Beginning Jan. 1, 2026, UnitedHealthcare will require most members enrolled in Medicare Advantage HMO and HMO-POS plans to obtain a primary care provider (PCP) referral before seeing certain specialists in outpatient, office, or home settings. Referrals must be submitted to UnitedHealthcare before the visit (and can be backdated up to five days), though many specialties and services—including mental health, OB/GYN, radiology, therapy services, labs, preventive care, telehealth, and emergency care—are excluded from the referral requirement. Providers should also note that claims will not be denied for missing referrals through April 30, 2026, but denials will begin May 1, 2026, making the provider financially responsible if a required referral is not on file. The policy does not apply to certain plans, such as Institutional SNP plans, Erickson Advantage plans, and the Michigan Integrated DSNP plan, and some delegated providers may follow different referral processes.
Resources: Referral requirements for Medicare Advantage HMO/HMO-POS plans Jan. 1, 2026