Some Medicare Advantage (MA) benefit plans require referrals to specialists and rehabilitation centers. These plans focus on coordination of care through the PCP. These plans are network-only benefit plans. Members must have a referral to receive network benefits for services from specialists. If members see a specialist without a referral, we will not pay for it. The care provider is responsible for confirming that there is a referral. If there is no referral, the care provider is liable for the charges; you cannot bill the member. These plans require notification and prior authorization for some services as well. A referral does not replace a notification or prior authorization.
Check the front of the member’s ID card for referral language. MA members of gated plans have “Referral Required” printed on the front of their ID card. You can also check eligibility and benefits or referrals on Link to see if referrals are required.
These services do not require a referral. However, they may require prior notification or authorization. For information on authorization requirements, refer to UHCprovider.com/priorauth.
Any service provided by a network PCP
Any service provided by a network physician practicing under the same tax ID as the member’s PCP
Any service from a network OB/GYN, chiropractor, optometrist, ophthalmologist, optician, podiatrist, audiologist, oncologist, nutritionist, or disease management and infectious disease specialist
Services performed while in an observation setting
Allergy immunotherapy injections
Mental health/substance use services with behavioral health clinicians
Any service from a pathologist or inpatient consulting physician including hospitalists
Any service from an anesthesiologist
Services rendered in an emergency room, emergency ambulance, or a network urgent care center or convenience clinic
Medicare-covered preventive services, kidney disease education or diabetes self-management training
Routine annual physical exams, vision or hearing exams
Any lab services and radiological testing service, excluding radiation therapy
Durable medical equipment, home health, prosthetic/orthotic devices, medical supplies, diabetic testing supplies and Medicare Part B drugs
Additional benefits that may be covered by some MA benefit plans but are not covered by Medicare, such as hearing aids, routine eyewear, fitness memberships, or outpatient prescription drugs
Services obtained while accessing the National Network or UnitedHealth Passport®, which allows for services while traveling
1 *Delegated benefit plans may follow a separate referral exclusion list. For Medica and Preferred Care Partners of Florida plans, refer to the Medica HealthCare and Preferred Care Partners supplements.