New Referral Requirements for Our Medicaid Plans - New York

This referral requirement has been updated – please see the March 2021 notification.

Starting March 1, 2021, UnitedHealthcare Community Plan of New York is implementing a referral process for members who need specialty care. This referral process will be implemented for the following product lines:

• UnitedHealthcare Community Plan for Families (Medicaid)
• UnitedHealthcare Community Plan Wellness 4 Me (HARP) 
• UnitedHealthcare Community Plan ChildHealthPlus (CHP)

You can begin to use this referral process for specialist visits occurring on or after March 1, 2021. This will require you, the primary care provider (PCP), to generate a referral for members to see in-network specialists. 

Between now and the March 1, 2021 effective date, claims for specialists will continue to be paid as usual. Services that do not require a referral from a member’s PCP include the following: 

• Women´s Health Care
• Family Planning 
• HIV and STI Screening
• Eye Care (subject to benefit limits in member handbook)
• Dental Care
• Behavioral Health – (Mental Health and Substance Use)
• Smoking Cessation
• Maternal Depression Screening
• Services rendered in any emergency room or network urgent care center
• Physician services for emergency/unscheduled admissions
• Any services from inpatient consulting physicians
• Radiologist, Pathologist, Anesthesia, etc. Providers that are part of inpatient hospital care or surgical teams do not need referrals
• A specialist who has arranged to act as the member’s PCP does not need a referral for him or herself. Please see FAQs for additional information. Any other services for which applicable laws and regulations do not allow us to impose a referral requirement.

Specialist visits not listed above, occurring after March 1, 2021, will require a PCP referral. 

The referral must be in place prior to the specialist visit for the specialist claims to be paid. You may begin to write referrals immediately if you anticipate the date of service will be March 1, 2021, or later.

The new requirement aims to strengthen PCP engagement with our Medicaid members while helping direct members to the appropriate specialty care. The change is expected to help improve health outcomes for members and improve collaboration and coordination of care between members’ respective PCP and specialty providers.

For more information, review our frequently asked questions.

Questions? Call your Network Representative directly or Provider Services for UnitedHealthcare Community Plan at 888-362-3368.