Medicare Advantage referrals
UnitedHealthcare Medicare Advantage referral plans emphasize the role of the primary care provider (PCP). Members choose a PCP to oversee their health care needs and manage referrals to network specialists and other health care professionals.
With referrals, the PCP can provide more personalized, consistent care to members by connecting patients with appropriate specialists while keeping the PCP involved in all aspects of a member’s care. Referrals are an important tool that helps the PCP:
- Enhance care coordination
- Reduce gaps or delays in treatment
- Strengthen provider collaboration
Specialist services
Most UnitedHealthcare Medicare Advantage HMO and HMO-POS members need a PCP referral before receiving certain specialist services in outpatient, office or home settings.
Things to know
Timing
Referrals are effective immediately upon submission. To avoid rescheduling or cancellations, PCPs can submit referrals up to 5 calendar days after the visit by selecting a start date up to 5 days prior to the visit.
Exceptions
Referral requirements do not apply to members enrolled in Institutional SNP plans, Erickson Advantage plans or the Michigan Integrated D-SNP plan (H2247-005).
Referral use
Members with an active referral may see providers of the same specialty who bill under the same TIN — including physicians, nurse practitioners, physician assistants or other health care professionals - without a separate referral.
Submission requirements
Referrals must be submitted by the PCP before the specialist visit.
California, Nevada and Texas
Existing referral requirements remain in place. UnitedHealthcare will not track or enforce referrals in these states. Providers should follow delegate or plan-specific guidance.
| Referrals are not required for these specialty services and provider types | |
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| Services | Providers |
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Member plan benefit materials may list additional referral requirements. However, UnitedHealthcare will not check for referrals for the exclusions listed above when processing claims.
Frequently asked questions
Overview and purpose
Why are referrals required?
Referrals help ensure care is clinically appropriate and coordinated across the care continuum.
Does UnitedHealthcare have any guidelines the PCP must follow to determine when to issue a referral to a specialist?
No. It is at the PCP's discretion what process will be used to determine if the member should be referred to a specialty provider. UnitedHealthcare does not track individual PCP referral practices. The PCP may:
- Determine a referral to a specialist is not required and can be managed by the PCP
- Submit a referral after a phone consultation
- Require an in-person visit prior to submitting a referral
Submitting referrals and required information
Who is responsible for submitting referrals?
The member’s PCP is responsible for submitting referrals before the member seeks care from a network specialist. All referrals submitted to UnitedHealthcare by a network PCP and visible in the UnitedHealthcare Provider Portal will be honored, regardless of whether the submitting provider is currently the member's assigned PCP. Any network PCP for the member’s plan can submit referrals, in addition to any PCP with the same TIN as the member’s assigned PCP.
Can out-of-network PCPs issue referrals to network specialists?
No. Out-of-network PCPs cannot issue referrals.
How do I submit and validate referrals?
Use the Referrals tool, found in the UnitedHealthcare Provider Portal to submit any referral requests. Sign in to the provider portal with your One Healthcare ID and select Referrals from the menu. Referrals are effective immediately upon submission. It may take up to 48 hours for them to appear online.
Are diagnosis and/or procedure codes required with the referral submission?
A diagnosis code is required with the referral submission with the ability to enter 1 additional diagnosis code on the referral. The diagnosis code(s) are informational only and will not be used to process claims. Procedure codes are not required with referrals.
Referral validity, timing and visit limits
How long is a referral valid?
Referrals are valid for the number of visits entered by the PCP (up to 99 visits) or for 6 months from the referral's effective date, whichever comes first.
Can referrals be entered retroactively?
PCPs can choose an effective date of up to 5 calendar days prior to the date of submission. Referrals are effective immediately upon submission but may take up to 2 business days to display in the portal. UnitedHealthcare does not approve or deny referrals; they are accepted as entered by the PCP.
Can I change or extend the referral after submission?
Referrals cannot be amended or extended once submitted.
What if additional visits are needed?
If additional visits or time are needed after a referral expires or visit limits are reached, the member or specialist should contact the member’s PCP to request another referral for additional visits and/or time.
Additional or subsequent specialty care
What happens if a member needs to see an additional specialist?
If a specialist recommends care from another specialty or sub-specialty that requires a referral, the member or specialist should contact the member’s PCP to determine whether an additional referral is needed. If the specialist or sub-specialist falls under a specialty that does not require a referral, no additional referral is needed.
Referrals vs. prior authorization and notifications
Are prior authorizations still needed?
Yes. Prior authorization and advance notification requirements still apply.
Are referrals, prior authorization and advance notification required for the same services?
Yes. Referrals, prior authorization and advance notification may be required for the same services. If a service requires prior authorization or advance notification, those requirements must be met regardless of whether a PCP referral is on file. Prior authorizations are subject to UnitedHealthcare review and approval
PCP changes and member coverage scenarios
What happens to an active referral if a member changes their assigned PCP?
Members may request to change their PCP at any time. Referrals previously submitted by the member’s PCP are not affected by PCP changes. PCP change requests for members are effective the first day of the following month.
If a member has Tricare For Life and a Medicare Advantage HMO plan, is a referral required?
Yes. Tricare For Life (TFL) becomes secondary and members must use the Medicare Advantage plan network and follow Medicare Advantage coverage rules. If the member’s HMO plan requires referrals, those rules apply.
If a member sees a non-network Veterans Affairs (VA) PCP, can that provider refer them to in-network HMO specialists or hospitals?
Yes. VA PCPs can call Provider Services and have the referral entered to a specialist in the plan network on their behalf
Referrals after ER or inpatient care
If a member is seen in the ER and/or admitted to inpatient and has specialty visits scheduled as part of discharge, are referrals required for those visits?
Members should schedule visits with their PCPs upon discharge. The PCP should enter any necessary referrals to the specialists.
- If the visit with the specialist occurs within 7 days of the ER or inpatient discharge, the referral requirement will be waived
- PCPs can submit retroactive referral effective dates up to 5 calendar days prior to the date the referral is submitted
- If the specialist visit is not within 7 days of the ER or inpatient discharge and the member is unable to get an appointment with their PCP, members or specialists may call UnitedHealthcare to request a one-time courtesy referral for follow-up with the specialist after discharge from ER and/or inpatient admission
Resources
- Get answers to your questions about referral requirements: 2026 UnitedHealthcare Medicare Advantage Referral Requirements Guide
- Get updated plan information: 2026 Medicare Advantage, CSNP & DSNP Plan Overview Course
- Delegate referral requirements: UHCprovider.com/plans > Choose your state > Medicare > Choose plan > Look for the delegate name
- Verify eligibility and request referrals digitally: We offer several digital tools to help you manage eligibility and referral activity. The digital solutions comparison guide can help you choose which tools are right for your practice.
- Learn how to verify referral requirements, submit requests and see the status of referrals in the Provider Portal: Referrals Interactive User Guide
Questions? We’re here to help.
Connect with us through chat 24/7 in the UnitedHealthcare Provider Portal.