UnitedHealthcare Out-of-Network Referrals: Prior Approval, Patient Consent
By Ellen Terry


Here’s some news you might have missed that was published in UnitedHealthcare’s Network Bulletin in January.  

If you are a UnitedHealthcare (UHC) participating physician referring a patient out of network in a nonemergency, you’re now required to first obtain either (1) prior approval from UHC; or (2) the patient’s written consent. 

This new uniform requirement for referrals to out-of-network physicians or health care professionals affects all UHC commercial plans. Previously, UHC allowed exceptions to mandatory in-network referrals that varied by service type. 

Request prior approval by calling the number on the back of your patient’s UnitedHealthcare ID card. UHC will review your request and mail you and your patient its decision. If UHC approves the request, it will apply network benefits to the referred physician/professional’s services. 

Alternatively, have the patient sign a Member Consent for Referring to an Out-of-Network Provider form, which warns patients of higher out-of-network costs. Place the form in the patient’s medical record. Find more information about exceptions and the form on the UHC provider website. 

Special requirements for lab referrals

For referrals to an out-of-network lab, UHC requires that you document the referral and signed patient consent online. Follow the steps in this guide to register your referral using the eligibilityLink Tool on Link, the UHC portal at UHCprovider.com. After filling out information online about your referral, you’ll receive a prepopulated patient consent form to print and have the patient sign. Then scan the form and upload it to complete the referral documentation. The consent form is valid only for the lab services you order on the date of the patient consent. See more information on the UHC website.

If you violate these protocols, and do not confirm your patient’s consent for a referral, you will be in violation of your UHC participation agreement. As a result, UHC might:

  • Disqualify you from any rewards or incentive program;
  • Decrease your fee schedule;
  • Hold you financially responsible for any costs collected from your patient by the out-of-network physician, health care professional, or lab; or
  • Terminate your agreement.

New Claims Edit Helps With Documentation Requirements  

UnitedHealthcare’s claims optimization tool, called Smart Edits, now provides a documentation edit, which alerts you when a submitted claim requires supporting documentation. The edit, indicated by status code R1:294 on your 277CA clearinghouse rejection report, will describe what documentation is required and the appropriate format. Claim processing will be paused for five calendar days, allowing you time to submit the needed documentation using the claimsLink tool on Link, UHC’s portal. 

Look for Bind Health Insurance Cards  

You might see a new insurance ID card among your patients, from Bind Benefits, Inc. This on-demand health insurer has become available to UnitedHealthcare employer groups across the nation. Bind, acting as an administrator, accesses UHC networks and contracts. 

UHC recommends that you add the Bind Benefits payer ID – 25463 – into your systems to avoid delays in claims handling and processing. 

  • Although Bind is the payer, depending on your system, you can enter Bind Benefits Inc., as the “insurance” carrier.
  • Bind’s payer ID might be attached to multiple networks. Refer to the insurance ID card for your patient’s specific network. 

See the UHC website for more information and sample ID card images.

Last Updated On

February 05, 2020

Originally Published On

February 04, 2020

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Ellen Terry

Project Manager, Client Services

(512) 370-1391

Ellen Terry has been writing, editing, and managing communication projects at TMA since 2000. She hails from Victoria, Texas; has a journalism degree from Texas State University; and loves to read great fiction. Ellen and her husband have two grown sons and a couple of cats.

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