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Medicare Advantage Referral Required Plans - Chapter 5, 2018 UnitedHealthcare Administrative Guide

Some MA benefit plans require referrals to specialists and rehabilitation centers. These plans focus on coordination of care through the PCP. These plans are network-only benefit plans.

Members must have a referral to receive network benefits for services from specialists. If members see a specialist without a referral, we will not pay for it. The care provider is liable for the charges; you cannot bill the member. 

These plans require notification and prior authorization for some services as well. A referral does not replace a notification or prior authorization. 

Check the front of the member’s health care ID card for referral language. MA members of gated plans have ‘Referral Required’ printed on the front of their health care ID card. The eligibilityLink app also shows if referrals are required. 

For more detailed information on health care ID cards and to see a sample health care ID card, please refer to the Health Care Identification (ID) Cards section of Chapter 2: Provider Responsibilities and Standards.

MA Services Not Requiring a Referral*

These services do not require a referral. However, they may require prior notification or authorization. For information on authorization requirements, refer to UHCprovider.com/priorauth.

  • Any service provided by a network PCP
  • Any service provided by a network physician practicing under the same tax ID as the member’s assigned PCP 
  • Any service from a network OB/GYN, chiropractor, optometrist, ophthalmologist, optician,  podiatrist, audiologist, oncologist, nutritionist, or disease management and infectious disease specialist 
  • Services performed while in observation 
  • Allergy immunotherapy 
  • Mental health/substance use services with behavioral health clinicians
  • Any service from a pathologist or anesthesiologist (excludes office-based or pain management services), and any inpatient consulting physicians including hospitalists 
  • Services rendered in an emergency room, emergency ambulance, or a network urgent care center or convenience clinic 
  • Virtual visits**
  • Medicare-covered preventive services, kidney disease education or diabetes self-management training 
  • Routine annual physical exams, vision or hearing exams 
  • Any lab services and radiological testing service, excluding radiation therapy
  • Durable medical equipment, home health, prosthetic/orthotic devices, medical supplies, diabetic testing supplies and Medicare Part B drugs 
  • Additional benefits that may be covered by some MA benefit plans but are not covered by Medicare, such as hearing aids, routine eyewear, fitness benefits that may include a gym membership, or outpatient prescription drugs 
  • Services obtained under the UnitedHealth Passport® Program, which allows for services while traveling
* Delegated benefit plans may follow a separate referral exclusion list.
** Applies to select MA benefit plans.

Referral Submission Requirements

The member’s assigned PCP must:

  • Submit referrals electronically using:
    • EDI Transaction 278R 
    • UHCprovider.com/eligibility
    • Delegated entity’s website listed on the back of the member’s health care ID card
  • Enter a start date within five calendar days of submission date 
  • Follow all requirements 
    • If not, we deny the claim and the charge is non-billable to the member.

Referrals are effective immediately. They are viewable online within 48 hours.

Maximum Referral Visits

The PCP determines the number of visits needed for each referral in a six-month period. They may submit another referral after the member uses the visits or they expire. Services done under a new referral are established patient visits.