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Capitated Providers - Capitation and/or Delegation Supplement, 2018 UnitedHealthcare Administrative Guide

What is a Capitated provider?

Capitation is a payment arrangement for health care providers. If you have a capitation agreement with us, you are a capitated provider. We pay you a set amount for each member assigned to you per period of time. We pay you whether or not that person seeks care, e.g., per member, per month. In most instances, the capitated provider is either a medical group or an Independent Practice Association (IPA). In a few instances the capitated provider may be an ancillary provider or hospital.

If you do not have a capitation agreement with us, this supplement does not apply to you. Refer to the main guide or appropriate supplement.

For this supplement, we use the term “medical group/IPA” interchangeably with the term “capitated providers”.

This supplement is intended for participating physicians, health care providers, facilities and ancillary providers who are capitated for certain UnitedHealthcare products. This applies to all benefit plans for members who:

  1. Have been assigned to or who have chosen a care provider who receives a capitation payment from UnitedHealthcare for such member, and
  2. Are covered under an applicable benefit plan insured by or receiving administrative services from UnitedHealthcare. Currently, there is a reference to “UHC” or ‘WEST” on the back of the member’s health care ID card. In the future, we will notify you if additional benefit plans in your area include other references.

Capitated providers are subject to both the main guide and this supplement. This supplement controls if it conflicts with information in the main guide. If there is more information online, you will be directed to that location when applicable. For protocols, policies and procedures not referenced in this supplement, please refer to appropriate chapter in the main guide.

Additionally, capitated providers may be subject to the protocols, policies and procedures related to any or all delegated activities. Capitated providers should refer to their Delegation Grids within their participation agreements to determine which delegated activities, if any, the capitated providers are performing on behalf of UnitedHealthcare.