Arizona: No referrals required with HMO Open Access

Applies to certain Medicare Advantage plans

As of Jan. 1, 2024, the UnitedHealthcare Medicare HMO service area in Arizona includes all counties statewide for all contracted primary care providers. In addition, all in-network Medicare HMO specialists, ancillary providers and hospitals/facilities are considered in-area for all UnitedHealthcare Medicare HMO members in Arizona. This includes all delegated networks, including OptumCare and Banner Health networks.

No referrals required

Out-of-area referral authorization is no longer required to obtain care within the state of Arizona. This means members can receive care from Phoenix to Flagstaff or from Tucson to Phoenix without concern of claim denial for care being out of area.

If members reside in Arizona and are seeking referrals within the state of Arizona, they do not have to activate the Passport benefit. Providers should allow members to be seen without Passport activation.

This also means members can self-refer to any in-network HMO provider for both non-delegated and delegated Medicare plans without concern of claim denial as out of area. The provider directory will still guide members to providers and facilities within 30 miles of their home ZIP code.

However, it is possible a member residing in Flagstaff could self-refer to a specialist in Tucson, for example. Services rendered in this example would be payable, as long as the specialist is in the HMO network and follows standard claim processes. Prior authorization may still be required for some services in accordance with the current prior authorization list.

Please continue to provide specialty and ancillary care direction for your patients, this includes addressing concerns or helping to find local specialist. This can help members avoid self-referring to distant specialists.

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