Non-Participating Providers Consent Form
Except in emergent situations, we require you to follow this protocol when directing members to use these types of non-participating care providers/services.
Excluded Plans (benefit plans not subject to the following requirements)
- Neighborhood Health Partnership
- M.D.IPA, Optimum Choice, or OneNet
- Benefit plans subject to the River Valley Entities Supplement
- UnitedHealthcare West
Impacted Care Provider/Service Types:
- Ambulatory Surgical Centers – free-standing and hospital outpatient non-emergent
- Surgical Assistant - a care provider or other health care provider who is assisting in or monitoring the care during the performance of a surgical procedure, where the participating entity selects the Surgical Assistant.
- Home Health
- Air Ambulance, fixed-wing non-emergency transport
- Laboratory Services – for specimens collected in the physician’s office and sent out to a non-participating laboratory for processing
- Outpatient Dialysis
- Specialty Drug vendor
- For Oxford Members on New York Products – refer to the Participating Provider Laboratory & Pathology Protocol (New York) for specific requirements and instructions on non-participating laboratory and pathology services.
- For UnitedHealthcare Members on Delaware, New York, Oklahoma, Pennsylvania and Texas Products – refer to the Participating Provider Laboratory and Pathology Protocol for specific requirements and instructions on non-participating laboratory and pathology services.
Before you provide services, you must:
1. Discuss options and costs with the member:
- Review this policy and the Member Advance Notice Form
- Provide participating care provider alternatives and explain the reason for using the non-participating care provider
- Discuss the cost of using a non-participating care provider
- If the member has out-of-network benefits, they can use those benefits to see a non-participating care provider. However, they may pay more when using them.
- Members who do not have out-of-network benefits may have to pay all of the costs for the nonparticipating care provider.
2. Complete the UnitedHealthcare Member Advance Notice Form. Fill in the required information on the form and have the member sign it.
- Participating care providers must keep a copy of the signed form on file to give to us upon request.
- A separate form is required for each non-participating care provider/service.
- Use the Laboratory and Pathology Services Consent Form for Members.
This protocol does not apply in emergent situations or instances where the care provider or member has obtained a network exception to utilize a non-participating care provider.
We want to help members make informed decisions. We do not want to deter them from using out-of-network benefits. Members can use their out-of-network benefits at any time.
Administrative Actions for Non-Compliance
We monitor the involvement of the non-participating care provider types and services outlined above in our ER’s care. We may request a copy of the completed Member Advance Notice Form. We will review your compliance with this protocol, in accordance with state and federal laws and regulations.
If you do not comply with this protocol, we may take action as stated in your Agreement. Such actions may include, but is not limited to payment sanctions, ineligibility for performance based compensation, or termination of your Agreement.