Requirements for Out-of-Network Laboratory Referral Requests
Out-of-network laboratory referrals can create excess costs in the health care system and may pose a potential quality risk to your patients. To help protect your patients, you are required to refer lab services to a participating lab provider.
Our new process doesn’t change a member’s access to labs or lab services. The process will help ensure that referring care providers meet existing referral requirements and that members are aware of potential out-of-pocket costs associated with using a non-participating laboratory.
Your UnitedHealthcare Participation Agreement requires that when you refer members to other care providers, you’ll refer them to UnitedHealthcare in-network care providers, unless an exception applies. Beginning Nov. 8, 2019, UnitedHealthcare will require that you complete an online process to document those exceptions before referring UnitedHealthcare commercial benefit plan members to out-of-network laboratories for testing services.
The documentation required as part of this process helps make the member aware that their referring provider intends to use an out-of-network laboratory, and the member may be responsible for greater out-of-pocket costs. This process records the member’s permission to use the out-of-network lab in this instance.
You’ll use the Eligibility and Benefits tool on the UnitedHealthcare Provider Portal to complete this exception process. To sign in, go to UHCprovider.com and click on the Sign In button in the top right corner. The ability to register an exception and upload the required forms will be available starting Nov. 8, 2019. This process allows you to:
Upload the member’s written consent to use an out-of-network laboratory
Receive UnitedHealthcare approval to refer that member to an out-of-network laboratory
You don’t need to follow the out-of-network referral process when you refer a member to a network laboratory or when the referring provider already has a network exception to refer the member to a non-participating laboratory.
To refer a member to an out-of-network laboratory, you must have both:
Written consent from the member to use an out‑of‑network laboratory for that member’s lab service for that date of service
The consent indicates the member has discussed the option to use an in‑network lab with their care provider and they have made an informed decision to receive services from an out‑of‑network laboratory despite the potential increased out‑of‑pocket costs associated with that decision.
UnitedHealthcare approval to refer the member to use an out-of-network laboratory for that member’s lab service for that date of service
Care providers who refer a laboratory service to an out-of-network care provider and haven’t completed the referral request process and documented the member’s written consent are out of compliance with their Participation Agreement and may be subject to administrative actions, which include:
Loss of eligibility for the Practice Rewards programs
A decreased fee schedule
Financial responsibility for any costs or expenses collected from a member by a non-participating laboratory, including non-covered services and balance bills, if there is no written member consent authorizing the referral to the non-participating laboratory
Ending network participation, as outlined in the Participation Agreement
Using a network laboratory service provider requires no additional requests or processes. UnitedHealthcare maintains a large network of regional and local labs. These labs provide a comprehensive range of services and provide clinical data and related information to support:
Healthcare Effectiveness Data and Information Set (HEDIS®) reporting
If you can’t find an in-network laboratory for a specific lab test, call us at the Provider Services number listed on the member’s ID card before ordering the test. We’ll help you find a laboratory where covered tests can be performed.
As we get close to the start date for this requirement, we’ll add information and resources to help you use these tools and follow the new process.