Delegated credentialing program, Capitation and/or delegation supplement - 2021 Administrative Guide

This information is supplemental to the credentialing requirements outlined in Chapter 15: Credentialing and recredentialing. Delegated entities and capitated providers are also subject to the following requirements.

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. that complies 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 the Credentialing Entity’s standards:

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

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 delegate’s compliance with the established standards for delegation of credentialing. Every year after that, we assess the delegate to monitor its compliance with established standards. This includes NCQA standards and state and federal requirements. If needed, we may conduct a focused assessment review based on specific delegate activity.

Improvement action plans

If delegates are not compliant, we may require an improvement action plan. If compliance is not reached within a determined time frame, we continue oversight. We may revoke delegated functions if delegates remain non-compliant 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, include these in your notice:

  • Demographic information including name, gender, specialty and medical group/IPA address and locations
  • Initial credentialing committee date
  • Recredentialing committee date
  • 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
    • TIN
  • Product participation (e.g., Commercial, Medicare Advantage)
  • Languages spoken and written by the care provider or clinical staff

Reporting changes

Every month, the delegate must provide to the credentialing entity current demographics for their care providers and/or changes to a status. Changes include:

  • Address
  • Phone number a member can call to make an appointment
  • TIN
  • Status of accepting patients: open, closed or existing patients
  • Directory display indicator
  • Additional elements per roster template (e.g., office hours, languages spoken)
  • Product participation (only applies if your group has the option to opt in/out of certain products)

The delegate must provide full roster submissions at least twice a year per NCQA requirements. Submit reports to delprov@uhc.com or to the email address the Roster Manager provides to the Delegated Entity. UnitedHealthcare has a submission template you can use, or you can make changes with CAQH ProView for Groups (requires approval from UnitedHealthcare).

When you submit demographic updates, list only those addresses where a member may make an appointment and see the care provider. On-call and substitute care providers, who are not regularly available to provide covered services at an office or practice location, should not be listed at that address. Report all demographic changes, open/closed status, product participation or termination to your local network account manager, provider advocate or the My Practice Profile tool on Link.

Delegate reporting of terminations

The delegate must notify us, in writing, of any terminations of care providers or other licensed independent health care professionals. Send notice 90 calendar days before the termination effective date. It is imperative we receive such notices on a timely basis to comply with our regulatory obligations related to the terminations of care providers and other licensed independent health care professionals.

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:

  • Reason for termination.
  • Effective date of termination.
  • Direction for reassignment of members (for PCP terminations, if UnitedHealthcare does assignment). When a PCP terminates affiliation with a delegate, our members have 2 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, we 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 as described in their benefit plan.

Negative actions reporting requirements

The delegate must notify us, in writing, of a change in a care provider’s status that results in any restrictions, limitations, suspension or termination.