As a UnitedHealthcare agent, you are required to report certain types of events. This includes things like changes in the coverage, changes in the terms of the policy, and cancellations.
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Event reporting is a critical part of UnitedHealthcare’s (UHC) compliance program. As a UHC agent, you are required to report certain events that may impact the company’s business relationship with you.
An “event” is defined as anything that could potentially affect UHC’s business relationship with you, including but not limited to:
-Arrests or indictments
-Convictions (including guilty pleas, nolo contendere pleas, and probations before judgment)
-Administrative actions or sanctions by any governmental agency or self-regulatory organization
-Judgments or settlements in litigation to which you were a party
-Reportable complaints filed against you with any state insurance department or self-regulatory organization
If you become aware of any event that may trigger a reporting obligation, you must notify UHC within 30 days. Failure to do so may result in termination of your contract.
Types of events that must be reported
Any type of event that could potentially impact the care of the member or the cost of care must be reported. These events could be changes in the member’s condition, changes in the member’s care plan, or changes in the provider’s status.
Changes in ownership
An agent must notify UnitedHealthcare of any change in ownership, including but not limited to:
-Addition or deletion of an owner
-Transfer of ownership interest
-Change in business entity (e.g., from sole proprietor to LLC)
-Change in agent/agency name
Changes in contracting status
If you’re a contracted UnitedHealthcare agent, you must report any change in your contracting status with UnitedHealthcare, another insurance company or your business structure within 30 days. For example, if you sell your agency, start working for another agency or become an independent contractor, you must notify us. You can report a change by emailing [email protected] or calling the Producer Change Request Line at 1-866-842-3278.
Changes in provider type
In order to prevent fraud, waste and abuse, agents are required to report certain events that may indicate potential fraudulent activity. These events may be related to the agent, a provider or a member. Refer to the list below for examples of events that must be reported, and see the Unites States Department of Health and Human Services (HHS) Office of Inspector General (OIG) for more information.
-A change in provider type
-A change in practice location
-An increase in complaints or requests for service
-Unusual billing patterns or excessive billing
-Abusive or excessive use of emergency services
-Improper prescribing practices
-Intentional upcoding or incorrect coding
-Failure to meet quality standards
Changes in group size
If the group size decreases, please submit a new Member List reflecting the decrease and send it to your account manager.
Changes in geographic location
– if the agent relocates their business office
– if the agent changes his/her mailing address, email address or phone number
– if the agent will be out of the office for an extended period of time
– any other change in the agent’s business operation that might affect the ability of UnitedHealthcare to contact the agent or the agent’s ability to service clients
Changes in specialties
An agent must report any change in specialties to UnitedHealthcare. A change in specialty is defined as adding or deleting a specialty, or a change in the type of specialty. For example, an agent who deletes the Internal Medicine specialty and adds the Pediatrics specialty would need to report the change.
When to report an event
If an agent becomes aware of an event that could affect the company’s relationship with a provider, the agent must report the event to UnitedHealthcare.
How to report an event
If you are an event sponsor, you must report the event to UnitedHealthcare within seven days of the event taking place by completing the Event Submission Form and returning it to your account manager.
As an agent, you are required to report any material change that may affect the risk profile of a policyholder or contract. This includes, but is not limited to, changes in:
-Number of Dependents