Referrals - Chapter 6, 2022 UnitedHealthcare Administrative Guide

Referrals vs. advance notification and/or prior authorization 

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.

Referral submission requirements^₁

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:

• Submit referrals electronically, prior to the service being rendered, using:
  • API | uhcprovider.com/api.
  • EDI Transaction 278 | uhcprovider.com/edi278.
  • UnitedHealthcare Provider Portal | Click Sign In in the top right corner of uhcprovider.com.
  • Delegated entity’s website listed on 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 in 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 in the following section 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 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.

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.

¹ Delegated benefit plans may follow a separate referral exclusion list. For Preferred Care Network and Preferred Care Partners of Florida plans, refer to the Preferred Care Network and Preferred Care Partners supplements