Medicare Advantage Referral Required Plans - Chapter 5, 2020 UnitedHealthcare Administrative Guide

Medicare Advantage Referral Required Plans

Some Medicare Advantage (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 responsible for confirming that there is a referral. If there is no referral, 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 Eligibility and Benefits (on Link) and referralLink tools also show 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

  • Any service provided by a network PCP
  • Any service provided by a network physician practicing under the same tax ID as the member’s 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 an observation setting
  • Allergy immunotherapy
  • Mental health/substance abuse services with behavioral health clinicians
  • Any service from a pathologist or inpatient consulting physician including hospitalists
  • Any service from an anesthesiologist
  • 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 memberships, 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.