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Delegated Providers and Accountable Care Organizations - Capitation and/or Delegation Supplement, 2018 UnitedHealthcare Administrative Guide

What is a Delegated Provider/ACO?

Delegation is a process that we use to give another entity the authority to perform specific functions on our behalf.

UnitedHealthcare may delegate:

  1. Medical management,
  2. Credentialing,
  3. Claims,
  4. Complex case management, or
  5. Other clinical and administrative functions.

When we delegate any of these responsibilities to you, you are a Delegated Provider. UnitedHealthcare remains responsible to external regulatory agencies and other entities for the performance of the delegated activities. As such, a delegated provider/ACO (referred to in this supplement as “delegated entity” or “delegate”) must demonstrate compliance with our established standards before we delegate any activities to them. Additionally, a delegated provider/ACO must continuously comply with our standards to retain delegation status. We may revoke any or all delegated activities if the delegate is noncompliant with the delegated activity.

If you are associated with a delegated medical group, IPA, or other entity, you must use their office policies and protocols.

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

  1. Whose medical group, IPA, or other care provider performs any of the above functions on behalf of UnitedHealthcare, or
  2. Whose care provider is a member of an Accountable Care Organization (ACO), where the ACO performs any of the above functions on behalf of UnitedHealthcare.