Compliance Bulletin
Choosing a Primary Care Physician (PCP) for UnitedHealthcare HMO and PPO Plans
April 25, 2018

Network/Provider Access Information is one of the top complaint allegations received. Read the information below for tips on how to prevent this from possibly happening to you.

Member selected PCP assignments are a critical component of every member enrollment completed for both the HMO and PPO plans. It helps to close the gap between provider and membership.

Lack of a valid member selected PCP leads to:

  • A system-generated auto-assignment
  • A higher rate of member rapid dis-enrollments (within 60 days of submission)
  • Member dissatisfaction
  • Gaps in member care and negative impact to Star Ratings

Who Receives a Primary Care Physician Assignment?

Some plans require the member to have a designated Primary Care Physician (PCP) and it will be noted on their member ID card.

If the enrollment application contains Name and ID fields for a PCP, then a PCP is required and both fields must be populated.

Otherwise, if there is not a PCP field on the enrollment application, then a PCP does not need to be assigned.

What are the requirements for an accurate PCP Assignment?

The name and ID fields on the enrollment application must be populated exactly as the information appears in the online Provider directory. If the provider of choice does not show an ID number, this reflects a termination and an alternate PCP should be chosen to avoid an auto-assignment.

What are the consequences if an incorrect/invalid PCP is populated on the enrollment application?

Auto-assignment of a PCP has the potential to:

  • Cause member dissatisfaction
  • Lower Star Rating for the plan
  • Delay member access to service due to inaccurate PCP assignment
  • Lead to negative auto-assignment for the writing agent

Rule of Thumb: If the application contains a section for PCP information, then this information must be populated on the enrollment forms.

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