Delegated Credentialing Requirements
This information is supplemental to the credentialing requirements outlined in Chapter 14: Credentialing and Re-Credentialing. Delegated entities and capitated providers are also subject to the following requirements.
We maintain standards, policies and procedures for credentialing and recredentialing of care providers and other licensed independent health care professionals, facilities and other organizational care provider facilities that provide medical services to our members. We may delegate credentialing activities to a medical group, IPA, PHO, hospital, etc. that complies with our Credentialing and Recredentialing Plan.
The delegate must maintain a written description of its credentialing program that documents the following activities, in a format that meets Credentialing Entity’s standards:
- Credentialing;
- Recredentialing;
- Assessment of network care providers and other licensed independent health care professionals;
- Sub-delegation of credentialing, as applicable; and
- Review activities, including establishing and maintaining a credentialing committee.
Monitoring Sanction Activity
If a capitated provider is sanctioned, loses their license or has a material restriction, the termination date is retroactive to the first day of the month of the sanction.
Confidentiality
Delegated entities must not share credentialing and recredentialing information to anyone without the care provider’s written permission or as required by law.
Initial Credentialing Process
When credentialing is delegated, applicants must use the medical group’s/IPA’s application form and process or as prescribed by law.
Delegation Oversight
We perform an initial assessment to measure the delegate’s compliance with the established standards for delegation of credentialing. Every year after that, we assess the delegate to monitor its compliance with established standards. This includes NCQA standards and state and federal requirements. If needed, we may conduct a focused assessment review based on specific delegate activity.
Improvement Action Plans
If delegates are not compliant, we may require an improvement action plan. If compliance is not reached within a determined timeframe, we continue oversight. We may revoke delegated functions if delegates remain non- compliant with our credentialing standards.
Credentialing Reporting Requirements for Delegates
In addition to complying with state and contractual requirements, we require all delegates to adhere to the following standards for notification procedures. The delegate provides prior written notice to us of the addition of any new care providers or other licensed independent health care professionals. For all new and current care providers with changes to credentialing information, please include these in your notice:
- Demographic information including name, gender, specialty and medical group/IPA address and locations.
- License.
- DEA registration.
- Education and Training, including board certification status and expiration date.
- Facilities with admitting privileges, or coverage arrangements.
- Billing information — to include:
- Legal entity name.
- Billing address.
- TIN.
- Product participation (e.g., Commercial, Medicare Advantage).
- Languages spoken and written by the care provider or clinical staff.
Reporting Changes
The delegate must provide to Credentialing Entity with current demographics for their care providers and/or changes to a status. Changes include:
- Address
- TIN
- Status of accepting patients: open, closed or existing only patients
- Product participation
Report all demographic changes, open/closed status, product participation or termination to your local Network Account Manager, Provider Advocate or the My Practice Profile app on Link.
Delegate Reporting of Terminations
The delegate must notify us, in writing, of any terminations of care provider or other licensed independent health care professionals. Send notice 90 calendar days before the termination effective date. It is imperative we receive such notices on a timely basis to comply with our regulatory obligations related to the terminations of care providers and other licensed independent health care professionals.
Effective dates of termination must be the last day of the month to properly support group capitation. We do not accept mid-month terminations.
Termination notice requires:
- Reason for termination.
- Effective date of termination.
- Direction for reassignment of members (for PCP terminations, if UnitedHealthcare does assignment).
- Product participation.
When a PCP terminates affiliation with a delegate, UnitedHealthcare members have two options:
- Stay with their existing medical group/IPA and change care providers.
- Transfer to another medical group/IPA to stay with the existing care provider.
If the delegate fails to indicate the reassignment preference, we assign the member to another PCP within the same medical group/IPA, based on the medical group/ IPA’s direction for reassignment. We make exceptions to this policy on a case-by-case basis. Members may change their care provider as described in their benefit plan.
Negative Actions Reporting Requirements
The delegate must notify us, in writing, of any of the following actions taken by or against a PCP, specialty care provider or other licensed independent health care professional:
- Surrender, revocation, or suspension of a license or current DEA registration.
- Exclusion of care provider from any federal program (e.g., Medicare or Medicaid) for payment of medical services.
- Filing of any report regarding care provider, in the National Practitioner Data Bank, or with a state licensing or disciplinary agency.
- Change of care provider’s status that results in any restriction or limitations.
- When the delegate reasonably determines serious deficiencies in the professional competence, conduct or quality of care of the network care provider that affects, or could adversely affect the health and safety of the member.
- External sanction or corrective action levied against a provider by a government entity.