intended to provide our dental providers with a prompt, fair and full investigation and resolution of claim issues.

When a dental provider is dissatisfied with a claim payment, including determinations, prompt payment or no payment made by Horizon NJ Health, he/she may file a claim appeal, as described herein. Claim appeals can be requested over the phone or in writing. The appeal must be received by Horizon NJ Health within 60 calendar days following receipt by the dental provider of the payer’s remittance advice.

To file a claim appeal, a dental health care professional may call or mail the appeal:

Phone: 1-855-878-5371

Mail:
SKYGEN USA
Provider Claim Appeals
P.O. Box 295
Milwaukee, WI 53201

IMPORTANT - Supporting documentation (e.g., proof of timely filing) may be submitted. Please follow all appropriate procedures as defined in the Dental Provider Administrative Manual before submitting an appeal.

Corrected claims should be sent to: Horizon NJ Health Corrected Claims, P.O. Box 541, Milwaukee, WI 53201. These claims should not be submitted through the appeals process.

Upon review of the appeal, a decision will be rendered within 30 business days of the date of Horizon NJ Health’s receipt of the claim appeal request.

FQHC Encounters Dental Services Requiring Multiple Visits

FD Revised 3.31.21

Space Maintainers: (2 Encounters)

• D1510, D1516, D1517, D1526, D1527, D1551, D1552, D1575 (2 Encounters)

Crowns: (Up to 3 Encounters)

• D2720, D2721, D2722, D2740, D2750, D2751, D2752, D2790, D2791, D2792

Fixed Bridges: (Up to 4 Encounters)

• Fixed bridges (pontics): D6210, D6211, D6212, D6240, D6241, D6242, D6250, D6251, D6252
• Fixed bridges (abutments): D6720, D6721, D6722, D6750, D6751, D6752, D6790, D6791, D6792
• Bonded bridges (retainers): D6545

Root canals: (Up to 3 Encounters)

• D3310, D3320, D3330, D3331, D3346, D3347, D3348

Dentures & Prosthetics: (Up to 6 Encounters)

• D5110, D5120, D5130, D5140, D5211, D5212, D5213, D5214, D5225, D5226, D5863, D5864, D5865, D5866, D5867, D5911, D5912, D5913, D5914, D5915, D5916, D5919, D5922, D5923, D5924, D5925, D5926, D5927, D5928, D5929, D5931, D5932, D5933, D5934, D5935, D5936, D5937, D5951, D5952, D5953, D5954, D5955, D5958, D5959, D5960, D5982, D5983, D5984, D5985, D5986, D5987, D5988, D5991, D5992, D5993, D5994, D5999

Repairs, Rebase and Lab Reline: (Up to 2 Encounters)

• D5511, D5512, D5520, D5611, D5612, D5621, D5622, D5630, D5640, D5650, D5660, D5710, D5711, D5720, D5721, D5750, D5751, D5760, D5761

Orthodontics: (2 Encounters)

• Habit Appliances: D8210, D8220
• Repair/Replacement of Appliance: D8691, D8692

Occlusal Guard: (2 Encounters)

• D9944, D9945

Appliances: (2 Encounters)

• TMJ: D7899

FQHC Bundled Dental

Dental Services Requiring Additional Visits Prior-Auth Instructions

• When additional encounters are medically necessary to complete a bundled service, the FQHC can submit an ADA Claim form and CDT code D1999 for each additional encounter. The claim form should be marked prior-auth in the box on the top left.
• An example of this would be when a provider requires an additional encounter than allowed on the encounter list. For example see below:
  • D1999 Additional encounter for new impression for D2751(crown) $0.00
• The service provided is required to be in the descriptor field and the fee would be $0.00
  • This would be picked up as an encounter for state reporting

EPSDT Services:

No frequency limitations for EPSDT services will be applied when members received the same services at a different FQHC. Frequency limitations do apply when performed at the same FQHC.