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UnitedHealth Premium Designation Program (Commercial Plans) - Chapter 13, 2018 UnitedHealthcare Administrative Guide

The UnitedHealth Premium® program provides physician designations based on quality and cost-efficiency criteria to help members make more informed choices about their medical care.

To evaluate care providers across 16 premium specialties which represent 46 sub-specialties, this program uses:

  • Evidence based standards
  • Medical society standards
  • National industry standards
  • Transparent methodology
  • Robust data sources

The program shows how a care provider’s cost-efficiency compares to peer groups in the same geographic area.

Cost-efficiency is assessed by comparing the physician’s case-mix adjusted cost of care to a benchmark and applying a statistical test to determine if the difference is statistically significant.

Evaluation for quality compares a physician’s observed practice to the UnitedHealthcare national rate among other physicians who are responsible for the same services. The quality evaluation is separate from the cost-efficiency designation. The results of the quality and cost-efficiency evaluation, but if a  physician is not evaluated for quality or does not meet the UnitedHealth Premium program quality care criteria, the physician is not eligible for the Premium Care Physician designation are used together to determine the physician’s Premium designation.

Quality and cost efficiency evaluations include adjustments for the physician’s case mix and the level of the patient’s severity of illness where appropriate.

The referrals you make impact your UnitedHealthcare Premium designation. This includes referrals for DME/orthotics, medical devices, and to care providers or facilities. For example, if you often refer to higher cost care providers or services, your designation in the UnitedHealth Premium program may be impacted.

Physicians receive one of the following designations:

Premium Care Physician
The physician meets the UnitedHealth Premium program quality and cost-efficient care criteria.
Quality Care Physician
The physician meets the UnitedHealth Premium program quality care criteria, but does not meet the program’s cost-efficient care criteria or is not evaluated for cost-efficient care
Does not Meet Premium Care
The physician does not meet the UnitedHealth Premium program quality criteria so the physician is not eligible for the Premium designation.
Not Evaluated for Premium Care
The physician’s specialty is not evaluated in the UnitedHealth Premium program, the physician does not have enough claims data for program evaluation, or the physician‘s program evaluation is in process.

Employers may choose to offer their employees a tiered benefit plan. This may offer an enhanced benefit of lower out-of-pocket costs for using Premium Care Physicians. For more information on tiered benefits, go to > select your state.

For more information regarding the UnitedHealth Premium program (including the measures, measurement methodology and how we use the results), go to, or call 866-270-5588.

Note: The UnitedHealth Premium program does not apply to MA benefit plans