UHC PCP Referral Requirements

Memo

Date: December 15, 2025

To: All Providers, APPs, Clinical Staff, Scheduling, Billing & Coding

From: Medical Director & Coding Director

Subject: Specialist services referral requirement for Medicare Advantage plans Effective January 1, 2026

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Bottom Line

Starting Jan. 1, 2026, most members enrolled in UnitedHealthcare Medicare Advantage HMO and HMO-POS plans will be required to obtain a referral from their primary care provider (PCP) before accessing certain specialist services in outpatient, office or home settings.

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Update

Starting Jan. 1, 2026, most members enrolled in UnitedHealthcare Medicare Advantage HMO and HMO-POS plans will be required to obtain a referral from their primary care provider (PCP) before accessing certain specialist services in outpatient, office or home settings. Referrals must be submitted by the PCP to UnitedHealthcare prior to the specialist visit.

The new referral requirements will NOT apply to services provided by a:

Primary care provider	Hematologist	Optometrist
Mental health provider	Nuclear medicine	Ophthalmologist
Obstetrician/gynecologist	Neonatology	Optician
Chiropractor	Emergency medicine	Radiologist
Audiologist	Nutritionist	Therapeutic radiologist
Oncologist	Podiatrist	Infectious disease specialist

In addition, PCP referral is not required for these services:

• PT/OT/ST, cardiac therapy or pulmonary therapy

• Provision of anesthesiology (pain management services rendered by an anesthesiologist do require a referral)

• Home health agency services

• Services performed in an observation setting

• Any services from a pathologist or inpatient consulting physician, including hospitalists

• Emergency room, ambulance or urgent care services

• Telehealth services

• Medicare-covered preventive services, kidney disease education or diabetes self- management training

• Routine annual physical exams, routine vision exams or hearing exams

• Any lab services, radiological or non-radiological testing services, or radiation therapy

• Durable medical equipment, home health, prosthetic/orthotic devices, medical supplies, diabetic testing supplies, Medicare Part B drugs or allergens

• Additional coverage that may be included by some Medicare Advantage plans but are not covered by Medicare, such as hearing aids, routine eyewear, dental care, fitness memberships or outpatient prescription drugs

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Key dates

Claims denied due to missing referrals will be considered provider liability. Members must not be balance billed for services rendered without a valid referral.

• For plans with new referral requirements, referrals for the 2026 plan year can’t be submitted before Jan. 1, 2026

• Claims may still be denied even if a referral is on file if:

  • The services are not covered under the members’ benefit plan

  • Required prior authorization was not obtained

Referral requirements do not apply to members enrolled in:

• Institutional SNP plans

• Erickson Advantage plans

• Michigan Integrated DSNP plan (H2247-005)

Delegated providers may have their own referral policies and processes that differ from UnitedHealthcare’s standard procedures.

Note, California, Nevada and Texas have referral requirements currently in place. Existing referral policies in these states will not change and referrals are required for all 2026 dates of service. For referral exclusions, requirements and details in these states, please refer to the member’s evidence of coverage.

— End of Memo —

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