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Credentialing/Profile Reporting Requirements - Chapter 14, 2019 UnitedHealthcare Administrative Guide

Credentialing / Profile Reporting Requirements

Credentialing Program

We credential physicians, health care professionals, and facilities who want to join our network and be listed in our Provider Directory. We recredential 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 thorough, written credentialing program, outlined in our Credentialing Plan in our Join Our Network section. We review and revise our credentialing program at least every two years, or as NCQA, state or federal requirements change. When we contract with a delegate to carry out credentialing activities, they must meet our standards as outlined in:

  • This guide,
  • The Credentialing Plan and,
  • The delegation Agreement.

We use the Council for Affordable Quality Healthcare (CAQH) process for credentialing application submissions, unless state law requires differently. Care providers applying to join our network, and those scheduled for recredentialing, must use CAQH ProView. Instructions are provided on Credentialing for Care Providers.

Minnesota, North Dakota, and South Dakota providers may submit applications to the Minnesota Credentialing Collaborative (MCC) also known as ApplySmart. Log intocredentialsmart.net/mcc to select UnitedHealthcare as a Preference, complete your application and submit to us.

As a participating care provider, you are responsible for verifying your clinical staff have applicable licenses and other credentials.

Non-Discrimination

Credentialing and recredentialing decisions are not based on a care provider’s or health care professional’s:

  • Race or ethnic/national identity,
  • Gender,
  • Age,
  • Sexual orientation, or
  • The types of procedures or members they specialize in.

We may however choose to include care providers in our network because they meet certain demographic, specialty, or 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 qualifications.

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. Our contracts require Delegated Entities to maintain the confidentiality of credentialing information.

Credentialing staff or representatives will not disclose confidential care provider credentialing information to any persons or entity except with the express written permission of the care provider or as otherwise permitted or required by law.