Avoid claim denials: Tips for Exchange plans

Last modified: March 15, 2021

UnitedHealthcare Exchange plans have some unique requirements for care providers. With these plans now available in 11 states, we want to some tips to help you avoid claim denials and make it easier to work with us as you care for Exchange plan members.

Determining your network status

• Care providers participating in UnitedHealthcare commercial plans also participate in Exchange plans, unless the network is listed as an excluded plan in your Participation Agreement
• Participating providers must have a location in the network service area to be eligible for in-network coverage. Exchange plans do not have out-of-network benefits.

Referral requirements

• Referrals are required for members to see a network specialist, with some exceptions. To see which services do not require a referral, see the UnitedHealthcare Exchange plan FAQs
• Specialists must be in-network and located within the defined service area for the member to have coverage. You can view the service area for each state at UHCprovider.com/exchanges.
• Unless required by state law, referrals must be submitted electronically or the claim will be denied
  • You can submit a referral using the Referrals option or through an EDI 278R transaction
  • Care providers in Maryland can submit referral requests electronically or by mail or fax

Confirming that a referral is on file

• Network specialists should use the Referrals option to make sure a referral is on file before rendering services to UnitedHealthcare Exchange plan members, or the claim will be denied
• You can use the Referrals option to view the number of authorized visits and number of visits remaining

Prior authorization requirements

• Some services require prior authorization. Your prior authorization request must be submitted electronically using the Prior Authorization and Notification option.
• To see which services require prior authorization, visit UHCprovider.com/exchanges > Prior Authorization

Learn more

Visit UHCprovider.com/exchanges for Exchange plan FAQs, state-specific information, training and more.