Referrals, Neighborhood Health Partnership supplement - 2022 UnitedHealthcare Administrative Guide

The PCP is responsible for determining when the member needs a referral. Only the PCP may make an initial referral. These must be made to participating health care providers. We deny claims for services rendered without a proper referral. You may not bill the member for those services unless, prior to receiving the service, the member agrees in writing:

1. That the referral is not in place or the service is not a covered service.
2. To be financially responsible for the cost of the service. 

Referrals to a specialist may be necessary:

• When a member fails to respond to current medical treatment.
• To confirm or establish a member’s diagnosis and/or treatment modality.
• To provide diagnostic studies, treatments or procedures that range beyond the scope of the PCP. PCPs may make referrals to a specialist according to the following Specialty Referral Guidelines section.

These specialty services do not require referral:

• Chiropractic (subject to benefit limitations)
• Dermatology
• Gynecology
• Podiatry*
• Substance use treatment*
• Mental health*

Out-of-network referrals

Out-of-network referrals are only approved when the services are not available from a participating health care provider. Request out-of-network referrals by calling NHP at 1-877-842-3210. Once we receive the referral, the data will be reviewed and, if approved, entered into the system to help ensure payment of the specialist claims.

Specialty referral guidelines

• Once the specialty services have been properly authorized, the member or PCP may schedule an appointment with the specialist.
• Submit specialist referrals in the UnitedHealthcare Provider Portal at uhcprovider.com > Sign In.
• We mail an authorization letter to the specialist for the member’s medical record.
  
• We do not pay specialist claims without a referral.
• The specialist should re-verify the member’s eligibility at the time of visit by calling Provider Services 1-877-842-3210. Refer to the back of the member’s ID card to help ensure the appropriate Provider Services department is contacted.
• Call 1-800-817-4705 for behavioral health service requests.
• All NHP HMO members require a referral before scheduling appointments for specialty services.

Obstetrics

A member may self-refer to an NHP obstetrician who is a participating health care provider for routine OB care. If the member is referred to a non-participating specialist, the specialist must notify us through uhcprovider.com or by calling 1-877-842-3210 to make sure accurate claims payment for ante- and postpartum care.

• Plain film radiography performed by an NHP participating health care provider or in the obstetrician’s office during an authorized visit, does not require prior authorization.
• Routine labs performed in the obstetrician’s office, or that are provided by a participating health care provider in support of an authorized visit, do not require prior authorization.
• Office procedures and diagnostic and/or therapeutic testing performed in the obstetrician’s office that do not require prior authorization may be performed.authorization may be performed.
  

* See the prior authorization section of this supplement.