Applicable to all states except NC
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:
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.
Delegated entities must not share credentialing and recredentialing information to anyone without the care provider’s written permission or as required by law.
When credentialing is delegated, applicants must use the medical group’s/IPA’s application form and process or as prescribed by law.
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.
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.
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:
The delegate must provide to Credentialing Entity with current demographics for their care providers and/or changes to a status. Changes include:
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:
When a PCP terminates affiliation with a delegate, UnitedHealthcare members have two options:
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: