Non-Participating Care Provider Referrals (All Commercial Plans) - Chapter 5, 2021 UnitedHealthcare Administrative Guide

In non-emergent circumstances, you are required to refer our members to an in-network care provider. You can confirm if a care provider is in our network at UHCprovider.com, or call 1-877-842-3210.

For an exception to this requirement, you must:

  1. Follow the prior approval process outlined in the next paragraph, or
  2. Get the member’s written consent to involve an out-of-network care provider.

To get prior approval to involve an out-of-network care provider, submit a request by calling the number on the back of the member’s ID card. We review the request and network care providers available. If approved, we will apply the network benefits to the services done by the out-of-network care provider. We will mail our decision to the requesting care provider and the member.

To get a member’s written consent to involve an out-of-network care provider, you must use the Member Consent for Referring Out-of-Network form. This form is located on UHCprovider.com > Policies and Protocols > Protocols > Member Consent for Referring Out-of-Network Form. The member must acknowledge that you:

  1. Summarized the reason you are referring them to an out-of-network care provider,
  2. Disclosed whether you have a financial interest in, or relationship with, the care provider to whom you are referring the member, and
  3. Explained that the member may have no coverage or additional costs as a result of your referral.
  • Some members may have additional costs for services they receive from out-of-network care providers. Some members don’t have any out-of-network benefits, which means the out-of-network care provider will bill the member for the entire cost of the referred service.

For referrals to an out-of-network laboratory, go to eligibility and benefits on UHCprovider.com/link to provide us with the completed Member Consent for Referring Out-of-Network form.

If you violate this protocol, and do not confirm the member’s consent for the referral, you will be in violation of our Agreement. As a result, we may:

  1. Disqualify you from any rewards or incentive program.
  2. Decrease your fee schedule.
  3. Hold you financially responsible for any costs collected from a member by a non-participating care provider.
  4. Terminate your agreement.

Before submitting a request for network benefits for services from a non-participating care provider:

  1. See if there is a network care provider available by searching on the Physician Directory.
  2. If a network care provider is not available, see if the W500 icon appears on the back of the member’s ID card.
  • If W500 is indicated, search for a network care provider in the W500 Emergent Wrap directory.
    • If you find a W500 Emergent Wrap care provider, submit a request for coverage for the member to see that care provider.
  • If W500 is not on the member’s ID card or you cannot find a network care provider in the W500 Emergent Wrap Directory, continue submitting your request.

To find a list of care providers participating in the W500 network, go to UHCprovider.com/findprovider > Search for Care Providers in the General UnitedHealthcare Plan Directory > Medical Directory > All UnitedHealthcare Plans > Shopping Around > W500 Emergent Wrap.