Referrals and referral contracting, Capitation and/or delegation supplement - 2021 Administrative Guide

Direct access services

Members may receive certain services without prior authorization or referrals. Refer to Chapter 6: Referrals for details about direct access services.

Access to participating eye care providers (CA and CO only)

If the medical group/IPA is delegated for vision services, it must allow the member direct access to any eye care provider participating and available under the plan. An eye care provider is a licensed network optometrist or ophthalmologist. The medical group/IPA may require the eye care provider to submit requests for approval of surgical vision-related procedures.

Access to participating chiropractor (WA only)

If the medical group/IPA is delegated for chiropractic services, they must allow the member direct access to any participating chiropractor available under the plan. The medical group/IPA may use managed care cost and containment techniques.

PCP and care provider responsibilities

We assign each member a PCP at the time of enrollment if the member does not select one. The PCP coordinates the member’s overall health care, including behavioral health care, and the appropriate use of pharmaceutical medications.

The delegated medical group/IPA sets its own policies regarding care provider responsibilities.

Out-of-network care provider referrals (Commercial HMO and Medicare Advantage)

When medically necessary, the PCP refers the member to in-network care providers. If the needed care provider is not available in-network, not available within the needed time frame or too far away, the PCP needs to request an out-of-network care provider review. The delegated medical group/IPA reviews this request. If approved, the member is not responsible for costs over their applicable in-network cost-sharing.

Referral contracts (Medicare Advantage)

We encourage the medical group/IPA to establish contracts with care providers so they may refer our members for specialty services. Each contract must have the specific parts described in this section. The medical group/IPA may establish written contracts with referral care providers. They may use existing UnitedHealthcare contracts unless they are delegated for claims processing. Delegated medical group/IPAs must negotiate their own contracts. These contracts must comply with this guide:

  • No contractual arrangement between the delegate and any subcontracting care provider may violate any provision of law.
  • The delegate helps ensure all provisions of its Agreement with any care provider who provides services to MA members includes all provisions required under the delegate’s MA Agreement and regulatory requirements and applicable accreditation standards.
  • If a care provider has opted out of the Medicare program, the delegate does not contract with them to provide services to MA members.

Establishing contracts for specialty services

Any medical group/IPA delegated for claims processing must negotiate contracts with individual specialists or group practices to facilitate the availability of appropriate services to members. All contracts must be in writing and comply with state and federal law, accreditation standards and the MA Agreement.

Depending upon the delegate’s contract with us, this may include contracting for services with hospitals, home health agencies and other types of facilities.

Subcontract review (MA)

CMS requires us to check the written agreements the medical group/IPA has with its care providers. We check them at least annually. We recommend the medical group/IPA reviews their subcontracts annually. These checks help ensure compliance with federal law and CMS regulations. We require an Improvement Action Plan (IAP) for any medical group/IPA who has non- compliant contracts. The IAP lists our findings and expected time frame to reach compliance.

Referral authorization procedure

The delegated medical group/IPA may initiate the referral authorization process when asked to refer a member for services. Refer to their Notification/Prior Authorization list. These capitated medical services may need a referral authorization:

  • Outpatient services
  • Laboratory and diagnostic testing (non-routine, performed outside the delegated medical group/IPA’s facility)
  • Specialty consultation/treatment
  • Facility admissions
  • Out-of-network services

The medical group/IPA, PCP and/or other referring care provider verifies eligibility and participating care provider listings on all referral authorization requests. This helps ensure they refer a member to the appropriate network care provider. The medical group/IPA must comply with the following procedures:

  • When a member requests specific care provider services, treatment or referral, the PCP or treating care provider reviews the request for medical necessity.
  • If there is no medical indication for the requested treatment, the care provider discusses an alternative treatment plan with the member.
  • If the member’s treatment option requires referral or prior authorization, the PCP or treating care provider submits the member’s request to the delegate’s Utilization Management Committee or its designee for a decision. The PCP or treating care provider includes appropriate medical information and referral notes about why the requested service is medically necessary. Information should include results of previous treatment.
  • If the request is not approved in whole, the medical group/IPA (or if not delegated, UnitedHealthcare) issues a denial letter to the member. It states the requested services, treatment or referral and complies with applicable state and federal requirements.

Standing referral/extended referral for care by a specialist

The delegated entity must have specialty care referral procedures. They need to explain standing and extended referrals for specialists and specialty care centers. The entity needs a standing referral if the member requires:

  • Continued care from a specialist or specialty care center for a prolonged time.
  • Extended access to a specialist for a life-threatening, degenerative or disabling condition.

