During the credentialing process, we’ll work with you to verify your qualifications, practice history, certifications and registration to practice in a health care field.
UnitedHealthcare’s credentialing standards fully comply with the National Committee on Quality Assurance (NCQA) as well as specific state and federal requirements.
Licensed Independent Practitioners — Credentialing Requirements
Training and Education
- Practitioner degree (MD, DO, DPM), post-graduate education or training
- Details of medical or professional education and training
- Completion of residency program in the designated specialty
Licensing and Certification
- Current license or certification in the state(s) in which the care provider will be practicing (no temporary licenses)
- National Provider Identification (NPI) number
- Active Drug Enforcement Agency (DEA) number and/or Controlled Dangerous Substance (CDS) Certificate or acceptable substitute (if required)
- Medicare/Medicaid participation eligibility or certification (if applicable)
Work History Details
- Five-year work history
- If there are any gaps longer than six months, please explain.
- Statement of work limitations, license history and sanctions (only required if you are applying to join UnitedHealthcare’s Medicare and Medicaid plans).
The statement must include:
- Any limitations in ability to perform the functions of the position, with or without accommodation;
- History of loss of license and/or felony convictions; and
- History of loss or limitation of privileges or disciplinary activity.
- W-9 form
- Hospital staff privileges
- Active errors and omissions (malpractice) insurance or a state-approved alternative
- Malpractice history
- Other Credentialing requirements such as AMA profile or criminal history review as required by Credentialing Authorities
- Notification if this provider has ever been a delegated provider prior to this credentialing application
- Passing score on state site visit (if required)
Credentialing For Medicaid and State Programs (Community Plan)
- State-specific Credentialing and Recredentialing information on how to join the UnitedHealthcare Community Plan network can be found in the Care Provider Manual.
Facilities — Credentialing Requirements
Each facility must meet the following criteria to be considered for credentialing:
- Current required license(s)
- General/comprehensive liability insurance
- Errors and omissions (malpractice) insurance
- Proof of Medicare/Medicaid program participation eligibility
- Appropriate accreditation by a recognized agency, or satisfactory alternative
- Centers for Medicare & Medicaid Services (CMS) certification
If you have questions about any of the required items, please review the UnitedHealthcare Credentialing and Recredentialing Plan for 2017-2019, specifically:
- Section 4.2 – Credentialing Criteria/Source Verification Requirements.
- Section 7.0 - Credentialing and Recredentialing of Facilities
Completing a CAQH ProView application is a fast and easy way to securely submit credentialing information. You enter information just once and it’s available to multiple health insurers at no cost to you.
- For providers in Hawaii: If you are joining a Medicare or commercial plan, or a combination of Medicare, Medicaid and commercial, you will begin the credentialing process by working with MDW Hawaii. Contact MDX at 808-532-6989, option 2. If you are only joining a Medicaid (Community) plan, please follow the instructions detailed under "For all others" below.
- For providers in Minnesota: You can complete a credentialing application through either CAQH ProView or through the Minnesota Credentialing Collaborative.
- For providers in Washington: You will begin the credentialing process by registering with OneHealthPort ProviderSource.
- For all others: You can start the process at CAQH.org. If you have any questions on accessing the CAQH ProView database, just call the CAQH Help Desk at 888-599-1771 for assistance.
Many states require that you complete a state-mandated credentialing application. In most cases, you can do this through CAQH – the information you submit will be converted into the appropriate state application format. To find out if your state requires its own application, review the UnitedHealthcare Credentialing Plan State and Federal Regulatory Addendum.
Already completed a CAQH application?
If you have a CAQH Provider ID number and are registered with CAQH ProView, here’s what you need to do:
- Check to make sure the account is up to date and complete. Your application will not be released to UnitedHealthcare until CAQH verifies that your application is complete.
- Authorize UnitedHealthcare to access your data (either by selecting global authorization or manually authorizing UnitedHealthcare).
Need to complete the CAQH application?
Here’s what you need to do:
- Go to CAQH.org to set up an account and complete an application.
- If you don’t fully complete the application or if more information is needed, someone from CAQH will contact you.
- Please respond to any requests from CAQH promptly so that you can complete your application in a timely manner.
- CAQH will notify you when your application is complete.
What happens next?
- CAQH will send you a quarterly reminder to review and update your information – keeping your application up to date makes it easier to credential with other insurers and speeds up the recredentialing process.
Once we receive your completed application from CAQH, we’ll review your application and verify your credentials. Specifically:
- Verifying credentials – We’ll contact the state board for your license and verify your professional training/education, etc. This primary source verification is conducted by Aperture on behalf of UnitedHealthcare.
- Application review – Your application will be presented to a committee of your peers to determine if you meet UnitedHealthcare’s credentialing requirements. This peer review can take up to 25 calendar days
You can check on the status of your credentialing application by calling UnitedHealthcare at 877-842-3210. Enter your Tax Identification Number (TIN) then select Credentialing > Medical > Get Status.