ModifiedUnitedHealthcarePolicy BIP131.O

Physician Services: Primary Care and Specialist Visits

Defines covered and not-covered physician services (primary care and specialists), referral and standing referral procedures, and related state-mandated requirements applicable to UnitedHealthcare members in the referenced jurisdiction(s). Affects providers and enrolled members seeking primary care or specialist services.

Policy Summary

PayerUnitedHealthcare

PolicyPhysician Services: Primary Care and Specialist Visits

Policy CodePolicy BIP131.O

Change TypeWording clarifications and reorganizations (material and non-material)

Effective DateApril 1, 2025

Next Review Date

Key ActionSubmit requests for standing or specialized-care referral determinations and required treatment plans within the California HSC business-day timelines (determination within 3 business days; referral within 4 business days after treatment plan submission).

SourceLink

POLICY UPDATE CHANGES

Revised language pertaining to California Health and Safety Code Section 1367.695 and updated examples of covered benefits and copayment language for Coumadin clinics.

Replaced language about availability of treatment by non-physician practitioners as supplemental benefits.

Revised list of non-covered services (e.g., completion of forms, employer medical clearance).

Revised list of non-covered services and updated wording for completion of forms and employer medical clearance.

Replaced language describing treatment by non-physician practitioners as available only via supplemental benefit with slightly edited wording.

Clarified that services by specialists/consultants may be provided regardless of HMO affiliation when no contracted specialist is available or when unavailable at time services are needed.

Replaced wording about services oriented to social/developmental/learning problems to emphasize services primarily intended to address those issues except covered rehabilitative/habilitative services.

Replaced phrasing 'treatment by someone other than a licensed physician, surgeon, or healthcare professional' with 'treatment by an individual who is not a licensed physician, surgeon, or other licensed healthcare professional'.

Adjusted Workers' Compensation related wording to require state or federal mandate for coverage in Federal/State Mandated Regulations section.

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Apr 1, 2025effective date

1policy number listed

04/01/2026last revision date

CAstates referenced

multiplenon-physician wording edits

Coverage Criteria: Physician Services

Covered Benefits (Primary Care and Specialists)

Covered when ALL of the following are met

General coverage: Diagnostic, consultation, and treatment services provided by the member's PCP are covered when provided by a licensed physician or practitioner within the network medical group, including network consultants and referral services.

Refer to member EOC for benefit limits

Specialist coverage via referral: Services provided by a specialist are covered when referred by the member's network medical group or UnitedHealthcare.

Includes consultations, preventive exams, development and implementation of treatment plans, Coumadin monitoring when referred and authorized by PCP, and emergency-requested consultant services.

Coumadin clinic copayment: A PCP office visit copayment may be applied by a Doctor of Pharmacy (PharmD) at a Coumadin clinic provided the PharmD is licensed and performing within scope and is under the direct supervision of an M.D. or D.O.

Copayment application contingent on state licensure, scope of practice, and direct supervision

Completion of administrative forms is listed as a non‑covered service. Examples include, but are not limited to, insurance, employment, school, sports, summer camp, Department of Motor Vehicles (DMV), or similar documentation; providers should not expect reimbursement for time spent completing these forms on behalf of members.

Employer requests for medical clearance that relate solely to absence from work (for example, documentation to justify missed work) are specifically not covered. Such requests and form‑completion obligations are distinguished from medically necessary evaluation and treatment and therefore are excluded from coverage.

Revised policy wording clarifies that requests to complete documentation — including but not limited to insurance, employment, school, sports, summer camp, and DMV forms — are non‑covered. The phrasing was broadened to indicate such requests include 'completion of forms, including but not limited to...' to capture common administrative examples.

Language was also clarified for employer‑related requests: the policy excludes employer requests for medical clearance to work or documentation related solely to the absence from work. This emphasizes that documentation requested only to support leave or attendance issues, rather than for medical care, is not a covered benefit.

Services rendered by individuals who are not licensed physicians, surgeons, or other licensed healthcare professionals are addressed as non‑covered. The policy uses the phrasing 'treatment of any illness or injury provided by an individual who is not a licensed physician, surgeon, or other licensed healthcare professional' to make this implicit exclusion explicit.

This exclusion encompasses treatment activities performed by unlicensed persons and signals that only services delivered by appropriately licensed practitioners meet the policy’s coverage requirements.

Coverage is governed by the member’s plan provisions. All services must be medically necessary, and each benefit plan contains its own specific limitations and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB).

If there is any conflict between the statements in this policy and the member’s EOC/SOB, the member’s EOC/SOB provisions will govern the coverage decision.

