1
A ______ is an order from the PCP for member to see a specialist or get specific services. It’s immediately accepted when submitted properly and isn’t reviewed, approved or denied by the member's health plan.
A referral is valid for either a set number of visits determined by your PCP or up to____ from the start date.
6 months
True or False: UHC does not issue referral denials.
True
A _______ is when a health plan checks whether a service, medication, or procedure meets coverage requirements before the member receives it.
Prior authorization
Once the PCP submits a referral, it becomes valid immediately and usually appears in the system within ________ .
48hours
PCP can start submitting referrals in our system on ____ .
Jan. 1, 2026
Yes or No: Can the PCP retro-request a referral?
Yes. PCPs may choose a start date of up to 5 calendar days prior to the entry date.
True or False: If PCP refuses to give me a referral or refer the member to a provider of their choice. UHC will not override the PCP’s referral decision.
True. The PCP is not required to give a referral. Sometimes the PCP may decide not to make a referral because they believe they can manage the member’s care best.
Give atleast 5 certain specialists that DO NOT require a referral.
Yes or No: Is there a limit on how many referrals I can get?
No. The member can receive as many referrals as necessary to continue their care or begin care with a new specialist.
I'm a new member and a new patient but my PCP on file is not accepting new patients. I need a referral to a specialist, what should I do?
Members should select a new PCP if their PCP on file is not accepting new patients.
BONUS
BONUS
If a member changes to a new HMO plan, will their referral transfer to a new plan?
No. If a member is already seeing a specialist and needs additional services from that specialist, they must obtain a referral from their PCP before any visits. Members should coordinate with their PCP before their next specialist visit.
Yes or No: The member is currently seeing a specialist. Do they need to get a referral to continue seeing their specialist?
Yes. Members should contact their PCP before their next specialist visit. Their PCP may ask them to come in for an office visit before they submit the referral.
A member’s referrals can be viewed in the _______ on the Summary tab within Maestro.
Medical Claim Tile
What is the referral grace period? (Give the specific date range)
January 1, 2026 to March 31, 2026
Yes or No: Does the member need a referral when traveling?
No. The member doesn’t need a referral if they have an emergency while traveling. Emergency medical care and urgently needed services are covered wherever and whenever they need it.
Yes or No: Does the member need to get a referral to see a specialist for a second opinion?
Yes. If the member has a referral to see a specialist but want a second opinion from a different specialist, they’ll need to work with their PCP to get another referral.
Yes or No: Does the provider that member is referred to needs to be in the plan’s network?
Yes. PCP enters the referral into our system, they can only select a network provider
Yes or No: Can the PCP refer the member to a provider group or clinic?
No. When the PCP submits a referral in our system, they select an individual provider. If the member wants to see multiple specialists, they can work with their PCP to get a referral for each specialist.