Medicare Advantage referrals

Why are referrals required?

Referrals help ensure care is clinically appropriate and coordinated across the care continuum.

Does UnitedHealthcare have any guidelines the PCP must follow to determine when to issue a referral to a specialist?

No. It is at the PCP's discretion what process will be used to determine if the member should be referred to a specialty provider. UnitedHealthcare does not track individual PCP referral practices. The PCP may:

• Determine a referral to a specialist is not required and can be managed by the PCP
• Submit a referral after a phone consultation
• Require an in-person visit prior to submitting a referral
• Submit a referral based on an established patient-PCP relationship without requiring a visit or phone consultation

Who is responsible for submitting referrals?

The member’s PCP is responsible for submitting referrals before the member seeks care from a network specialist. All referrals submitted to UnitedHealthcare by a network PCP and visible in the UnitedHealthcare Provider Portal will be honored, regardless of whether the submitting provider is the member's assigned PCP. Any network PCP for the member's plan can submit referrals

Can out-of-network PCPs issue referrals to network specialists?

No. Out-of-network PCPs cannot issue referrals.

How do I submit and validate referrals?

Use the Referrals tool, found in the UnitedHealthcare Provider Portal to submit any referral requests. Sign in to the provider portal with your One Healthcare ID and select Referrals from the menu. Referrals are effective immediately upon submission. It may take up to 48 hours for them to appear online.

Are diagnosis and/or procedure codes required with the referral submission?

A diagnosis code is required with the referral submission with the ability to enter 1 additional diagnosis code on the referral. The diagnosis code(s) are informational only and will not be used to process claims. Procedure codes are not required with referrals.

How long is a referral valid?

Referrals are valid for the number of visits entered by the PCP (up to 99 visits) or for 6 months from the referral's effective date, whichever comes first.

What are the options for the referral effective date?

PCPs can choose the date the referral is submitted, or up to 5 calendar days prior to the date the referral is submitted as the effective date. Referrals cannot be entered with a future effective date. Referrals are effective immediately upon submission, but may take up to 48 hours to display in the portal. UnitedHealthcare does not approve or deny referrals; they are accepted as entered by the PCP.

Can I change or extend the referral after submission?

Referrals cannot be amended or extended once submitted.

What if additional visits are needed?

If additional visits or time are needed after a referral expires or visit limits are reached, the member or specialist should contact the member’s PCP to request another referral for additional visits and/or time.

Is the diagnosis used on the specialist claim required to be the same as the referral?

No. The diagnosis provided by the PCP on the referral is informational only and will not be used to process claims.

Does the referral number need to be submitted with the claim?

No. While it may be included, UnitedHealthcare does not require the referral number be included on the specialist claim when billing for services. UnitedHealthcare has system logic to match claims to referrals.

Does the specialist need to verify the member has a referral?

If the member’s plan indicates referrals are required, specialists should confirm whether a referral is required for their specialty under the members Medicare Advantage plan. Specialists and other health care professionals should verify a referral has been issued from the member’s PCP before providing services that require a referral. On a Medicare Advantage plan, services denied for failure to follow referral requirements are provider liability once enforcement begins.

Can the member be billed for non-covered services due to lack of referral?

If you provide services that require a referral, but a referral was not in place, that service will be denied and cannot be billed to a member unless the requirements set forth in the “Charging members for noncovered services” section of Chapter 11 of the Administrative Guide have been met. Instead, specialists should inform the member that a referral needs to be submitted by their PCP before the member can receive specialty care. When a member needs immediate care, the specialist may try to assist the member by contacting the member’s PCP to request a same-day referral submission.

In accordance with CMS restrictions, members can be billed for non-covered services only in certain circumstances. These requirements are set forth in Chapter 11 of the 2026 UnitedHealthcare Care Provider Administrative Guide for Commercial, Individual Exchange, and Medicare Advantage under the heading: “Charging members for noncovered services” and include obligations to obtain a pre-service Integrated Denial Notice (IDN) in accordance with CMS requirements, which includes their appeal rights.

What happens if a member needs to see an additional specialist?

If a specialist recommends care from another specialty or sub-specialty that requires a referral, the member or specialist should contact the member’s PCP to determine whether an additional referral is needed. If the specialist or sub-specialist falls under a specialty that does not require a referral, no additional referral is needed.

Keeping the PCP at the center of the member's care helps to:

• Enhance care coordination
• Reduce gaps or delays in treatment
• Reduce duplication of services
• Strengthen provider collaboration

Are prior authorizations still needed?

Yes. Prior authorization and advance notification requirements still apply.

Are referrals, prior authorization and advance notification required for the same services?

Yes. Referrals, prior authorization and advance notification may be required for the same services. If a service requires prior authorization or advance notification, those requirements must be met regardless of whether a PCP referral is on file. Prior authorizations are subject to UnitedHealthcare review and approval

What happens to an active referral if a member changes their assigned PCP?

Members may request to change their PCP at any time. Referrals previously submitted by the member’s PCP are not affected by PCP changes. PCP change requests for members are effective the first day of the following month.

If a member has Tricare For Life and a Medicare Advantage HMO plan, is a referral required?

Yes. Tricare For Life (TFL) becomes secondary and members must use the Medicare Advantage plan network and follow Medicare Advantage coverage rules. If the member’s HMO plan requires referrals, those rules apply.

If a member sees a non-network Veterans Affairs (VA) PCP, can that provider refer them to in-network HMO specialists or hospitals?

Yes. VA PCPs can call Provider Services and have the referral entered to a specialist in the plan network on their behalf

Is a referral required when UnitedHealthcare is secondary insurance?

UnitedHealthcare Medicare Advantage referral requirements do not apply when UnitedHealthcare coverage is secondary to another insurance plan or is secondary to Original Medicare because a member has elected hospice services. In these cases, a referral is not required under the Medicare Advantage plan.

How do referrals work if a member has Medicare National Network or Passport Plans with National Network?

Some HMO and HMO-POS plans with referral requirements have access to the UnitedHealthcare Medicare National Network. If the member’s plan has the Medicare National Network, there will be a National Network logo on the back of the member ID card. For services requiring a referral, referrals are required to any participating network specialist nationwide, including specialists both inside and outside the member’s home plan service area.

Plans with UnitedHealth Passport®

Some HMO and HMO-POS plans with referral requirements have a locally based network and a Passport benefit.

If the member’s plan has Passport, there will be a UnitedHealth Passport logo on the back of the member ID card.

Passport gives eligible members access to participating care providers in specific counties and states at their network cost-share when getting care outside of their home location. Members call UnitedHealthcare prior to leaving the plan service area to activate Passport and locate available providers. Passport services do not require a PCP referral.

If a member sees a recognized Indian/Tribal/Urban clinic as their PCP, can that provider refer them to in-network HMO specialists or hospitals?

Yes. Indian/Tribal/Urban clinics listed as the member's PCP can call Provider Services and have the referral entered to a specialist in the plan network on their behalf.

If a member is seen in the ER and/or admitted to inpatient and has specialty visits scheduled as part of discharge, are referrals required for those visits?

Members should schedule visits with their PCPs upon discharge. The PCP should enter any necessary referrals to the specialists.

• If the visit with the specialist occurs within 7 days of the ER or inpatient discharge, the referral requirement will be waived
• PCPs can submit retroactive referral effective dates up to 5 calendar days prior to the date the referral is submitted
• If the specialist visit is not within 7 days of the ER or inpatient discharge and the member is unable to get an appointment with their PCP, members or specialists may call UnitedHealthcare to request a one-time courtesy referral for follow-up with the specialist after discharge from ER and/or inpatient admission