Treatment provided by an individual who is not a licensed physician, surgeon, or other licensed healthcare professional is not covered under this policy. Providers should ensure that billed services are performed and documented by appropriately licensed practitioners to meet coverage criteria.

The policy’s repeated revisions underscore that services must be delivered by licensed professionals to be considered for coverage; treatment by non‑licensed individuals may be denied as not covered.

Services that are primarily intended to address social, developmental, or learning problems — rather than a medical condition — are considered non‑covered except where rehabilitative or habilitative services are specifically indicated and covered. Refer to the policy sections and related Benefit Interpretation Policies on Habilitative Services and Rehabilitation Services (Physical, Occupational, and Speech Therapy) for details on covered rehabilitative/habilitative interventions.

In practice, interventions whose main purpose is social or educational (for example, services aimed at learning or developmental support without a defined medical treatment objective) should not be billed as medically necessary under this policy unless they fall within covered rehabilitative/habilitative benefit definitions.

Services that do not meet the policy’s medical necessity criteria are not covered. Providers are responsible for ensuring that documentation supports the medical necessity of services billed.

Benefit coverage, limitations, and exclusions remain subject to the member’s specific plan provisions; when discrepancies exist between this policy and the member’s EOC/SOB, the EOC/SOB controls coverage determinations.

Coding and Timelines

No codes listedmixed

No codes listed

Timelines for referral determinations

Determination timelineDetermination must be made within 3 business days of the request when all appropriate medical records and information are provided.

Referral issuance timelineOnce a determination is made, the referral must be made within 4 business days after the proposed treatment plan, if any, is submitted to the plan medical director or designee.

Triggering eventsRequest for determination may be made by the enrollee or the enrollee's primary care physician; timelines start when request and all required records are provided.

Provider Actions, Referrals, and Documentation

Prior Authorization

Timely Referral Determination (California HSC)

California law (HSC §1374.16) requires timely determinations for standing and specialized-care referrals. Determinations must be made within three business days after the request and receipt of all necessary medical records; once a determination is made, the referral must be issued within four business days after submission of the proposed treatment plan, if any.

Determination timeline: within 3 business days of request and receipt of necessary records
Referral timeline: within 4 business days after treatment plan submission (if a plan is submitted)

Note

Out-of-Network Specialist/Consultant Access

Specialist services are covered when referred by the member's network medical group or UnitedHealthcare. Specialists/consultants may be provided regardless of HMO affiliation when the network medical group has no contracted specialists available or a contracted specialist is unavailable at the time services are needed. Emergency-room requested specialist consultations for emergency treatment are also covered.

Covered when referred by network medical group or UnitedHealthcare

Background

Primary care physicians serve as the first point of contact for most health concerns, providing initial evaluation, ongoing management, and continuity of care. When a condition requires specialty input, the PCP is responsible for initiating referrals to specialists and arranging follow‑up as clinically indicated.

For conditions that require prolonged or specialized management — including standing referrals where more than one specialist visit is expected — the PCP coordinates with the specialist and, when required by plan rules or state law, may submit a treatment plan to support referral authorization and continuity of care.

Providers should follow plan procedures and the member’s EOC/SOB for referral requirements and timelines. Per applicable California statutes referenced in the policy, determinations for standing or specialized‑care referrals are subject to specified business‑day timelines and documentation requirements; the PCP should ensure referrals include necessary records to support timely determinations.

Definitions

Primary care physician — role and responsibilities

Primary care physician (definition)A physician responsible for providing initial and primary care, maintaining continuity of patient care, and initiating referral for specialist care.

Care coordination roleInitiates referrals to specialists or specialty care centers and consults with specialists and the plan medical director when determining need for continuing or specialized care.

Responsibility for treatment plansWorks with specialists, specialty care centers, the plan medical director, and the enrollee (if needed) to develop treatment plans when required for standing referrals or prolonged specialized care.

Scope of servicesProvides the majority of care for preventive services, acute and chronic conditions, and psychosocial issues; may authorize referrals when specialized care is medically necessary.

Standing referral

Policy Summary

PayerUnitedHealthcare

PolicyPhysician Services: Primary Care and Specialist Visits

Policy CodePolicy BIP131.O

Change TypeWording clarifications and reorganizations (material and non-material)

Effective DateApril 1, 2025

Next Review Date

SourceLink

On This Page

Out-of-network specialist/consultant access allowed if no contracted specialist is available or unavailable at time services are needed

Emergency-room requested specialist/consultant services are covered as part of emergency treatment

Denial Risk

Employer / Workers' Compensation Services

Services required by an employer or related to Workers' Compensation may be excluded unless coverage is mandated by state or federal law. Employer requests for medical clearance to work or documentation related solely to an absence from work are typically non-covered services per the policy revisions.

