Referrals, River Valley - 2022 UnitedHealthcare Administrative Guide

Network referrals

Primary Care Coordinator Plans (PCC Plans) do not require a referral.

Out-of-network referrals

An out-of-network referral means a written authorization provided by a participating health care provider and approved by us for services to be received from a non-participating health care provider. Out-of-network referrals must be requested by the member’s PCP. If an out-of-network referral is obtained, services received from a non-participating health care provider are covered at a network level of benefits under the member’s benefit plan. An out-of-network referral is needed when services are not available from a participating health care provider and may be needed for various services including, but not limited to, podiatry, chiropractic and mental health/substance use services.

Out-of-network referral approval

A referral to an out-of-network provider must be approved by us before the services are rendered. We must also give prior approval for modified or expired out-of-network referrals as described in this supplement. We may approve an out-of-network referral when services are needed but not available from a participating health care provider. Prior approval of an out-of-network referral is required for each follow-up visit unless we indicate otherwise. A medical director will review requests that do not meet approval criteria.

In the case of emergencies, notify us the first business day following the referral.

Out-of-network referral process

To determine whether an out-of-network referral is necessary under a member’s benefit plan, contact us at the number on the back of the member’s ID card.

Refer to the section Non-participating health care providers (all commercial plans), in Chapter 6: Referrals, for more instructions.

  • We will make decisions within the time frames required by state and federal law (including ERISA) and in accordance with NCQA standards.
  • We will send a letter confirming our approval or denial of a referral to the member and your office.

If a member requests approval after the fact, advise them this is against policy. Ask them to call 1-877-842-3210.

Participating health care providers may not refer their own family members to non-participating physicians/facilities due to conflict of interest. If the health care provider denies a referral, the health care provider must refer the member to their benefit document for any appeal rights. Or have them call 1-877-842-3210.