New York: Referrals updates for Medicaid plans

Starting March 8, 2021, UnitedHealthcare Community Plan of New York is implementing a referral process for members who need specialty care. This will require primary care providers (PCPs) to generate a referral for members to see in-network specialists.

PCPs should start using this referral process for specialist visits beginning on March 8, 2021.

This referral process will be implemented for all in-network providers and UnitedHealthcare Community Plan of New York members for the following:

  • UnitedHealthcare Community Plan for Families (Medicaid)
  • UnitedHealthcare Community Plan Wellness4Me (HARP)
  • UnitedHealthcare Community Plan ChildHealthPlus (CHP)

Integrating the new process

Members with planned care needs during the ramp-up period should not have their services interrupted. We encourage you to quickly integrate this process into practice for specialist visits.

We will not issue specialist claim denials between March 8, 2021 and April 1, 2021, to allow time for you and your staff to generate referrals on behalf of members using the new process. After April 1, 2021, a referral must be in place prior to the specialist visit for the specialist claim to be paid.  

Services that do not require a referral from a member’s PCP include:

  • 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. – health care professionals who 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 themselves
  • Any other services for which applicable laws and regulations do not allow us to impose a referral requirement

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 updated frequently asked questions.

Call your network representative directly or Provider Services for UnitedHealthcare Community Plan at 888-362-3368.

This is an update to a previous article posted in December 2020.