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:
That the referral is not in place or the service is not a covered service.
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)
Substance use treatment*
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.
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 throughuhcprovider.comor 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.