Credentialing is a process to verify your experience, expertise, interest and willingness to provide medical care to our members. Without successful credentialing, provider reimbursement for medical services can be denied.
Credentialing is a separate process from network contracting.
What is Credentialing?
Credentialing is a peer-review process to review and verify your credentials. We diligently work to provide our members with access to providers who are appropriately trained, licensed and meet quality standards.
This process collects and evaluates your qualifications and practice history, which includes, but is not limited to:
- Relevant training
- Certification and/or registration to practice in a health care field
- Academic background
- Professional competence and conduct
The following sections can help you prepare your credentialing application. The review and approval of your credentialing application takes 25 or more calendar days.
Whether you are new to credentialing with UnitedHealthcare or have an existing CAQH ProViewTM Provider ID number and are registered with CAQH ProView, please start the process by calling UnitedHealthcare at 877-842-3210.
- Enter your Tax Identification Number (TIN)
- Select Credentialing > Medical > Join the Network
A member of our Credentialing team will gather appropriate details, explain the process on becoming a part of our network and either issue or confirm your CAQH ProView Provider ID for the application process.
This is done in real time. At the end of the call, you may immediately access the CAQH ProView site with your CAQH ProView Provider ID number.
The Credentialing team is available Monday - Friday from 8:00 a.m. to 5:00 p.m. Eastern Time.
The CAQH ProView application is a fast and easy way to securely submit credentialing information. You enter information just once and it is available to multiple plans and networks. Application data can be submitted online at any time. It is provided at no cost.
Your application will not be released to UnitedHealthcare until CAQH verifies that your application is complete. Please select global authorization or manually authorize UnitedHealthcare to access your data.
- If you do not fully complete the application or if more information is needed, someone from CAQH will contact you.
- It is important to respond promptly to those requests to complete your application.
When the credentialing application is complete, UnitedHealthcare will perform primary source verification. That means we will contact the state board for your license, verify your professional training/education, etc.
Once source verification is complete, your application is presented to a committee of your peers to decide if you meet UnitedHealthcare’s requirements. Please allow 25 calendar days for this review following confirmation of a complete application from CAQH Proview.
You can check on the status of your credentialing application by calling UnitedHealthcare at 877-842-3210.
- Enter your tax ID number (TIN)
- Select Credentialing > Medical > Get Status
UnitedHealthcare will notify you when your credentialing is approved. Then, your network management contact will help you to begin the contracting process. You will be asked to sign a Participation Agreement.
You will need a provider number from Medicare and Medicaid programs to participate in these health plans.
To streamline the credentialing and contracting process, you may receive a contract to review before you complete the credentialing process. The receipt of the contract is not a confirmation of an approved credentialing or authorization to see UnitedHealthcare members.
Providing services to members before you are BOTH credentialed and contracted can result in denied claims.
If you are joining a group that currently participates with UnitedHealthcare on a group contract, call UnitedHealthcare at 877-842-3210 to initiate credentialing.
After credentialing is approved and you sign the Participation Agreement, you will be added to the group contract. Once the contract is loaded into our system, you will be notified in writing of your effective date.
Network Participation Approvals
Upon completed and approved credentialing, our National Contracting Team will send a Welcome Packet for your review.
The Welcome Packet contains:
- Fee schedules
- Administrative guide
- Contact information
Contract Denied (or Terminated) From the Network
You may receive a letter stating that your credentialing application was not approved. It will have appropriate contact information if you need additional clarification.
Your denial or termination letter explains your rights and the timelines you must follow.
Depending on the reasons why the committee made that decision, you may be offered the opportunity to submit additional information and/or submit an appeal.
You may resubmit your information at any time through the CAQH ProView application at http://www.caqh.org
Credentialing standards are set by national accrediting agencies and state and federal regulating bodies. UnitedHealthcare’s credentialing standards fully comply with the National Committee on Quality Assurance (NCQA) and specific State and Federal requirements.