Demographic changes - Chapter 2, 2021 UnitedHealthcare Administrative Guide

Provide official notice

Notify us, at the address in your Agreement, within 10 calendar days if any of these situations occur:

• Material changes to, cancellation or termination of liability insurance.
• Bankruptcy or insolvency.
• Any indictment, arrest or conviction for a felony or any criminal charge related to your practice or profession.
• Any suspension, exclusion, debarment or other sanction from a state or federally funded health care program.
• Loss, suspension, restriction, condition, limitation, or qualification of your license to practice. For physicians, any loss, suspension, restriction, condition, limitation or qualification of staff privileges at any licensed hospital, nursing home, or other facility.
• Relocation or closure of your practice, and, if applicable, transfer of member records to another physician/facility.
• External sanctions or corrective actions levied against you by a government entity.

Provide timely notice of demographic changes

Primary care physicians

As a PCP, you are responsible for monitoring your office capacity based on member assignments and for notifying us if you have reached your maximum capacity. A self-reporting tool is available for you to generate a PCP panel roster report using UHCprovider.com/reports.

We have developed specific definitions for open, closed or existing-only practices to promote consistency throughout the participating care provider network related to acceptance of new or transferring members. For purposes of this section, a new member may be a member who has switched health plans and/or coverage plans, such as a member who switches from a Fee- For-Service (FFS) plan to a Commercial HMO/MCO plan.

Follow these definitions:

• Open status – the PCP’s practice is open to additional new members and transferring members.
• Closed status – the PCP’s practice is closed to all new members and transferring members.
• Existing-only status – the PCP’s practice is only open to new or transferring members who have an established chart with the care provider’s office.

Notification of changes must be proactive

Every quarter, you, or an entity delegated to handle credentialing activities on behalf of us (a “delegate”), are expected to review, update and attest to the care provider information available to our members. If you or the delegate cannot attest to the information, correct it online or through the Provider Service Center. You or the delegate must tell us of changes to the information at least 30 calendar days before the change is effective. This includes adding new information and removing outdated information, as well as updating the information listed in the following paragraph. Delegates are responsible for notifying us of these changes for all of the participating care providers credentialed by the delegate. If you or a delegate fails

to (1) update records, or (2) give 30 days prior notice of changes, or (3) attest to the information, you, or the participating care providers credentialed by the delegate, may be subject to penalties. Penalties may include a delay of processing claims or the denial of claims payment, until the records are reviewed and attested to or updated.

You and the delegates are required to update all care provider information, such as:

• Patient acceptance status
• Address(es) of practice location(s)
• Office phone number(s)
• Email address(es)
• Care provider groups affiliation
• Facility affiliation
• Specialty
• License(s)
• Tax identification number
• NPI(s)
• Languages spoken/written by staff
• Ages/genders served
• Office hours

If a health care provider leaves your practice, notify us immediately. This gives us time to notify impacted members.

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.

California Commercial: The penalties do not apply to benefit plans issued or administered by UnitedHealthcare Benefit Plans of California.

To change panel status (open/closed/existing-only)

If you wish to change your panel status (i.e., open to new patients, open to existing patients only, or closed), the request must be made in writing 30 days in advance. Changes to panel status applies to all patients for all lines of business (LOB) and products for which a care provider is participating. If you feel that exceptional circumstances exist, you may request to have a different panel status for an LOB or product. The exception must be included in the written request and approval is at our discretion. We may notify you in writing of changes in our panel status including closures based on state and/or federal requirements, current market dynamics and patient quality indicators. Access the My Practice Profile tool on Link at UHCprovider.com to update your information.

To change an existing TIN or to add a physician or health care provider

To submit the change, complete and email the Provider Demographic Change Form to the appropriate email address listed on the form.

The Provider Demographic Change Form is available on UHCprovider.com/findprovider.

You can also submit detailed information about the change and the effective date of the change on your office letterhead. Send it to us using the fax number on the bottom of the demographic change request form.