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Out-of-Area Coverage


Use of Health Care Services

Use of Health Care Services FAQs

What happens if I need services that are not provided by a network physician or hospital?

Our UnitedHealthcare networks are developed to provide you with access to most of the health care services that you will need. If your physician determines that needed care is not available within the network, he or she will request a preauthorized referral from UnitedHealthcare. Coverage authorization must be approved before out-of-network services are received for any care not provided at an emergency or urgent care facility.

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If I am in the service area and need emergency care, what should I do?

If you need care in a medical emergency*, you should dial 911 when appropriate or seek care from the nearest hospital. After treatment, your network physician should be contacted within 48 hours or the next business day to arrange follow-up care.

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What if my physician’s office is closed?

If you do not think emergency care is needed, call your physician’s office for information on how to contact the network physician on call and then follow the physician’s instructions for treatment. If you have questions or need medical advice, you may contact Optum® NurseLine (1-800-867-6760), a 24-hours-a-day, seven-days-a-week, toll-free phone number line staffed by registered nurses. They can answer your questions about general health and minor emergencies or illnesses. UnitedHealthcare contracts with Optum to provide this service for our members.

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Do I have to know who is in my network or do I use whomever my doctor refers me to?  Shouldn't my doctor know who is in my network?

It is the responsibility of our members to be aware of their network of providers. To see if a provider is in your network, you can search our online provider directory, consult your member handbook, or contact Customer Service at the toll-free number on the back of your ID card.

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What are the referral requirements for both in- and out-of-network referrals and who is responsible for obtaining referrals for me?

It is your responsibility to make sure that your providers comply with referral requirements. It is your primary care physician’s responsibility to handle a referral request if your plan requires referrals. For an in-network referral, you must use an in-network provider. Out-of-network referrals are required for UnitedHealthcare to allow the in-network benefit to be paid to an out-of-network provider. With this option, the primary care physician will need to show the medical necessity of why an out-of-network provider is being used.

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What services require preauthorization?

Many procedures, drugs, and medical equipment require preauthorization from UnitedHealthcare. It is your responsibility as a member to ensure that your provider complies with preauthorization requirements. Preauthorization does not mean that benefits are payable in all cases. Your coverage depends on the health care services actually provided, your eligibility status at the time of the services, and any benefit limitations. If your provider fails to obtain preauthorization from UnitedHealthcare, your benefits may be reduced or denied. For a complete listing of items requiring preauthorization, please call the Customer Service number listed on your ID card.

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What if I need to go to a specialist?

Depending on your benefit plan, you may need to get a referral before seeing a specialist. Your provider directory lists a range of specialists or you can view the most up-to-date listing on our online Provider Directory. Your Primary Care Physician works closely with them and will recommend one. If you are enrolled in a Heritage Choice, Premier, Heritage Heritage Select Advantage, or UnitedHealthcare Midwest Secure Plus plan, you do not need to obtain a referral before seeing a specialist in the network.

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How do I use mental health and substance abuse services?

For most of our members, we offer convenient and confidential mental health and substance abuse benefits through United Behavioral Health. Mental health care professionals can help you with problems affecting your family and your happiness. They can also help if you have a problem with substance abuse. By calling 1-800-867-6758 (TTY/TDD hearing impaired 1-630-467-8751), you will be connected with an experienced mental health care expert.

He or she will determine your needs and then link you with a mental health or substance abuse provider in your area. This is called "prior authorization." It helps you get the help you need quickly and conveniently from a participating provider. Remember: All inpatient and outpatient mental health and substance abuse services require prior authorization before treatment.

If you do not have benefits through UBH, call the mental health/substance abuse phone number listed on the back of your ID card. If you are not sure about these benefits, please contact Customer Service.

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How many well-child and routine physicals are covered during a year?

Routine physicals are limited to one per calendar year. Well-child visits are covered from birth to age seven as medically necessary.

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What is considered to be part of a routine exam? Does this cover any lab tests and X-rays that my doctor may feel I need?

Preventive care exams and associated services for a member must be done by a network physician (routine physicals, well-baby and well-child care), as well as such services that may be ordered in conjunction with the examination, such as immunizations, laboratory tests, and X-ray examinations. Covered preventive care services are those considered medically necessary. “Preventive care” refers to services recommended by the U.S. Preventive Services Task Force.

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What happens if I become too sick to make my own decisions regarding medical care?

Your family and doctor must decide what treatment to use, when not to treat, and when to stop treatment. It's better if they know in advance what treatments you want or don't want and who you want to make your health care decisions. A federal law called The Patient Self-Determination Act gives you the right to make decisions about your future health care.

This includes the right to accept or refuse medical or surgical treatment and to plan and direct the types of health care you may receive if you become unable to express your wishes. You can exercise this right by making an Advance Medical Directive. We support your rights under this law.

Coverage of your medical care is in no way influenced by your having an Advance Medical Directive. Because of different state laws, our network providers have varying practices on implementing an Advance Medical Directive. They must make these practices known to you when you select or receive care from them. For example, if your physician, as a matter of conscience, is unable to comply with your directives, he or she must take all reasonable steps to arrange to transfer you to another physician.

* A “medical emergency” is a condition brought on by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect that not getting immediate medical attention could result in:

  • serious jeopardy to the health of the individual or, in the case of a pregnant woman, the health of the woman or her unborn child;
  • serious impairment to bodily functions; or
  • serious dysfunction of any bodily organ or part.
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Popular Links
- Lab Corp (use to find laboratory services out of your local service area)
- National Committee for Quality Assurance (NCQA)
- NCQA HealthChoices
- Compare Hospital and Provider Quality

 


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Search our online directory to Find a Physician or Facility. For a paper provider directory or assistance finding a provider, please call the Customer Care number on the back of your health plan ID card.


 
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