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Maidawat nga pilyen iti pagilyan nu sadinoka nga agsansanay.

Welcome to the UnitedHealthcare Community Plan Health Professionals area for Tennessee providers.

Ditoy, masarakam ti impormasyon ken kamang a masapul mo tapno mangibanag ti negosyo iti UHC a Plano a Komunidad. Please choose your topic of interest, by selecting one of the navigation buttons on the left-hand side of the page, or select one of the topics or products below to reveal our Contact Information, Provider Administrative Manuals and Forms.

Medicaid Managed Care Rule External FAQ’s (PDF 64.57 KB)

Medicaid Managed Care Rule Presentation (PDF 90.71 KB)

 


UnitedHealthcare On Air Is On Demand!

There are a whole lot of changes going on that will affect how you operate your practice.

  • Payment Reform and new pay for performance programs
  • ICD-10
  • Electronic Processing Improvements
  • Provider Data Management
  • Claims Processing Improvement
  • Peer to Peer Best Practices.

Stay in touch through live video updates and emails. Click here to register or login. 

 

Provider Call Center

800-690-1606
8 a.m. – 6 p.m., EST

Postal Mailing Address

UnitedHealthcare Community Plan
8 Cadillac Drive, Suite 100
Brentwood, TN 37027

Claims Address

UnitedHealthcare Community Plan
P.O. Box 5220
Kingston, NY 12402

Utilization Management Appeals Address

UnitedHealthcare Community Plan
P.O. Box 5220
Kingston, NY 12402

Claims Appeals Mailing Address

Part C Appeals and Grievance Department
UnitedHealthcare Community Plan
Maawagan ti imatang: Complaint and Appeals Department
P.O. Box 31364
Salt Lake City, UT 84131-0364

 

Part D Appeals and Grievance Department
Maawagan ti imatang: CA124-0197
P.O. Box 6106
Cypress, CA 90630-9948

CHOICES (Long Term Care)

United Healthcare Community Plan (TennCare)

United Healthcare Dual Complete Preferred (HMO/SNP)

eServices

Medical Injectables 
View the clinical criteria/guidelines used to conduct medical necessity reviews.

CHOICES (Long Term Care) 

UnitedHealthcare Community Plan (TennCare) 
UnitedHealthcare Community Plan Provider Quick Reference Guide (PDF 261.46 KB)

UnitedHealthcare Dual Complete Preferred (HMO SNP) 
Frequently Asked Questions by Providers
Notice of Medicare Non-Coverage (NOMNC)
Non-Par Provider Appeal/Dispute Rights

TennCare Kids
E-Alert: Electronic Medical Records and Documentation of Seven (7) Required Components (PDF 18.58 KB) 
Preventive Visits Reimbursement Reference Guide (PDF 79.89 KB)
TennCare Kids / EPSDT General Information (PDF 61.79 KB)
TennCare Kids website 
Tennessee Chapter of the American Association of Pediatrics (TNAAP) 
TNAAP Age Specific Forms for EPSDT exams (PDF 3.97 MB)   

Immunization Schedules
Child / Adolescent 
Adult Schedule

Quality
2016 HEDIS Expanded Guide (PDF 327.52 KB)
2016 HEDIS Cheat Sheet (PDF 473.36 KB)
2012 Quality Improvement Program Evaluation (PDF 2.19 MB)
2013 Quality Improvement Program Description (PDF 405.8 KB)

Documentation Tools
COA Documentation Tool - Geriatric Form (PDF 249.7 KB)

TN Health Link Provider Attestation Form (PDF 110.24 KB)

Important Reminder for TennCare Behavioral Health Providers: Evaluation and Management Codes for Same-Day Services (PDF 40.27 KB)

Important Reminder for TennCare Behavioral Health Providers: Place of Service Codes (PDF 48.73 KB)

Important Reminder: TennCare Comprehensive Child & Family Treatment (PDF 26.15 KB)

 

ADHD Appointment Planner (PDF 141.26 KB)

ADHD Prescriptions - Importance of Provider Monitoring (PDF 22.65 KB)

ADHD Medication Log (PDF 126.77 KB)

Advance Directives and Living Wills (PDF 603.27 KB) 

Adverse Occurrence Form  (PDF 38.01 KB)

Behavioral Health Credentialing and Recredentialing Quick Reference Guide

Behavioral Health Information and Resources (PDF 57.11 KB)

Billing For Family Therapy Codes (PDF 57.11 KB)

Crisis Provider Information for Children and Adolescents (PDF 322.73 KB)

Crisis Services Training Curriculum (TDMH)

Declaration of Mental Health Treatment Information & Forms (TN Government site)

Diabetes Training for Mental Health Providers (PDF 221.7 KB)

Discharge Plan Requirements (PDF 25.01 KB)

HEDIS Behavioral Health Measures (PDF 9.48 KB)

Instructions for Discharge Summary Form (PDF 157.34 KB)

New Member Rx ADHD (PDF 84.24 KB)

Outpatient Management for TennCare Behavioral Health Providers (PDF 254.38 KB) (PDF 46.6 KB)

Prior Authorization and Concurrent Review Form  (PDF 46.6 KB)

Primary Care Provider Behavioral Health Screening Toolkit (PDF 42.07 KB)

TennCare Outpatient BH Certification Inquiry

TennCare Pre-Certification & Concurrent Review Fax Form

 Tennessee Department of Mental Health and Substance Abuse Services (TDMHSAS)

Tennessee Behavioral Health Quick Reference Guide (PDF 204.88 KB)

UHCCP Facility-Agency Site Audit Tools (PDF 171.16 KB)

UHCCP Member Record Audit Tool (PDF 283.4 KB)

UHCCP Provider Evaluation of Performance Plan (PDF 96.51 KB)

UnitedHealthcare Community Plan Behavioral Health Provider Directory

Substance Abuse and Co-Occurring Disorders

Mental Health, Substance Abuse and Co-Occurring Disorders

United Healthcare Community Plan currently utilizes the following Level of Care Guidelines (LOCGs) to conduct medical necessity reviews of requests for services as they apply to available Behavioral Health benefits.

