Commercial products referrals - Chapter 6, 2022 UnitedHealthcare Administrative Guide

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

  • Navigate, Navigate Balanced, Navigate Plus
  • NavigateNOW
  • Charter, Charter Balanced, Charter Plus
  • Compass, Compass Balanced, Compass Plus
  • Most Individual Exchange Plans (for more information, refer to Chapter 4: Individual Exchange Plans)
  • NexusACO R, NexusACO RB, NexusACO RP

Not obtaining a referral for a required service means that:

  • Navigate, NavigateNOW, Charter, Compass and NexusACO R — The service is not covered, and the member is responsible for the charges.
  • NexusACO RB, NexusACO RP, and Balanced and Plus versions of Navigate, NavigateNOW, Charter and Compass — 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.

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 provider (a network provider that is not within the same provider group and tax ID number as the member’s PCP). Referrals are valid for any health care provider within the same provider group and tax ID number as the specialist listed. It is best practice to communicate clinical findings to the referring PCP.

Direct PCP referrals (ME only)

If a member needs covered health care services, you must accept a referral from a direct PCP and they are treated the same regardless of whether the referring physician is a PCP or DPC provider. UnitedHealthcare may require a direct PCP making a referral (who is not a member of the carrier’s provider network) to provide information demonstrating the health care provider is a direct PCP through a written attestation or a copy of a direct primary care agreement with a member. To request a referral to an in-network health care provider, call the member phone number on the member health plan ID card.

Referral submission and status verification

There are multiple ways to submit referrals electronically to UnitedHealthcare:

  1. API | uhcprovider.com/api
  2. EDI: Transaction 278 | uhcprovider.com/edi278
  3. Online: UnitedHealthcare Provider Portal | Click Sign In 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 health care provider outpatient services, 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. You should review a list of referrals related to the member in the UnitedHealthcare Provider Portal 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.

Online submissions of referrals

Referral submissions are separate from both notification and prior authorization requests. Use the Referrals tool on the UnitedHealthcare Provider Portal to submit referrals.

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 provider group and 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 provider.
  • Network optometrists.
  • Mental health/substance use services with network behavioral health clinicians.
  • Services rendered in any emergency room, network urgent care center or network convenience care clinic.
  • Services performed by a designated virtual care network provider (e.g., Teladoc) for primary or urgent care needs.
  • 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.
    • Services billed by a network specialist require referral.
  • 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 provider group and 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
1Delegated may follow different referral submission requirements