Applicable to all states except NC.
The referral process, advance notification process, and prior authorization process are separate processes. You must follow the requirements when providing a service that requires a notification and/or prior authorization.
A referral does not replace the notification and/or prior authorization process.
Referrals must be submitted by the member’s PCP or by a PCP within the same provider group and 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:
Referrals are effective immediately. They are viewable online within 48 hours.
If you need to refer a member to an out-of-network provider because there are no available network providers in the area, request prior authorization by calling the Provider Services number on the member’s ID card. You can also sign into the UnitedHealthcare Provider Portal by going to uhcprovider.com and clicking on Sign In in the top right corner. Then, select Prior Authorizations from the drop-down menu in the portal.
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.