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Credentialing/Profile Reporting Requirements - Chapter 14, 2018 UnitedHealthcare Administrative Guide

Credentialing Program

We credential physicians, health care professionals, and facilities who want to join our network and be listed in our Provider Directory. We re-credential at least every 36 months. Our credentialing program helps us maintain and improve the quality of care and services delivered to our members. Our credentialing standards are fully compliant with and go beyond the National Committee for Quality Assurance (NCQA) and CMS requirements. We have a comprehensive, written credentialing program, outlined in our Credentialing and Recredentialing Plan on UHCprovider.com/join. We review and revise our credentialing program at least every two years, to follow NCQA standards as well as state and federal regulations.

When we delegate contracted organizations to perform credentialing activities, they must meet our standards as outlined in this guide, the Credentialing and Recredentialing Plan and the delegation agreement.

We are a member of the Council for Affordable Quality Healthcare (CAQH). We use CAQH ProView to collect credentialing data for physicians and health care professionals. There is no charge to physicians and other health care professionals.

The CAQH process reduces costs by:

  • Eliminating the time required to complete credentialing applications for multiple health benefit plans,
  • Reducing the need for credentialing software, and
  • Minimizing paperwork by allowing physicians and other health care professionals to make updates online.

We use the CAQH process as our only credentialing application, unless state law requires differently. All care providers applying to join our network, and those scheduled for recredentialing, must use CAQH ProView. Instructions are provided on UHCprovider.com/join > Credentialing for Care Providers

Participating physicians and health care professionals are responsible for verifying their clinical staff have applicable licenses and other credentials.

Non-Discrimination

Credentialing and recredentialing decisions are not based on a care provider’s or other health care professional’s race, ethnic/national identity, gender, age, sexual orientation or the types of procedures or members they specialize in. However, we may elect to include care providers in our network who meet certain demographic or specialty needs, such as cultural needs, of our members.

Network Care Providers and Business Needs

When we decide to approve or deny an application/reapplication, we consider:

• Our current network of care providers
• Our business needs
• The care provider’s professional credentials and qualification

UnitedHealthcare’s Discretion

Our credentialing criteria, standards and requirements do not limit our discretion in any way or create rights on the part of care providers who seek to provide health care services to our members. We retain the right to approve, suspend and terminate individual care providers and sites in situations where we have delegated credentialing decision-making.

Confidentiality

Our staff treats information obtained in the credentialing process as confidential. We (and our delegates) maintain mechanisms to properly limit review of confidential credentialing information. We contractually require Delegated Entities to maintain the confidentiality of credentialing information. Credentialing staff or representatives must not disclose confidential care provider credentialing and recredentialing information to any persons or entity except with the express written permission of the care provider or as otherwise permitted or required by law.

Medica HealthCare and Preferred Care Partners

For Medica Healthcare and Preferred Care Partners Credentialing process, please contact the plans’ Network Management Department by emailing pcp-NetworkManagementServices@uhcsouthflorida.com or calling 877-670-8432.