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Commercial Products Referrals - Chapter 5, 2019 UnitedHealthcare Administrative Guide

These referral requirements apply to covered services given to commercial members enrolled in these plans:

  • Navigate, Navigate Balanced, Navigate Plus
  • Charter, Charter Balanced, Charter Plus
  • Compass, Compass Balanced, Compass Plus
  • NexusACO R, NexusACO RB, NexusACO RP

Not obtaining a referral for a required service means that:

  • Navigate, Charter, Compass and Nexus ACO® — The service is not covered.
  • Navigate, Charter, Compass and Nexus ACO® (Balanced and Plus versions) — There is a higher cost for the member.

Online Submissions of Referrals

Referral submissions are separate from both notification and prior authorization requests. Online referral submissions tools vary based on the members benefit plan. The easiest way to determine the correct online submission method is to look up the member in eligibilityLink. You’ll see whether a referral is required and you can click on the “Referrals” link to open the correct submission tool.

Commercial members of gated benefit plans have “In-Network Referral Required” printed on the back of their health care ID card.

Specialist Referrals

The member’s assigned PCP manages their care. The member’s PCP needs to submit electronic referrals to us before the member sees another network care provider (a network care provider that is not within the same tax ID as the members PCP). Referrals are valid for any care provider within the same TIN as the specialist listed. 

Online Referral Submission & Status Verification

There are multiple ways to submit referrals electronically:

  1. EDI: Transaction 278R
  2. Link: Go to referralLink to determine referral requirements by plan.

Managing Referrals

Specialists and facilities must check the status of a referral for their TIN before each visit. For planned admissions and outpatient services rendered by a physician, facilities must check that the servicing physician has a referral to see the member. If not, the facility claim may not be covered, or the member may have a higher cost share. Referrals are for the specialist rendering the service or for the facility. Care providers should review a list of referrals related to the member on Link when verifying the member’s eligibility.

  • Referrals are only valid for the authorized number of visits or through the indicated referral end date. Any unused visits are not valid after the end date. 
  • If a referral is no longer valid, but the member requires additional care, the member or specialist must contact the member’s PCP to request a new referral. The PCP then decides whether to issue an additional referral. 
  • If a network specialist sees a need for a member to go to another specialist, the specialist must ask the member’s PCP to issue an additional referral.

Commercial Benefit Plan Services Not Requiring a Referral

You do not need a referral for:

  • Services from network physicians in the same TIN as the member’s PCP or their covering network physicians
  • Services from a network OB/GYN specialists, nurse practitioners, nurse midwives, and physicians assistants 
  • Routine refractive eye exam from a network care provider 
  • Network optometrists
  • Mental health/substance use services with network behavioral health clinicians
  • Services rendered in any emergency room, network urgent care center, network convenience care clinic or designated network online “virtual clinic visits”
  • Services billed as observation 
  • Admitting physician services for emergency/unscheduled admissions
  • Services from facility-based inpatient/outpatient network consulting physicians, network assisting surgeons, network co-surgeons, or network team surgeons 
  • Services from a network pathologist, network radiologist or network anesthesia physician
  • Outpatient network lab, network, x-ray, or network diagnostic services
    • Services billed by a network specialist require referral.
  • Network rehabilitative services with exception of manipulative treatment and vision therapy (physician services)
    • Services billed by a network specialist require referral.
  • Other services for which applicable law does not allow us to impose a referral requirement

Referral Submission Requirements

  • Referrals must be submitted electronically.
  • Referrals are effective immediately.
  • They are viewable online within 48 hours.
  • We do not accept referrals by phone, fax or paper, unless state law requires us to.
  • We can backdate them up to five calendar days from the date of submission.
  • Web users must have access to the Referral Submission role on their user profile to submit and verify referrals.
  • Only the member’s PCP, or other PCP practicing under the same TIN, can submit referrals for the member to see a network specialist. A specialist cannot enter a referral.

Maximum Referral Visits

The PCP may submit up to six visits on a referral. Unused visits expire after six months. For members with the following chronic conditions, the PCP may submit up to 99 visits for up to six months per referral. 

  • Allergic Rhinitis
  • Anemia
  • Amyotrophic Lateral Sclerosis
  • Cancer
  • Cystic Fibrosis
  • Epileptic Seizure
  • Fracture Care
  • Glaucoma
  • Multiple Sclerosis
  • Myasthenia Gravis
  • Parkinson’s Disease
  • Retinal detachment
  • Renal Failure (acute)
  • Schizophrenia spectrum and other psychotic disorders
  • Seizure
  • Thrombotic Microangiopathy

Direct Access Services

Women’s Health Specialists

Females can receive obstetrical and gynecological (OB/GYN) services from a:

  • OB/GYN
  • Family practice physician
  • Surgeon providing OB/GYN services

Flu Vaccine

Educate our members about:

  • The annual flu vaccine
  • How to get the vaccine
  • The availability of the vaccine

Direct access services do not need a referral. However, the physician must be affiliated with their assigned care provider and participating with us.