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:
Delegated entities must not share credentialing and recredentialing information to anyone without the care provider’s written permission or as required by law.
When credentialing is delegated, applicants must use the medical group’s/IPA’s application form and process or as prescribed by law.
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.
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.
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:
Every month, the delegate must provide to the credentialing entity current demographics for their care providers and/or changes to a status. Changes include:
The delegate must provide full roster submissions at least twice a year per NCQA requirements. Submit reports to firstname.lastname@example.org 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:
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.