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UnitedHealth Premium® Physician Designation Program Notification Form

Please provide as much information as you can about your notification from UnitedHealthcare regarding your Premium designation. If needed, you can fill out the form multiple times.  

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Contact Information

Full name

Practice name

City, State, ZIP*

Email address

Phone number

Can we contact you directly if more information is needed?

• Yes
• No

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UnitedHealthcare Plan Information

Plan name

(e.g., OneNet PPO, Oxford Health Plans, United HealthcareOne, UnitedHealthcare Medicare Advantage)

City/State

Type of plan*

• Commercial Preferred Provider Organization (PPO)
• Commercial Health Maintenance Organization (HMO)
• Commercial Point of Service (POS)
• Commercial Provider Sponsored Organization (PSO)
• Commercial Health Savings Account (HSA)
• Commercial Religious Fraternal Benefits (RFB)
• Medicare Advantage PPO
• Medicare Advantage HMO
• Medicare Advantage POS
• Medicare Advantage Medicare Savings Account (MSA)
• Medicare Advantage Private Fee-For-Service (PFFS)
• Medicare Advantage RFB

Number of patients enrolled in plan(s)

What is your UnitedHealthcare provider designation?

(e.g., Ophthalmologist or Ophthalmologist; Retina Surgery)

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Premium® Physician Designation Program Information

Where you aware of your assignment into the Premium Physician Designation Program

• Yes
• No

Name of physician receiving Premium Designation letter

First, MI, Last

Total number of physicians in practice under Premium Designation Program

Date Premium Designation letter received

mm/dd/yyyy

Practice name

Address where Premium Designation letter received

Do you have other office locations where a Premium Designation letter was not received?

• Yes
• No

If yes, please provide the address of the other office location(s) and details of the assessment result

What was the outcome of your Assessment Result?

• Quality & Cost Efficiency
• Cost Efficiency & Not Enough Data to Assess Quality
• Quality & Not Enough Data to Assess Cost Efficiency
• Quality & Did No Meet Cost Efficiency
• Not Enough Data to Assess Quality & Did Not Meet Cost Efficiency
• Not Enough Data to Assess
• Not Evaluated
• Did Not Meet Quality & Cost Efficiency

Have you attempted a reconsideration?

• Yes, received response
• Yes, no response to date
• No, do not plan to submit
• No, planning to submit

If you submitted a reconsideration and received a response, please provide information on the response

Please include any change to your designation

How many days were you given to request a reconsideration?

Have you received unofficial communications from the plan directing you toward a specific treatment option?

• Yes
• No

If you answered yes, please describe the interaction

Please provide any other information that you think might be helpful

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