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 > 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 through 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.