Plan requirements/features - Chapter 4, 2022 UnitedHealthcare Administrative Guide

PCP recommendation

Members enrolled in Individual Exchange benefit plans are assigned a 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 or through their online account at This process is outlined in Chapter 3: Commercial products. PCPs can view a panel roster report at

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 health care provider locations within the service area to be covered. Members may be responsible for full cost of services rendered by out-of-network or out-of-area providers. Members can search for in-network health care providers by logging into their online account at

Specialist referral requirements

Where applicable, the PCP must submit referrals on when the member needs additional care by a network specialist. Any eligible service provided by a specialist, in any setting, requires a referral to a participating network specialist1. 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

Individual Exchange 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.
  • Routine refractive eye exams from a network 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 (DME), home health, prosthetic devices, hearing aids, outpatient lab, X-ray or diagnostics, physical therapy, speech therapy, occupational therapy, chiropractic care, pulmonary rehabilitation services, cardiac rehabilitation services, post cochlear implant aural therapy, cognitive rehab - with the exception of 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 Make sure you and your staff are familiar with the Exchange-specific prior authorization list.

Unless otherwise allowed by law, 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).

Note: Prior authorization is not required for chiropractic services. However, prior authorization is required for physical therapy, occupational therapy and speech therapy in most states. Go to for state-specific information. In addition, submit behavioral health services from in-network health care providers requiring prior authorization on, or you can call the provider services phone number on the back of the member’s ID card.

1 Referrals are NOT required for Individual Exchange Benefit Plans in AL, LA and NC.