June 01, 2024

Colorado: No referrals required with HMO Open Access

Applies to certain Medicare Advantage plans

Effective Jan. 1, 2024, the UnitedHealthcare Medicare HMO service area in Colorado includes all 15 counties for all contracted primary care providers (PCPs). In addition, all in-network Medicare HMO specialists, ancillary providers and hospitals/facilities are considered in-area for all UnitedHealthcare Medicare HMO members in Colorado. This includes all delegated networks, including OptumCare and PHP Prime, among others.

No referrals required 

Out-of-area referral authorization is no longer required to obtain care within the 15-county service area in Colorado. This means members can receive care from Denver to Colorado Springs or from Boulder/Longmont to Estes Park/Fort Collins without concern of claim denial for care being out of area.

This also means members can self-refer to any in-network HMO provider for both non-delegated and delegated Medicare plans without concern of claim denial as out of area. The provider directory will still guide members to providers and facilities within 30 miles of their home ZIP code.

However, it is possible a member residing in Pueblo could self-refer to a specialist in Fort Collins, for example. Services rendered in this example would be payable, as long as the specialist is in the HMO network and follows standard claim processes. Prior authorization may still be required for some services in accordance with the current prior authorization list.

Please continue to provide specialty and ancillary care direction for your patients, this includes addressing concerns or helping to find local specialist. This can help members avoid self-referring to distant specialists.

Durable medical equipment (DME) for H0609 plans uses Preferred/Lincare as our exclusive DME provider. For members in need of these services, please verify eligibility and benefits to ensure care is directed to the appropriate, in-network DME supplier in the member’s service area.

Questions? We're here to help.

Connect with us through chat 24/7 in the UnitedHealthcare Provider Portal. For additional contact information, visit our Contact us page.


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