There may be a limit to the number of specialist visits or time authorized. The specialist may need to provide regular reports to the PCP.

For an extended specialty referral, the PCP and specialist must determine which health care service each manages. The PCP should handle primary care and keep records of the reason, diagnosis, and treatment plan for the referral.

HIV/AIDS extended referrals (CA commercial only)

The delegated medical group/IPA must have a written process for extended referrals to HIV/AIDS specialists when the PCP and medical group/IPA medical director agree the diagnosis and/or treatment of the member’s condition requires an HIV/ AIDS specialist’s expertise. To comply with the state laws and regulations, the delegated medical group/IPA must identify care providers within their group who qualify as HIV/AIDS specialists. If no such care providers are in the medical group/IPA, the medical group/IPA must have a way to refer members to a qualified HIV/AIDS specialist outside of the group. The qualification of an HIV/AIDS specialist are outlined in the California Health and Safety Code 1374.16.

Referral and/or authorization forms

The delegate may design its own request for referral and/or authorization forms without our approval. When the forms communicate approvals to the member, use at least 12-point Times New Roman font. If the form is not at least 12-point font, the delegate needs to send a written notification that is. For MA members, we provide an approval template letter.

At a minimum, include all the following components in the form or written notice:

  • Member identification (e.g., member ID number and birth date)
  • Services requested for authorization including appropriate ICD-10-CM and/or CPT codes
  • Authorized services including appropriate ICD-10-CM and/or CPT codes
  • Name, address, phone number and TIN of the care provider the member is referred to
  • Proper billing procedures, including the medical group/IPA address
  • Verification of member eligibility

The delegate provides copies of the referral and/or authorization form to the:

  • Referral care provider
  • Member
  • Member’s medical record
  • Managed care administrative office

Looking for more information about notification requirements?

Member requests for services carved out of UnitedHealthcare (MA)

CMS regulations allow a member to make a direct request for services from either the MA plan or the entity making the determination, which is the utilization management/medical management delegated medical group/IPA. This applies to both standard and expedited pre-service Initial Organization Determinations (IODs). The established requirements for pre-service standard and expedited IODs apply.

Delegated medical groups/IPAs handle the timely processing of all pre-service organization determination requests, including the delegate’s requests that are UnitedHealthcare’s responsibility. The medical group/IPA must have explicit policies and procedures for the following:

  • Starting the referral or authorization processes when a member contacts the delegate to request services, or when a care provider requests a service of the delegate that is UnitedHealthcare’s responsibility. The medical group/IPA must use the date and time the member or care provider first called as the received date and time of the request to comply with required turn-around times.
  • Working with UnitedHealthcare on service referrals or authorizations where a member or care provider has contacted us to request services. The medical group/IPA must use the date and time of the request to UnitedHealthcare as the received date and time of the request for compliance with turnaround times.

If the carved-out service is UnitedHealthcare’s responsibility, the delegated medical group/IPA will:

  • Transfer member requests to the customer service number on the back of the member’s ID card
  • Transfer care provider requests to Provider Services at 1-877-842-3210.
  • Stay on the line and explain the request.

If the carved-out service is the responsibility of an outside vendor, the delegated medical group/IPA will:

  • Locate vendor contact information on or on the member’s Evidence of Coverage (EOC) and transfer member to the appropriate contact.
  • Call 1-877-842-3210 to verify information to complete the request.
    • Follow the IVR menu to reach correct department or obtain vendor information.
    • Submit request directly to vendor and inform the member of vendor name and contact information.

Medicare Advantage and Commercial delegated medical groups/IPAs cannot send a carve-out letter.

Looking for more information on referrals?

Additional detailed information and requirements for referrals can be found in Chapter 6: Referrals

Coordination of care between medical and behavioral health care

Capitated/delegated medical groups/IPAs providing behavioral health services must collect information about how to improve coordination of care with the behavioral health care providers. Based on the data collected, the medical group/IPA must work with those care providers to make improvements. The medical group/IPA submits this report annually to their quality improvement or appropriate committee. The medical group/IPA must have procedures describing how it will complete this cycle. We look at the process and report during our annual review of the capitated medical group/IPA.

A capitated medical group/IPA providing and paying for behavioral health services must also review members’ experiences at least annually. This includes a member survey. Based on the survey results, the medical group/IPA identifies areas for improvement and makes necessary changes. The medical group/IPA then measures the effectiveness of these changes.

It submits this report to its quality improvement or appropriate committee. We look at the process and report during our yearly review.


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