UnitedHealthcare requiring stricter notification requirements for out-of-network ASC referral

April 06, 2017
Area(s) of Interest: Commercial Payors 

UnitedHealthcare (UHC) recently issued a notification to approximately 80 California physicians reminding them that their participation agreement requires them to refer to in-network ambulatory surgical centers (ASC) for elective services. This notice comes on the heels of an August 2016 announcement that UHC will begin enforcing stricter notification requirements related to out-of-network ASC referrals. According to the UHC letter, physicians wishing to perform services at an out-of-network ASC will be required to notify UHC at least five days in advance of the procedure. Additionally, physicians will be expected to complete the UHC Member Advance Notice Form any time they are referring a patient out-of-network. The new policy does not apply to emergencies. 

The California Medical Association (CMA) raised concerns with the August 2016 notice, as it was unclear whether physicians were required to submit a copy of the completed Member Advance Notice Form to UHC and what the impact would be for non-submission of the form by a physician. In response to CMA’s questions, UHC issued a clarifying notification to physicians, which stated that UHC will request that physicians submit a copy of the completed Member Advance Notice Form at the time of prior notification to the payor.


If a provider fails to submit the completed form with the prior notification, UHC will contact the patient to verify that his or her choice to use an out-of-network facility was discussed with the care provider, and that the patient agreed to receive services from a non-participating provider while understanding the potential increased out-of-pocket costs associated with that decision. Additionally, UHC has advised CMA that non-submission of the form will not be grounds for non-payment of any associated claims. However, failure to provide prior notification to UHC may result in the denial of claims per the Administrative Actions for Non-Compliance section contained in the UnitedHealthcare Administrative Guide.

UnitedHealthcare states that the intent of the policy change is not to dissuade patients from utilizing their out-of-network benefits, but is rather an effort to “minimize unnecessary member costs.” Similar programs have already been implemented by Anthem Blue Cross and Blue Shield of California.

More information regarding the change to the notification requirements can be found in the UnitedHealthcare Administrative Guide 2016 located on the UnitedHealthcareOnline.com website. Providers can also contact UnitedHealthcare at (866) 574-6088 for additional information.



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