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Initial Credentialing Process - Chapter 14, 2018 UnitedHealthcare Administrative Guide

Instructions, information and policies about our credentialing plan are located on UHCprovider.com/join > Credentialing for Care Providers.

Applicants must contact the United Voice Portal at 877-842-3210. They enter their Tax ID, then select the following prompts: 1) Credentialing, 2) Medical, 3) join the network. After entering the last prompt, the system provides the applicant the information required for the credentialing process. The applicant is transferred to a credentialing member service representative to notify us of their application.

From there, the process is completed online by logging into the CAQH Proview website at caqh.org.

Applicants to delegated medical group/IPAs must use the delegate’s application form and process.

Network care providers and health care professionals are responsible for getting and maintaining licenses and other credentials of their clinical support staff.

Credentialing Criteria

Each licensed independent practitioner (LIP) must meet the following criteria. They also must meet state and federal requirements, as applicable:

  • Having the requisite medical or professional education and training to practice within the scope of the care provider’s license, including residency completion if applicable to practice;
  • Verification of post-graduate education or training;
  • Current license or certification in all states where the applicant practices without material restrictions, conditions or any other disciplinary action;
  • Valid DEA or Controlled Substance Certificate or Acceptable Substitute, as required per practice;
  • Medicare/Medicaid program participation eligibility;
  • Work history — five years;
  • Malpractice Insurance or State-Approved Alternative, equal to or greater than the minimum amounts required and outlined in care provider’s contract;
  • Malpractice history —five years;
  • Passing score on site visit, as applicable;
  • No sanction or limitation on being licensed;
  • No prior denials or terminations within the last 24 months; and
  • Admitting hospital privileges or arrangements with a participating licensed care provider to admit and provide facility coverage at a UnitedHealthcare participating hospital.

A completed application includes a signed statement attesting to:

  • Applicant’s current professional liability insurance policy;
  • Limitations on ability to perform functions of the position with and without accommodation;
  • History of loss or limitation of privileges or disciplinary activity;
  • Absence of current, illegal drug use;
  • History of loss of license and felony convictions; and
  • Completeness and accuracy of the information provided.

The credentialing program applies to:

  • Allopathic care providers (MDs)
  • Osteopathic care providers (DOs)
  • Dentists (DDSs, DMDs)
  • Podiatrists (DPMs)
  • Chiropractors (DCs)
  • Behavioral Health (MDs, PhDs, LCSWs)
  • Other licensed independent health care providers approved to provide services to our members outside the inpatient setting and listed in our care provider directory

While current board certification is not required to join our network, it is a requirement to take part in the UnitedHealth Premium designation program. Providing updated board certification is part of the credentialing application process.

Collection and Verification of Information

After we receive a completed application, we verify the professional credentials and qualifications. Next, we present the application to our credentialing committee. The process generally takes up to 25 calendar days to complete, depending on response times from medical schools, residencies, specialty boards, and hospitals.

Right to Reapply

Care providers who were denied initial credentialing or were terminated (for reasons other than network need) can reapply. They must wait 24 months from the date of their denial to reapply under their current criteria. We reserve the right to review the applicant against all credentialing criteria applicable at the time of the reapplication.