Significant changes to Medicare Advantage referral requirements are underway, and expectations are not consistent particularly when comparing two major Idaho payors - Blue Cross of Idaho (BCI) and UnitedHealthcare (UHC). Practices can no longer rely on assumptions and must verify the specific insurance product policy before determining whether a referral is required.
Blue Cross of Idaho just published an updated policy MAPAP310 – Medicare Advantage Referral Requirements that applies to all of its Medicare Advantage plans. In short:
• Referrals are required for any specialty or ancillary care outside of routine primary care. This applies to all BCI MA plans.
• Members must have an in-network PCP (family practice, general practice, internal medicine, OBGYN, or pediatrics), and the PCP must submit referrals before the member sees a specialist. Retroactive referrals are not allowed.
• Referrals must be submitted electronically via the BCI provider portal.
• Referrals issued are valid for 12 months, reducing administrative burden over time when appropriate.
• Specialists and ancillary providers must confirm a referral is on file before seeing the patient.
• There are exceptions (emergent/urgent care, behavioral health, preventive services, routine wellness services, certain equipment/services), but the key rule is that most specialty referrals now require documented PCP authorization. See all the exceptions here https://providers.bcidaho.com/resources/pdfs/providers/FAQs/talk-points-for-provider-operations-medicare-advantage-true-blue-and-secure-plan.pdf
• If the patient has been established with the specialist, BCI will still require a new referral authorization for 2026. Note, a 90 day grace period will apply starting January 1, 2026 in order to get referrals in place. Visit https://providers.bcidaho.com/authorizations-and-notifications/jiva.page to submit a new referral.
UnitedHealthcare national policy around MA plan referrals is a big shift for how specialists and PCPs interact.
• Effective Jan. 1, 2026, most UnitedHealthcare Medicare Advantage HMO and HMO-POS plans will require a referral from the PCP before accessing certain specialist services in outpatient, office, or home settings. See policy here https://www.uhcprovider.com/en/resource-library/news/2025/referral-req-specialist-services-medadv.html
• This is not a broad referral requirement for all services, but rather for specific specialty care areas and again varies by product (HMO/HMO-POS vs PPO/SNPs).
• UHC’s official guidance also includes a grace period through April 30, 2026. Providers are encouraged to begin submitting referrals for services on/after Jan. 1, 2026, and UHC will not deny claims through April 30, 2026 for lack of referrals.
We recommend practices visit payor sites for which they are participating with MA plan to organize referral processes and be attentive to grace periods for established patients.