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Network Contracting & Credentialing

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Contracting

Provider Contracting

Organizational/Provider Contracting Criteria

Provider applications to participate in any U of U Health Plan network are considered based on the following:

  • Business needs
  • The credentialing process

All providers must be approved through our credentialing process before they may participate in any network.

Business needs may include and are not limited to:

  • Network adequacy requirements based on state and/or federal guidelines
  • Network adequacy requirements based on the current or expected population of a given geographic area (usually defined by county or zip code)
  • Network adequacy requirements based on provider type and/or specialty
  • Network composition based on scope of services required by payer such as employer, health plan, union/trust, government entity, etc.
  • Network performance requirements in terms of cost/utilization, quality measures, outcomes, access, and/or patient or physician satisfaction
  • Demographic needs including but not limited to languages spoken
  • Existing, non-compensated, referral patterns with current network providers and/or U of U Health Plans members

Benefits of participating with a U of U Health Plan network include:

  • Claim payments made to you directly on a weekly basis
  • Provider Relations representatives are available to help you and your staff
  • Inclusion in our on-line and printed provider directories made available to brokers,employers and members for the applicable products
  • Member benefits are designed to encourage use of network providers
  • Eligibility to register for Provider Portal, our online tool to verify eligibility, check claims status, submit inquiries, and more

Organizational/Provider Contracting Process

Note: We are no longer accepting applications for Durable Medical Equipment/Medical Supplies providers, Laboratory/Pathology providers, Infusion Suites, or General Dentists (Oral Surgeons are accepted).

To apply, complete the Provider Application Form below.

Our Contracting Committee reviews applications within 15 to 20 business days.

  • If the application is approved, one of our Contracting Executives will extend a contract to you. When we receive the signed contract back from you, we will initiate credentialing of all providers listed in Exhibit B.
  • If the application is denied, you will be notified.

Credentialing typically takes 6-8 weeks to complete following receipt of the signed contract. The Credentialing Committee makes the final determination as to whether the provider meets our credentialing criteria. This committee meets the first Monday of each month, excluding holidays. Once credentialed, providers can begin to see members.

If you need to make an update to your practice, use the Provider Information Update Form, not a new Application.

Note: Adding a New Provider

If you already have a contract and are adding a new provider, follow instructions under Practitioner Credentialing.

Note: Provider Business Updates

If you need to update your existing location or business information, complete and submit the Provider Information Update Form.

For consideration in one or more of our networks please complete the application process.

Start Application

Credentialing

Credentialing Process

University of Utah Health Plans now partners with Certify OS to conduct all primary source verifications for our credentialing process. Learn more

The credentialing process varies depending on whether an individual practitioner or an organization is being credentialed.

organizational credentialing icon

Organizations

For Organizations, credentialing must be completed every three (3) years. Read more

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Providers

Providers must complete a CAQH profile and be contracted before credentialing. Read more

Practitioner Credentialing

Practitioners must complete the practitioner contract application and approval process prior to credentialing with University of Utah Health Plans. Once credentialed, providers may begin to see members.

Initial credentialing and subsequent re-credentialing every three (3) years is required for all physicians and other types of health care professionals practicing under their own license as permitted by state law with whom members schedule appointments. The credentialing program follows the standards set forth by the National Committee for Quality Assurance (NCQA) and uses CAQH exclusively for the credentialing application.

University of Utah Health Plans requires that Advanced Practice Professionals (APP), including PAs, complete credentialing.

Where to Start? Let’s Get Started!

For new practitioners with your practice, simply send the following information for each practitioner to be credentialed, or a roster containing the information below, to our credentialing team at provider.credentialing@hsc.utah.edu.

  • Practitioner’s first and last names with middle initial
  • Practitioner’s title
  • Practitioner’s specialty
  • Practitioner’s date of birth
  • Practitioner’s CAQH Provider ID
  • Provider NPI
  • Group Tax ID
  • Primary practice location
  • Credentialing contact name and email address

Do you have a CAQH ID?

  • Practitioner with CAQH ID

    Steps to Follow:

    1. Ensure University of Utah Health Plans has been granted permission to access your application
    2. Sign in to CAQH to review, update and re-attest to application's correctness and completeness

  • Practitioner without CAQH ID

    Steps to Follow:

    1. Register for a CAQH ID
    2. Complete a CAQH application
    3. Ensure University of Utah Health Plans has been granted access to application

Organizational Provider Credentialing

Credentialing is completed upon initial contracting and then every three (3) years in accordance with our Credentialing Policy.

University of Utah Health Plans ensures that all organizational practitioners have the following:

  1. Current state license(s) and/or certification in good standing with state and federal authorities
  2. Adequate liability coverage
  3. Site visits maybe required at the discretion of the credentials committee
  4. Birthing centers must have a clear, written plan of transfer and transition of care in emergency circumstances. The plan must include the name(s) of the Hospital and the OB/GYN practitioner(s) providing backup.

For new Organizational Providers, if you are not already contracted, please contact our Contracting team to begin this process. Credentialing can begin after you are contracted with U of U Health Plans.

For re-credentialing, please click on the link below to download the Organizational Provider Credentialing Application.
Organizational Provider Credentialing Application

A completed Organizational Provider Credentialing Application can be emailed to: facility.credentialing@hsc.utah.edu.

Credentialing Review

Initial and Reappointment Decisions

The decision to accept or reject a practitioner’s application for initial or reappointment is based on information generated through primary source verifications including but not limited to:

  1. Application information
  2. Complaints and grievances
  3. Malpractice history
  4. Licensure in good standing
  5. Education/training or board certification in the practice specialty

Other sources of information may be considered as appropriate and relevant at the sole discretion of the Credentialing Committee members.

Ongoing Monitoring

University of Utah Health Plans does ongoing monitoring of practitioner sanctions and disciplinary actions. Reports from the following are reviewed monthly:

  1. National Practitioner Databank (NPDB)
  2. Office of Inspector General (OIG)
  3. System for Award Management (SAM)
  4. Departments of Professional Licensing

Practitioners with Medicare / Medicaid sanctions, or who have a business relationship with another practitioner or entity that has been debarred or excluded, will be terminated from the University of Utah Health Plan's participating networks. Practitioners who have had restrictions placed upon their license to practice will be presented to the Credentialing Committee for a decision on the appropriate action to be taken.

For any unfavorable decisions, practitioners may consult the Practitioner Appeal Rights in the Credentialing Policy.

Practitioner Rights

The applicant shall have the right to be informed of their application status (Ready for Committee, App In-process, App Incomplete or Missing Information) upon request. The request shall be made via email to: provider.credentialing@hsc.utah.edu, or by phone to 801-587-2838, opt 3. Information on Practitioner Rights may also be found in the Provider Manual. Emails will be responded to within 24 hours, and voice mails returned within 48 hours.

The Practitioner will have the opportunity to correct any erroneous information, as applicable, during the 2-3 month credentialing process. Applicants are notified of this right through our Provider Manual and details of the process are outlined in our Credentialing Policy.

Upon request, applicants may review the information s/he has submitted in support of their credentialing or re-credentialing application and if something requires correction, practitioners will be asked to amend their CAQH application.

University of Utah Health Plans is not required to reveal sources of information that are part of our verification requirements or if federal or state law prohibits us, such as NPDB reports. The applicant may view their file in the presence of the University of Utah Health Plans Medical Director and a member of the credentialing team. Applicants are notified of these rights in the Provider Manual and Credentialing Policy..

Practitioner Rights

Practitioners must complete the practitioner contract application and approval process prior to credentialing with University of Utah Health Plans.