Any service required by an employer or related to Workers' Compensation is not covered unless state or federal regulations mandate coverage
Completion of forms (insurance, employment, school, DMV, etc.) and employer clearance requests are generally non-covered

Denial Risk

Risk of Denial for Treatment by Non-Licensed Providers

Treatment provided by individuals who are not licensed physicians or other licensed health care professionals may be non-covered. The policy history emphasizes edited language clarifying that treatment by non-physician practitioners (e.g., acupuncturists, chiropractors) may only be available if purchased as a supplemental benefit.

Risk of denial for services billed when care was provided by non-licensed individuals
Non-physician practitioner services may be covered only if purchased as supplemental benefits

Documentation Required

Medical Necessity and EOC/SOB Governance

All services must be medically necessary and coverage is governed by the member's Evidence of Coverage (EOC) and Schedule of Benefits (SOB). If this policy conflicts with the member's EOC/SOB, the EOC/SOB governs. Prior authorization and other plan-specific requirements are determined by the member's EOC/SOB.

Medically necessary: all services must meet medical necessity criteria
EOC/SOB governs plan-specific coverage, limits, and prior authorization requirements
If discrepancy exists between this policy and the member's EOC/SOB, the EOC/SOB controls

Documentation Required

Treatment Plan and Timeline Documentation

Providers must document treatment plans and timelines for standing referrals or prolonged specialized care when required. Treatment plans should describe the course of care, authorized visit limits, authorized period, and reporting requirements back to the PCP when applicable.

A treatment plan approved by the plan (in consultation with PCP, specialist, and enrollee) may be required for standing or prolonged referrals
Treatment plans may limit number of visits, time period authorized, or require regular reports to PCP

Billing Rule

Documentation and Plan-Specific Provisions

Providers must ensure billed services align with the member's EOC/SOB and this policy. If documentation or billed services conflict with plan provisions, reconcile with the member's EOC/SOB to avoid denials or payment adjustments.

Verify member-specific EOC/SOB provisions before billing
Reconcile discrepancies between clinical documentation, billed services, and EOC/SOB to mitigate denial risk

Prior Authorization

Prior Authorization and Authorization Documentation

Prior authorization requirements are plan-specific and governed by the member's EOC/SOB. This section does not list explicit prior authorization rules; providers should refer to the member's benefit documents or contact UnitedHealthcare for authorization requirements.

Prior authorization not documented in this section — check EOC/SOB
Contact UnitedHealthcare or the member's network medical group for authorization procedures

Step Therapy

Step Therapy (Provider Awareness)

Step therapy requirements are not specified in this section. Providers should review the member's EOC/SOB for any step therapy protocols that may apply to the requested services or medications.

Step therapy: check EOC/SOB for any applicable protocols
When in doubt, obtain prior authorization or contact UnitedHealthcare

DefinitionA standing referral is a referral by a primary care physician to a specialist that authorizes continuing care for more than one visit as indicated in an approved treatment plan.

Treatment plan linkageThe standing referral shall be made pursuant to a treatment plan approved by the plan in consultation with the PCP, specialist, and enrollee when a treatment plan is deemed necessary to describe the course of care.

Limits and reportingA treatment plan may limit the number of specialist visits, limit the authorized time period, or require the specialist to provide the PCP with regular reports on care provided.

Specialty care center

DefinitionA specialty care center is a center accredited or designated as having special expertise in treating a specific life‑threatening, degenerative, or disabling disease or condition.

Referral criteriaAn enrollee with a condition requiring specialized medical care over a prolonged period that is life‑threatening, degenerative, or disabling may receive a referral to a specialty care center when the PCP, specialist/center, and plan medical director determine the care is medically necessary.

Care coordination authorityAfter referral, the specialist or specialty care center is authorized to provide services within their expertise and training in the same manner as the enrollee's PCP, subject to the treatment plan terms.

Non-licensed provider treatment

DefinitionTreatment provided by an individual who is not a licensed physician, surgeon, or other licensed healthcare professional.

Coverage implicationSuch treatment is identified in the policy language as not covered (non‑covered or not medically necessary) unless plan documents state otherwise.

Policy emphasisPolicy history clarifies and standardizes wording describing treatment by non‑licensed individuals to reinforce exclusion and coverage risk.