New York Medicaid Specialist Referral Rules: What Has Changed

Apr 08, 2026

1 minute

New York Medicaid Specialist Referral Rules: What Has Changed

Starting January 01, 2026, UnitedHealthcare Community Plan of New York no longer requires referrals for one follow-up visit with certain specialists when the visit takes place within 7 days of a member’s discharge from the hospital or emergency room.

This change applies to these specialist categories:

Allergy and immunology
Dermatology
Endocrinology
Gastroenterology
General surgery
Neurological surgery
Orthopedic surgery
Otolaryngology
Physical medicine and rehabilitation/physiatry
Plastic surgery
Podiatry
Pulmonary medicine
Sports medicine
Urology
Vascular surgery

The referral waiver applies only to the first follow-up visit after discharge. If the member needs more visits after that, the specialist must get a referral from the member’s primary care provider (PCP) to continue care.

If a member is not connected with a PCP or does not know who their PCP is, UnitedHealthcare asks the member to call Member Services using the phone number listed on the back of their ID card.

Providers who need help can also use the chat feature in the UnitedHealthcare Provider Portal, which is available 24/7.

Services

Credentialing

Credentialing is the rigorous process of verifying a healthcare provider’s qualifications, including their education, training, licenses, and clinical experience. This service ensures that practitioners meet the high standards required by insurance networks and hospitals to provide care and receive reimbursement.

Billing & Collection

Billing and Collection service involves confirming a patient’s insurance coverage, active status, and specific benefits before their appointment. By identifying co-pays, deductibles, and required prior authorizations upfront, staff can prevent claim denials and help patients understand their financial responsibilities.

Eligibility Verification

Eligibility verification is the process of verifying a patient’s health insurance coverage and benefits to determine what services are covered and the level of coverage available. This process is essential for healthcare providers to ensure that they receive proper reimbursement for services rendered and that patients are not left with unexpected medical bills.

Revenue Cycle Management

RCM is the financial process that manages the entire lifecycle of a patient’s account, from the initial appointment scheduling to the final balance payment. It integrates eligibility, coding, billing, and collections into a single, cohesive workflow aimed at maximizing a practice's profitability.

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