Referrals - Chapter 6, 2021 UnitedHealthcare Administrative Guide

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 enter referrals in our system. They must ask the member’s PCP to enter a referral. Referrals are accepted to network physicians only.

• The member’s assigned PCP must:
• Submit referrals electronically, prior to the service being rendered, using
  • EDI Transaction 278 | UHCprovider.com/edi278
  • Referrals on Link | Click Sign in to Link in the top right corner of UHCprovider.com.
  • Delegated entity’s website listed on the back of the member’s ID card
• Enter a start date within 5 calendar days of submission date
  • Referrals are effective immediately but may take up to 2 business days to be viewable on the portal system. They may be backdated up to 5 calendar days before the date of entry.
• Follow all requirements
  • If you provide services when a referral is not on file, see the product-specific details below for the impact to your reimbursement and the member benefits, as this varies by product.

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 1-877-842-3210. You can also sign into Link by going to UHCprovider.com and clicking on Sign in to Link 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, up to the allowed max, needed for each referral in a 6-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.