Referrals vs. Prior Authorization and Notification
The referral process, advance notification process, and prior authorization process are separate processes. All care providers must follow the notification and/or prior authorization requirements when providing a service that requires a notification and/or prior authorization.
A referral does not replace the advance notification or prior authorization process.
Referral Submission Requirements*
Referrals must be submitted by the member’s PCP or by a PCP within the same tax ID number. Specialists can’t request referrals in our system. They must ask the PCP to make a referral. Referrals are accepted to network physicians only.
The member’s assigned PCP must:
- Submit referrals electronically using
- EDI Transaction 278R
- 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
- Referrals are effective immediately, but may take up to two business days to be viewable on the portal system. They may be backdated up to five calendar days before the date of entry.
- Follow all requirements
- If you provide services and a referral is not on file, we deny the claim and the charge is non-billable to the member.
Referrals are effective immediately. They are viewable online within 48 hours.
If you need to refer a member to an out-of-network care provider because there are no available network care providers in the area, request prior authorization by calling Provider Services at 877-842-3210. You can also sign into Link by going to UHCprovider.com and clicking on the Link button in the top right corner. Then, select the Prior Authorization and Notification tool tile on your Link dashboard.
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.
Topics in this section:
* Delegated may follow different referral submission requirements.