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Ch 22: Delegated Entities
Supplemental Information for Capitated and/or Delegated Providers
This information is applicable for VHP’s Commercial Employer Group, Covered California and Individual & Family plans for members whose provider, independent practice association (IPA), medical group, or other organized provider entity is paid on the basis of capitation and performs administrative responsibilities on behalf of VHP pursuant to a delegation agreement.
Does this Supplement Apply to Me?
This applies if the provider is a: • Capitated provider; or Delegated provider.
To summarize, this supplement applies if: 1. A VHP member has been assigned to or who has chosen a provider (either an individual participating provider or an entity as defined above) that receives a capitation payment from VHP for that member or for the performance of administrative or clinical functions; and 2. The member is covered under a plan insured by or receiving administrative services from VHP.
Capitated Providers What is a capitated provider?
Capitation is a payment arrangement for health care providers, which is generally paid based on a per member, per month (pmpm) or a percent of premium. If the provider has an agreement with VHP based on one of these reimbursement methodologies, the provider is considered a capitated provider. VHP pays capitated providers a set amount for each member assigned per period of time, which is generally a month. VHP pays capitation regardless of whether the member seeks care. In most instances, the capitated provider is associated with a medical group or an IPA. Sometimes, the capitated provider is an individual provider, ancillary provider or hospital.
Capitated providers may also be subject to VHP’s protocols, policies and procedures related to delegated activities, including by way of example only, submission of encounter data (see Chapter 14, “Encounter Data”) and other requirements reflected in the provider’s agreement with VHP.
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Delegated Providers What is a Delegated Provider?
Delegation is a process VHP uses to give another entity the authority to perform specific administrative or clinical functions on behalf of VHP. The functions delegated must be performed in accordance with VHP’s policies, procedures, protocols, VHP’s Provider Manual and all applicable regulatory and accrediting standards (Applicable Requirements).
Assuming a provider has successfully completed and passed the VHP’s pre-delegation audit, VHP may elect to delegate: 1. Utilization management (see Chapter 17, “Utilization Management”); 2. Credentialing (see Chapter 9, “Credentialing and Recredentialing”); 3. Claims adjudication and payment (see Chapter 13, “Claims & Billing Submission”); 4. Case management (see Chapter 18, “Case Management”); or 5. Other clinical and administrative functions.
Refer to the Delegation of Administrative Responsibilities in the provider agreement with VHP to determine which delegated activities, if any, are performed on behalf of VHP.
When VHP delegates any of these responsibilities, the provider is considered a Delegated Provider (“delegated entity” or “delegate”). VHP remains responsible to external regulatory and accrediting agencies and other entities for the performance of the delegated activities. To become a delegate, the provider must demonstrate compliance with VHP’s established standards and best practices. Additionally, to remain a delegate, the provider must continuously comply with VHP’s standards and best practices. If the delegate is non-compliant with VHP’s standards and best practices, VHP may revoke any or all delegated activities.
If an individual provider is associated with a delegated medical group, IPA, or other provider entity, the individual provider must conform to the policies and protocols of the Delegated Provider.
All delegates are formally reevaluated annually. Failure of the Delegated Provider to perform any delegated activity in accordance with VHP’s Applicable Requirements may result in a corrective action plan (CAP) or revocation of any or all of the delegated activities and a reduction in the capitation rate paid to the Delegated Provider by VHP.
VHP retains the right to determine in its sole discretion whether to delegate any functions regardless of results of an audit.
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Appendix
Book Table of Contents
Click the purple VHP circle logo, located at the bottom left corner, to return to the main TOC.
Printable forms are found in the Appendix. Links to fillable online versions can be found below.
Forms:
1. Authorized Representative Form
https://www.valleyhealthplan.org/sites/p/fr/Documents/ Provider-Forms/Authorized-Representative-Form.pdf
2. Continuity of Care Form
https://www.valleyhealthplan.org/sites/p/fr/Documents/ Provider-Forms/Continuity-of-Care-Request-Form.pdf
3. HIV-Aids Attestation Form
https://www.valleyhealthplan.org/sites/p/fr/Documents/ Provider-Forms/HIV-AIDS-Attestation-Form.pdf
4. Language Attestation Form
https://www.valleyhealthplan.org/sites/p/fr/Documents/ Provider-Forms/Language-Attestation-Form.pdf
5. Member Grievance and Appeal Form
https://www.valleyhealthplan.org/sites/p/fr/Documents/ Provider-Forms/Member-Grievance-and-Appeal-Form.pdf
6. Potential Quality Issue Reporting Form
https://www.valleyhealthplan.org/sites/p/fr/Documents/ Provider-Forms/Potential-Quality-Issue-Reporting-Form. pdf
7. Prescription Drug Prior Authorization Request Form
https://www.valleyhealthplan.org/sites/p/fr/Documents/ Provider-Forms/Prescription-Drug-Prior-AuthorizationRequest-Form.pdf
8. Provider Dispute Form
