Plan requirements/features - Chapter 4, 2021 UnitedHealthcare Administrative Guide

PCP selection

Members enrolled in Individual Exchange benefit plans are assigned a primary care provider (PCP) to manage their health care needs. Members may change their PCP by calling the member services number listed on the back of their ID card. This process is outlined in Chapter 3. PCPs can view a panel roster report at UHCprovider.com.

Specialist referral requirements

The PCP must submit referrals on UHCprovider.com when the member needs additional care by a network specialist. Any eligible service provided by a specialist, in any setting, requires a referral. Once the referral end date has passed, or the number of visits is exhausted, the member must contact their PCP to request a new referral before receiving additional care. Specialists should confirm a valid referral is on file before each office visit. Members seen without a valid referral on file may have no coverage.

Referral impacts on hospital claims

Benefit plans that require specialist referrals also apply to planned inpatient and outpatient procedures where the specialist is the admitting physician. The member must have a referral on file to see a network specialist for planned services in any setting, including in the hospital. The specialist referral requirement is in addition to notification requirements.

Members without a valid referral on file with the admitting physician for planned inpatient or outpatient services will have no coverage for both the admitting physician’s claim and the hospital claim. This does not apply to non-physician hospital services, such as radiology and lab testing.

Eligible services that do not require a referral

  • PCPs within the same tax ID as the member’s assigned PCP. Note: Specialists within the same TIN as the member’s assigned PCP require referrals.
  • Network OB/GYNs, including perinatologists.
  • Network urgent care centers or convenience clinics.
  • Routine refractive eye exams from a network care provider.
  • Mental health disorders/substance use from network behavioral health clinicians.
  • Pathologists, radiologists or anesthesiologists.
  • Emergency room or emergency ambulance.
  • Physician for emergency/unscheduled admissions.
  • Network, facility-based inpatient/outpatient consulting physicians, assisting surgeons, co-surgeons or team surgeons.
    • Non-physician services, including but not limited to durable medical equipment, home health, prosthetic devices, hearing aids, outpatient lab, X-ray or diagnostics, physical therapy, speech therapy, occupational therapy, pulmonary rehabilitation services, cardiac rehabilitation services, post cochlear implant aural therapy, cognitive rehab - with the exception of manipulative treatment and vision therapy (e.g., physician services). Services performed by a specialist will require a referral.
    • Other network services for which applicable laws do not require a referral.

Important facts about referrals

  1. Unless otherwise allowed by law, electronic referrals are required.
  2. Referrals can be backdated up to 5 days prior to the date of entry.
  3. Referrals are valid for up to 6 months or 6 visits, whichever comes first.

Prior authorizations

Prior authorization and notification requirements apply to Individual Exchange members and are posted at UHCprovider.com. Make sure you and your staff are familiar with the Exchange-specific prior authorization list.

You must submit prior authorizations electronically. We will not accept them by phone or fax. We will not accept prior authorization or notification requests that also require a referral unless a completed referral is on file. If you do not meet the referral requirements, we may deny the physician’s and hospital’s claim for planned inpatient admissions. Additionally, admission notification and authorization is not a guarantee of coverage or payment (unless mandated by law).

Out-of-network / out-of-area benefit coverage

Individual Exchange members do not have out-of-network or out-of-area benefit coverage, except for emergency services and related admissions, unless specifically approved by UnitedHealthcare. Members must receive eligible services at participating care provider locations within the service area in order to be covered.