Commercial products referrals - Chapter 5, 2021 UnitedHealthcare Administrative Guide

These referral requirements apply to covered services given to commercial members enrolled in these plans:

  • Navigate, Navigate Balanced, Navigate Plus
  • Charter, Charter Balanced, Charter Plus
  • Compass, Compass Balanced, Compass Plus
  • NexusACO R, NexusACO RB, NexusACO RP

Not obtaining a referral for a required service means that:

  • Navigate, Charter, Compass and Nexus ACO R — The service is not covered, and the member is responsible for the charges.
  • Navigate, Charter, Compass and NexusACO RB, NexusACO RP (Balanced and Plus versions) — There is a higher out-of- pocket cost for the member.

Commercial members of gated benefit plans have “PCP to send electronic referral” printed on the back of their ID card and “Referrals Required” on the front of the ID card.

Online Submissions of Referrals

Referral submissions are separate from both notification and prior authorization requests. Use the Link referral tool to submit referrals.

 

Specialist referrals

The member’s assigned PCP manages their care. The member’s PCP needs to submit electronic referrals to us before the member sees another network care provider (a network care provider that is not within the same tax ID as the member’s PCP). Referrals are valid for any care provider within the same TIN as the specialist listed. It is best practice to communicate clinical findings to the referring PCP.

Referral submission and status verification

There are multiple ways to submit referrals electronically to UnitedHealthcare:

  1. EDI: Transaction 278 | UHCprovider.com/edi278
  2. Online: Referrals on Link | Click Sign in to Link in the top right corner of UHCprovider.com.

Managing referrals

Specialists and facilities must check the status of a referral for the admitting physician’s TIN before each visit. For planned admissions and outpatient services rendered by a physician, facilities must check that the servicing physician has a referral to see the member. If not, the facility claim may not be covered, or the member may have a higher cost-share. Referrals are for the specialist rendering the service or for the facility. Care providers should review a list of referrals related to the member on Link when verifying the member’s eligibility.

  • Referrals are only valid for the authorized number of visits or through the indicated referral end date. Any unused visits are not valid after the end date.
  • If a referral is no longer valid, but the member requires additional care, the member or specialist must contact the member’s PCP to request a new referral. The PCP then decides whether to issue an additional referral.
  • If a network specialist sees a need for a member to go to another specialist, the specialist must ask the member’s PCP to issue an additional referral.

Commercial benefit plan services not requiring a referral

Members in these plans do not need a referral for:

  • Services from network physicians in the same TIN as the member’s PCP or their covering network physicians
  • Services from network OB/GYN specialists, nurse practitioners, nurse midwives, and physicians assistants
  • Routine refractive eye exam from a network care provider
  • Network optometrists
  • Mental health/substance use services with network behavioral health clinicians
  • Services rendered in any emergency room, network urgent care center, network convenience care clinic or designated network online “virtual clinic visits”
  • Services billed as observation
  • Admitting physician services for emergency/unscheduled admissions
  • Services from facility-based inpatient/outpatient network consulting physicians, network assisting surgeons, network co- surgeons, or network team surgeons
  • Services from a network pathologist, network radiologist or network anesthesia physician
  • Outpatient network lab, network x-ray, or network diagnostic services
    • ehabilitative services with exception of manipulative treatment and vision therapy (physician services)
  • Network rehabilitative services with exception of manipulative treatment and vision therapy (physician services)
    • Services billed by a network specialist require referral.
  • Other services for which applicable law does not allow us to impose a referral requirement

Referral submission requirements

  • Submit electronic referrals to UnitedHealthcare before rendering services.
  • Referrals are effective immediately.
  • They are viewable online within 48 hours.
  • We do not accept referrals by phone, fax or paper, unless state law requires us to.
  • The PCP can backdate them up to 5 calendar days from the date of submission.
  • Web users must have access to the Referral Submission role on their user profile to submit and verify referrals.
  • Only the member’s PCP, or other PCP practicing under the same TIN, can submit referrals for the member to see a network specialist. A specialist cannot enter a referral.

Maximum referral visits

The PCP may submit up to 6 visits on a referral. Unused visits expire after 6 months. For members with the following chronic conditions, the PCP may submit up to 99 visits for up to 6 months per referral.

  • AIDS/HIV
  • Anemia
  • Cancer
  • Cystic Fibrosis
  • Schizophrenia spectrum and other psychotic disorders
  • Parkinson’s Disease
  • Amyotrophic Lateral Sclerosis
  • Multiple Sclerosis
  • Epileptic seizure
  • Myasthenia Gravis
  • Glaucoma
  • Retinal detachment
  • Thrombotic Microangiopathy
  • Allergic Rhinitis
  • Renal failure (acute)
  • Seizure
  • Fracture care