The PCP is responsible for determining when the member needs a referral. Only the PCP can make an initial referral. These must be made to participating care providers. We deny claims for services rendered without a proper referral. You cannot bill the member for those services unless, prior to receiving the service, the member agrees in writing:
- That the referral is not in place or that the services is not a covered service, and
- To be financially responsible for the cost of the service.
Referrals to a specialist may be necessary:
- When a member fails to respond to current medical treatment
- To confirm or establish a member’s diagnosis and/or treatment modality
- To provide diagnostic studies, treatments or procedures that range beyond the scope of the PCP. PCPs may make referrals to specialist according to the Specialty Referral Guidelines section.
The following specialty services do not require referral:
- Chiropractic (subject to benefit limitations)
- Dermatology (five visits per calendar year)
- Substance use treatment*
- Mental health*
Out-of-network referrals are only approved when the services are not available from a participating care provider. Request out-of-network referrals by calling NHP at 800-550-5568.
Once we receive the referral, the data will be reviewed and, if approved, entered into the system to help ensure payment of the specialist claims.
Specialty Referral Guidelines
- Once the specialty services have been properly authorized, the member or PCP may schedule an appointment with the specialist.
- Please submit specialist referrals online. Use eligibilityLink and click on the referral icon in the member’s information.
- We mail an authorization letter to the specialist for the member’s medical record.
- We do not pay specialist claims without a referral.
- The specialist should re-verify the member’s eligibility at the time of visit by calling Provider Services 877-842-3210. Please refer to the back of the member’s health care ID card to help ensure the appropriate Provider Services department is contacted.
Call 800-817-4705 for behavioral health service requests.
All NHP HMO members require a referral before schedulingappointments for specialty services.
A member may self-refer to a NHP obstetrician who is a participating care provider for routine obstetrical (OB) care. If the member is referred to a non-participating specialist, the specialist must notify us through UHCprovider.com or by fax at the number designated on the top of the Prior Authorization Form to make sure accurate claims payment for ante- and postpartum care.
- Plain film radiography performed by a NHP participating care provider or in the obstetrician’s office during an authorized visit, does not require prior authorization.
- Routine labs performed in the obstetrician’s office, or that are provided by a participating care provider in support of an authorized visit, do not require prior authorization.
- Office procedures and diagnostic and/or therapeutic testing performed in the obstetrician’s office that do not require prior authorization may be performed.
* See the prior authorization section of this supplement.