UnitedHealthcare to Enforce Specialist Referral Requirement in 2026
Beginning January 1, 2026, the majority of members of UnitedHealthcare Medicare Advantage HMO and HMO-POS plans will need to get a referral from a primary care practitioner (PCP) before seeing some of the specialists in an outpatient, office, or home environment. With this new policy, PCPs will have to process the referral with UnitedHealthcare prior to the specialization visit.
The referral will not be necessary in the case of:
- Primary care provider
- Mental health provider
- Obstetrician/Gynecologist
- Chiropractor
- Audiologist
- Oncologist
- Hematologist
- Nuclear medicine
- Neonatology
- Emergency medicine
- Nutritionist
- Podiatrist
- Optometrist
- Ophthalmologist
- Optician
- Radiologist
- Therapeutic radiologist
- Infectious disease specialist
UnitedHealthcare is not to deny claims without referrals to the date of service until April 30, 2026. Nevertheless, as of May 1, 2026, claims made regarding specialist services in the absence of an approved referral will be rejected, and the rejection must be treated as provider liability-members should not be balance billed in the circumstance.
It is worth mentioning that the referrals to the 2026 plan year cannot be made prior to January 1, 2026. Besides, the claims can still be rejected in case of a referral, even when the service is not covered by the plan of a member, or when necessary prior authorization is not presented.
The changes are not applicable to members who take Institutional SNP plans, Erickson Advantage plans, or the Michigan Integrated DSNP plan (H2247-005). Delegated provider groups are also allowed to have their referral processes.
The current referral policies in California, Nevada, and Texas will remain the same, in which referrals are already obligatory to all services in 2026. The providers are advised to consult the Evidence of Coverage of the members for state-specific information and exclusions.
UnitedHealthcare has even provided a number of digital tools that providers can use to check eligibility, referrals, and referral statuses using the UnitedHealthcare Provider Portal. Additional details are available under the UnitedHealthcare Medicare Advantage Referral Guide and 2026 Medicare Advantage, CSNP & DSNP Plan Overview Course.
To get additional help, the providers can contact the representatives of UnitedHealthcare through the 24/7 chat support in the Provider Portal.
