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Commercial Product Overview - Chapter 3, 2018 UnitedHealthcare Administrative Guide

Organized by commercial product name 1, the following information answers these questions:

  • How do members access physicians and health care professionals?2
  • Is a referral required from the member's PCP to the network specialist?
  • Is the treating network physician and/or facility required to give notification when providing certain services? 

To view details, click on the "+" sign by the product name of interest. 

How do members access physicians and health care professionals?

Members can choose any network physician or health care professional without a referral and without designating a PCP.

UnitedHealthcare Choice Plus provides out-of-network benefits. UnitedHealthcare Choice does not cover out-of-network services (except for emergency services). 

Is a referral required from the member's PCP to the network specialist?

No, members have open access to a national network of care providers. 

Is the treating network physician and/or facility required to give notification when providing certain services? 

Yes, on selected procedures as described in Chapter 6: Medical Management of this guide.

How do members access physicians and health care professionals?

Members choose, or are assigned, a network PCP for each family member. Members are encouraged to see their PCP to coordinate their care, but are not required to see that PCP, or to obtain a referral from a PCP when accessing a specialist or facility for care.

UnitedHealthcare Select Plus provides out-of-network benefits. UnitedHealthcare Select does not cover out-of-network services (except for emergency services).

Is a referral required from the member's PCP to the network specialist?

No, members have open access to a national network of care providers.

Is the treating network physician and/or facility required to give notification when providing certain services? 

Yes, on selected procedures as described in Chapter 6: Medical Management of this guide. 

How do members access physicians and health care professionals?

Members can choose any network physician or health care professional without a referral and without designating a PCP. Options PPO provides, out-of- network benefits.3

Is a referral required from the member's PCP to the network specialist?

No, members have open access to a national network of care providers.

Is the treating network physician and/or facility required to give notification when providing certain services? 

Members are responsible for notifying us using the phone number on their health care ID card, as described under the members benefit plan.

How do members access physicians and health care professionals?

Members can choose any physician or health care professional.

Is a referral required from the member's PCP to the network specialist?

No, members have open access to any care provider.

Is the treating network physician and/or facility required to give notification when providing certain services? 

No, members are responsible for notifying us using the phone number on their health card ID card.

How do members access physicians and health care professionals?

Members can choose any network physician or health care professional without a referral and without designating a PCP. Core provides out-of-network benefits. Core Essential does not (except for emergency services). emergency services).

Is a referral required from the member's PCP to the network specialist?

No, members have open access to a national network of care providers.

Is the treating network physician and/or facility required to give notification when providing certain services? 

Yes, on selected procedures as described in Chapter 6: Medical Management of this guide.

How do members access physicians and health care professionals?

Members must see their assigned PCP and have electronic referrals submitted by their PCP before seeing another network physician. Navigate Balanced and Plus benefit plans provide additional network coverage at a higher member cost share for services from a network physician other than the member’s PCP without a referral. Navigate does not. Navigate Plus provides out-of-network benefits3. Navigate and Navigate Balanced do not (except for emergency services).

Is a referral required from the member's PCP to the network specialist?

Yes, an electronic referral from the member’s PCP is required prior to receiving services from a provider participating in a limited network. See Chapter 5: Referrals of this guide.

Is the treating network physician and/or facility required to give notification when providing certain services? 

Yes, on selected procedures as described in Chapter 6: Medical Management of this guide.

How do members access physicians and health care professionals?

Members must see their assigned PCP and have electronic referrals submitted by their PCP before seeing another network physician to receive the highest level of coverage. Charter Balanced and Charter Plus benefit plans provide additional network coverage at a higher member cost share for services from a network physician other than the member’s PCP without a referral Charter does not.

Charter Plus provides out-of-network benefits3. Charter and Charter Balanced do not (except for emergency services).

Is a referral required from the member's PCP to the network specialist?

Yes, an electronic referral from the member’s PCP is required prior to receiving services from a provider participating in a limited network. See Chapter 5: Referrals of this guide.

Is the treating network physician and/or facility required to give notification when providing certain services? 

Yes, on selected procedures as described in Chapter 6: Medical Management of this guide.

How do members access physicians and health care professionals?

Members must see their assigned PCP and have electronic referrals submitted by their PCP before seeing another network physician within the network service area to receive the highest level of coverage4. Compass Balanced and Plus benefit plans provide network coverage at a higher member cost share for services from a network physician other than the member’s PCP without a referral.Compass does not.

Compass Plus provides out-of-network benefits.3 Compass and Compass Balanced do not (except for emergency services).

Is a referral required from the member's PCP to the network specialist?

Yes, an electronic referral from the member’s PCP is required prior to receiving services from a provider participating in a limited network. See Chapter 5: Referrals of this guide.

Is the treating network physician and/or facility required to give notification when providing certain services? 

Yes, on selected procedures as described in Chapter 6: Medical Management of this guide. 

How do members access physicians and health care professionals?

NexusACO OA is a tiered benefit plan where members choose, or are assigned, a network PCP for each family member. The member is encouraged to see their PCP to coordinate their care, but is not required to see that PCP or obtain a referral when accessing other network care providers.

NexusACO OAP is a tiered benefit plan and provides out-of-network benefits.3 NexusACO OA does not cover out-of-network services (except for emergency services).

Is a referral required from the member's PCP to the network specialist?

No, members have open access to a national network of care providers.

Is the treating network physician and/or facility required to give notification when providing certain services? 

Yes, on selected procedures as described in Chapter 6: Medical Management of this guide.

How do members access physicians and health care professionals?

NexusACO® is a tiered benefit plan where members must see their assigned network PCP and have electronic referrals submitted by their PCP before seeing another network specialist to receive the highest level of coverage. NexusACO R provides out-of-network benefits.3

NexusACO RB and RP do not (except for emergency services).

All NexusACO benefit plans are tiered.

Is a referral required from the member's PCP to the network specialist?

Yes, an electronic referral from the member’s PCP is required prior to receiving services from a provider participating in a limited network. See Chapter 5: Referrals of this guide.

Is the treating network physician and/or facility required to give notification when providing certain services? 

Yes, on selected procedures as described in Chapter 6: Medical Management of this guide.

1 The UnitedHealthcare Network may be different among commercial products in your local market. Please refer to your contract to determine whether you are part of that local network.
2 Physicians and health care professionals must be licensed for the health services provided and the health care services provided must be covered under the member’s benefit contract.
3 The benefit level for non-emergency services from out-of-network physicians and other care providers generally less than for services from network physicians and other care providers.
4 For more information the Compass service area, please go to UHCprovider.com/plans.