Medicare Advantage update: PCP referrals required for specialist visits
AI Summary
Starting January 1, 2026, UnitedHealthcare Medicare Advantage HMO and HMO-POS members will need PCP referrals before specialist visits, with claims denied for missing referrals beginning May 1, 2026. Many specialties are exempt including orthopedics, cardiology, oncology, and mental health providers.
Action Required
By January 1, 2026: Front desk staff must verify referral requirements for UnitedHealthcare Medicare Advantage HMO/HMO-POS members before scheduling specialist appointments. Update scheduling system to flag these plans. Billing team must track referrals starting May 1, 2026 when claims will be denied without valid referrals. Note: Claims denied for missing referrals are provider liability - members cannot be balance billed.
Plan Types
Medicare Advantage
Specialties
all-specialties