Referrals, Oxford Commercial Supplement - 2022 UnitedHealthcare Administrative Guide

Submitting and verifying referrals

A PCP or OB/GYN may issue a referral to participating health care providers using any of the methods outlined in the How to Contact Oxford Commercial section. 

Once you enter the referral, the referring health care provider may receive a reference number by fax. Provide the referral reference number to the member. The member may bring this reference number to the specialist who can directly confirm a referral is on file using the UnitedHealthcare Provider Portal at > Sign In or by phone at 1-877-842-3210.

Find additional details regarding our Referrals policy at > For Commercial Plans > UnitedHealthcare® Oxford Clinical, Administrative and Reimbursement Policies

Referral policies and guidelines

Our physician contracts require referrals be issued to participating physicians, hospitals, ancillaries and other health care professionals within the applicable network of health care providers available to our members enrolled in gated health benefit plans. The only exceptions to this are:

  1. Emergency cases.
  2. There are no participating health care providers who can treat the member’s condition.

If you would like to direct a member to non-participating health care providers, you must request a network exception from our Clinical Services department and receive approval before the member receives service. If the member requests to see a specialist and is unable to reach their PCP or OB/GYN (after-hours, weekends or holidays), the PCP may issue a referral up to 72 hours after the member received services.

Prior authorization guidelines still apply to those covered services requiring prior authorization.

We must review and approve all referrals. A referral does not guarantee coverage of the services provided by the participating specialist. Covered services are subject to:

  • Medical necessity, as determined by Oxford’s Clinical Policies.
  • Member eligibility on the date(s) of service.
  • Member’s benefits as defined in the conditions, terms and limitations of their Summary of Benefits/Certificates/Contract.

Participating specialists may only issue referrals within the applicable network of health care providers available to the members enrolled in gated health benefit plans for certain covered services as outlined in the Referrals policy. You may not refer a member to a non-participating specialist. For more information, refer to the section on Using Non-Participating Health Care Providers or Facilities.  

Automated fax notification

When you submit a referral, we send a fax to the referred-to health care provider or other health care professional, usually within 24 hours. This fax serves as a confirmation notice of the referral.

You have the option to update your referral fax number or decline the auto-fax notification feature on our website in the My Account section.

Member self-referrals

We have programs to improve outcomes for members and help us better manage the use of medical services. You may refer members to these programs, or members may self-refer, to network specialists for the following services:

  1. OB/GYN care, to include prenatal care, 2 routine visits per year and any follow-up care, or for care related to an acute gynecological condition
  2. One mental health visit and one substance use visit with a participating health care provider per year for evaluation
  3. Vision services from a participating health care provider
  4. Diagnosis and treatment of tuberculosis by public health agency facilities
  5. Family planning and reproductive health from participating or Medicaid health care providers

Outpatient radiology self-referral procedures

We designed the Outpatient Imaging Self-Referral Policy to promote appropriate use of diagnostic imaging by network PCPs, specialty physicians and other health care professionals in the office and outpatient setting.

This policy does not apply to radiology services performed during an inpatient stay, ambulatory surgery, ER visit, or pre- operative/pre-admission testing. See the How to Contact Oxford Commercial section for contact information.

The outpatient imaging self-referral list is applicable to commercial benefit plans. You may find more information in Oxford’s Outpatient Imaging Self-Referral Clinical Policy at > For Commercial Plans > UnitedHealthcare® Oxford Clinical, Administrative and Reimbursement Policies

Standing referrals and specialty care centers

You may request a standing referral to a participating specialist, ancillary provider, or specialty care center if a member requires ongoing specialist treatment, has a life-threatening condition or disease, or a degenerative and disabling condition or disease. This referral is available only if the condition or disease requires specialized medical care over a prolonged period. The participating specialist or ancillary provider must have the necessary medical expertise and be properly accredited or designated (as required by state or federal law or a voluntary national health organization) to provide the medically necessary care required for the treatment of the condition or disease. We cover the services provided only to the extent outlined in the member’s Certificate of Coverage.