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FAQ - Credentialing Process

How do I join the OptumHealth Care Solutions - Physical Health Network?

You must first sign a Participating Provider Agreement (PPA) that describes the legal and regulatory requirements of joining the network. Once you agree to the contractual terms in the PPA, you must complete and submit a credentialing application. If you successfully complete the credentialing process you will receive an executed copy of your PPA and a welcome letter which indicates your participation effective date.

How do I get an application?

If you are interested in joining the network, please submit a Letter of Interest.

In my state, I am required to credential at an individual basis with OptumHealth but with the other health plans I participate with, they credential me at a group level. Why does OptumHealth require individual credentialing?

The requirement of group versus individual credentialing credentialing is a requirement of the State that you are participating with or a requirement of specific health plans.

What are the steps to complete credentialing?

(1) You must fully complete the application. If you do not fully complete the application or if more information is needed, someone from OptumHealth or Aperture (an Ingenix company) will contact you. It is important to respond promptly to those requests or we can't finish processing your application. (2) OptumHealth and Aperture verify certain information with the "primary source." That means the state board for your license, your professional training/education, etc. (3) Once the source verification is complete, your application is presented to a committee of your peers to decide if you meet our requirements. (4) If approved you will receive a welcome packet and instructions in the mail. Click Here to view the credentialing flow diagram

How long will it take to process my application?

OptumHealth strives to process complete credentialing applications in 60 days or less. It may take longer if you submit an incomplete application or if requested attachments are not submitted with the application.

How often are providers re-credentialed?

Providers are required to complete the credentialing every three years based on their initial credentialing date (unless their state has other requirements). A provider must successfully complete recredentialing in order to remain a participating provider.

What happens during recredentialing?

After you have been in the network for about 2 ½ years you will receive notification for recredentialing. The notification will include instructions specific to your specialty. If your application is on CAQH and is kept updated, you may not need to take any action at the time of recredentialing.

What if the Credentialing Committee denies my initial application for participation or my recredentialing application?

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. Your denial or termination letter explains your rights and the timelines you must follow.

What is the submission deadline for the Cred/Re-Cred forms?

There is no deadline to submit an initial credentialing application but you can't become a network provider until you have successfully completed the credentialing process. Recredentialing applications should be completed as soon as possible after you receive the notification. If you do not submit a complete recredentialing application, your network participation will be terminated, and you may not be eligible to reapply for two years.

The state I practice in has a mandated state application - can I submit that?

Yes. OptumHealth complies with all the state mandated application rules.

What is a National Provider Identification Number (NPI) and where can I obtain one?

NPI is a National Provider Identification (NPI) number. If you don't know how to get an NPI, you should contact your state licensing board to find out the requirements.

Do I need a Medicare number to participate with OptumHealth Care Solutions, LLC.?

You need a Medicare number if you are going to provide any services for members with Medicare. OptumHealth prefers that you have one so you can participate with all health plans. Some health plans require that you have this number to participate with any of their products.

Do I need a Medicaid number to participate with OptumHealth Care Solutions, LLC.?

You need a state Medicaid number if you are going to provide any services for members covered under any of the state Medicaid programs. OptumHealth prefers that you have one so you can participate with all health plans. Some health plans require that you have this number to participate with any of their products.

What is professional liability (malpractice) insurance?

This is the insurance that pays if the provider is sued by a patient for wrong treatment, etc. This is different than general liability insurance that covers your building in case of a fire or in case someone falls and is injured on your property.

How much professional liability (malpractice) insurance does Optum require?

OptumHealth requires a minimum of $100,000 per occurrence / $300,000 in aggregate. Many health plans require higher limits. If you are a physical, occupational, or speech therapy provider you must have $1,000,000 per occurrence / $3,000,000 in aggregate to participate with any health plans.

What does CV mean and is it required?

CV means curriculum vitae (pronounced ker-ik-u-lum vee-tae). It is similar to a resume and contains a summary of your educational background, work history, professional license, and any other special training you may have taken. OptumHealth does not require you to submit a CV. Simply complete the questions on the application.

What is ERISA?

ERISA is a specific government regulation for certain kinds of insurance-like benefit plans. Usually "ERISA plans" are created by large employer groups that are considered "self-insured" to provide health care benefits for the employees and families of that employer.

I received a letter that my credentialing application is missing some information. What do I do?

You should follow the directions provided. If you have questions you should contact the person who sent the request. Respond promptly to these requests so OptumHealth can continue processing your application.

Why do I have to send you all the same information for recredentialing?

If you have a CAQH application and have kept it up to date, Optum will obtain the information from CAQH. If you have not completed a CAQH application, you will need to do so. Once the application is completed, you need to keep the information up to date. If your clinic is being credentialed as an organization, you will need to complete a separate “group” credentialing application.

I don't understand why I was denied (or terminated) from the network.

The letter you received should have a name on it and a phone number you can call for further information.

Can I appeal this decision?

Yes, usually you can. The letter you received should have instructions about how to submit a written appeal.