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Delegated Credentialing Program, Capitation and/or Delegation - 2019 UnitedHealthcare Administrative Guide

Delegated Credentialing Requirements

This information is supplemental to the credentialing requirements outlined in Chapter 14: Credentialing and Re-Credentialing. In addition to the requirements outlined in Chapter 14, delegated entities and capitated providers are subject to the requirements outlined in the following sections.

We maintain standards, policies and procedures for credentialing and recredentialing of care providers and other licensed independent health care professionals, facilities and other organizational care provider facilities that provide medical services to our members. We may delegate credentialing activities to a medical group, IPA, PHO, hospital, etc. (referred to as a “delegate”) that demonstrates compliance with our Credentialing and Recredentialing Plan.

The delegate must maintain a written description of its credentialing program that documents the following activities, in a format that meets Credentialing Entity’s standards:

  • Credentialing;
  • Recredentialing;
  • Assessment of network care providers and other licensed independent health care professionals;
  • Sub-delegation of credentialing, as applicable; and
  • Review activities, including establishing and maintaining a Credentialing Committee.

Monitoring Sanction Activity

If a capitated provider is sanctioned and lost their license or has a material restriction, the termination date is retroactive to the first day of the month of the sanction.

Confidentiality

Delegated entities must not share credentialing and recredentialing information to anyone without the care provider’s written permission, or as required by law.

Initial Credentialing Process

When credentialing is delegated, applicants must use the medical group’s/IPA’s application form and process,or as prescribed by law.

Delegation Oversight

We perform an initial assessment to measure the compliance of the delegate with the established standards for delegation of credentialing. At least annually thereafter, we assess the delegate to monitor its compliance with established standards, including NCQA standards, and state and federal requirements. We may initiate a focused assessment review based on specific activity by the delegate that warrants such an assessment.

Improvement Action Plans

If delegates do not achieve compliance, we may require an improvement action plan to reach compliance. If compliance is not reached within a determined timeframe, we will continue oversight. We may revoke delegated functions if there is continued non-compliance with our credentialing standards.

Credentialing Reporting Requirements for Delegates

In addition to complying with state and contractual requirements, we require all delegates to adhere to the following standards for notification procedures. The delegate provides prior written notice to us of the addition of any new care providers or other licensed independent health care professionals. For all new and current care providers with changes to credentialing information, please include these in your notice:

  • Demographic information including, but not limited to, name, gender, specialty and medical group/IPA address and locations;
  • License;
  • DEA registration;
  • Education and Training, including board certification status and expiration date;
  • Facilities with admitting privileges, or coverage arrangements;
  • Billing information — to include:
    • Legal entity name;
    • Billing address; and
    • TIN.
  • Product participation (e.g., Commercial, Medicare Advantage); and
  • Languages spoken and written by the care provider or clinical staff.

Reporting Changes
The delegate must provide to Credentialing Entity with current demographics for their care providers and/or changes to a status. Changes include:

  • Address
  • TIN
  • Status of accepting patients: open, closed or existing only patients
  • Product participation

All demographic changes, open/closed status, product participation or termination needs reporting via email to: delprov@uhc.com or until the My Practice Profile app on Link is available.

Delegate Reporting of Terminations
The delegate must notify us, in writing, of any terminations of care provider or other licensed independent health care professionals. We must receive such notice 90 calendar days in advance of the termination effective date.

Note: Effective dates of termination must be the last day of the month to properly support group capitation. We do not accept mid-month terminations.

Termination notice requires the following information:

  • Reason for termination
  • Effective date of termination
  • Direction for reassignment of members (for PCP terminations, if UnitedHealthcare does assignment)
  • Product participation

When a PCP terminates affiliation with a delegate, UnitedHealthcare members have two options:

  • Stay with their existing medical group/IPA and change care providers.
  • Transfer to another medical group/IPA to stay with the existing care provider.

If the delegate fails to indicate the reassignment preference, UnitedHealthcare’s default position is to assign the member to another PCP within the same medical group/IPA, based on the medical group/IPA’s direction for reassignment. We make exceptions to this policy on a case-by-case basis. Members may change their care provider prospectively as described in their benefit plan.


Negative Actions Reporting Requirements
The delegate is required immediately to notify us, in writing, of any of the following actions taken by or against a PCP, specialty care provider or other licensed independent health care professional, as applicable:

  • Surrender, revocation, or suspension of a license or current DEA registration;
  • Exclusion of care provider from any federal program (e.g., Medicare or Medicaid) for payment of medical services;
  • Filing of any report regarding care provider, in the National Practitioner Data Bank, or with a state licensing or disciplinary agency;
  • Change of care provider’s status that results in any restriction or limitations; or
  • When the delegate reasonably determines serious deficiencies in the professional competence conduct or quality of care of the network care provider that affects, or could adversely affect the health and safety of the member.

External sanction or corrective action levied against a provider by a government entity.