ASAM 3rd Edition criteria are currently utilized for all Substance Abuse services.  ASAM criteria are proprietary and cannot be given to providers or members unless a denial of service(s) is rendered, at which time a copy of the criteria in question can be obtained upon request.  Providers wishing to access these criteria independently may purchase them using the following link: ASAM American Society of Addiction Medicine (American Society of Addiction Medicine- Patient Placement Criteria, 3rd Edition).

Guidelines currently used for all other levels of care listed below can be found at http://www.uhccommunityplan.com/health-professionals/TN/provider-information

 

Levels of Care and Services Not Utilizing ASAM or Milliman Criteria:

Adult Residential Treatment (Adult RTC) (PDF 67.04 KB)

Acute Inpatient Hospitalization (PDF 55.6 KB)

Applied Behavioral Analysis (PDF 99.1 KB)

Program of Assertive Community Treatment (PDF 66.19 KB)

Community Assesment and Stabilization Team (CAST) (PDF 89.32 KB)

Child and Adolescent Residential Treatment (C&A RTC) (PDF 53.78 KB)

Comprehensive Child and Family Treatment (CCFT) (PDF 79.26 KB)

Continued Service (PDF 51.93 KB)

Continuous Treatment (CTT) (PDF 79.43 KB)

Crisis Stabilization Unit (CSU) (PDF 59.23 KB)

Intensive Outpatient Program (PDF 51.69 KB)

Medical Necessity Criteria Systems of Support (PDF 230.44 KB)

Nursing Home Plus (PDF 59.24 KB)

Outpatient (PDF 65.07 KB)

Partial Hospital Program (PHP) (PDF 98.62 KB)

Psychological and Neuropsychological Testing  (PDF 98.95 KB)

Psychosocial Rehabilitation Medical Necessity Criteria (PDF 78.24 KB)

Sub-Acute Inpatient treatment (PDF 65.19 KB)

Supported Housing and Enhanced Supported Housing (Combined) (PDF 109.28 KB)

Tennessee Health Link: Children and Adolescents Medical Necessity Criteria (PDF 179.78 KB)

Tennessee Health Link: Adults Medical Necessity Criteria (PDF 180.84 KB)

Transcranial Magnetic Stimulation (PDF 44.26 KB)

Specialty pharmacy medications covered under the member’s medical benefit may be obtained through various sources ‒ home infusion providers, outpatient facilities, physicians or specialty pharmacy.

If you don’t want to buy and bill a specialty pharmacy medication covered under the member’s medical benefit, you may order it through the following network specialty pharmacy:

Ispesyalista a Parmasiya ti Network

Numero iti Telepono

BriovaRx

855-427-4682

The following specialty pharmacies also provide certain types of specialty medications:

Ispesyalista a Parmasiya ti Network

Kategorya ti Panagagas

Numero iti Telepono

Accredo (nursing services)

Enzyme Deficiency

Gaucher's Disease

Immune Globulin

Pulmonary Hypertension

800-803-2523

 

Option Care (nursing services)

Enzyme Deficiency

Gaucher's Disease

Hemophilia

Immune Globulin

Makena

866-827-8203

Ispesyalista a Parmasiya ti CVS Caremark

Pulmonary Hypertension

800-237-2767


Coverage of a requested medication depends on the member’s benefit, and availability of a specific drug from a network specialty pharmacy may vary.

Upon request, a specialty pharmacy can deliver the medication to your office or another site such as a member’s home.

Medications obtained through a specialty pharmacy will be directly billed to the patient’s health plan.

 

Prior Authorization 

New TennCare Expedited Prior Authorization Appeal Guidelines (PDF 146.87 KB)

Prior Authorization for Outpatient Injectable Chemotherapy and Colony-Stimulating Factors (PDF 70.97 KB) - 11.01.2017

UnitedHealthcare Medicare Solutions & UnitedHealthcare Community Plan
UnitedHealthcare Medicare Prior Authorization Requirements - Effective 1/1/2018 (PDF 282.37 KB)

UnitedHealthcare Community Plan
UnitedHealthcare Community Plan Prior Authorization TN - Effective 1/1/2018 (PDF 263.94 KB)

UnitedHealthcare Medicare Prior Authorization Requirements - Effective 10/1/2017 (PDF 286.74 KB)

UnitedHealthcare Community Plan Prior Authorization TN - Effective 11/1/2017 (PDF 273.59 KB)

UnitedHealthcare Community Plan Prior Authorization TN - Effective 10/1/2017 (PDF 272.91 KB)

UnitedHealthcare Medicare Solutions and UnitedHealthcare Community Plan-Medicare Notification/Prior Authorization Requirements - Effective 7/1/2017 (PDF 300.09 KB)

UnitedHealthcare Community Plan Prior Authorization TN - Effective 7/1/2017 (PDF 266.06 KB)

UnitedHealthcare Community Plan Prior Authorization TN - Effective 4/1/2017 (PDF 264.28 KB)

UnitedHealthcare Medicare Solutions and UnitedHealthcare Community Plan-Medicare Notification/Prior Authorization Requirements - Effective 5/1/2017 (PDF 299.55 KB)

UnitedHealthcare Medicare Solutions and UnitedHealthcare Community Plan-Medicare Notification/Prior Authorization Requirements -  Effective 1/1/2017 (PDF 306.96 KB)

UnitedHealthcare Medicare Solutions and UnitedHealthcare Community Plan-Medicare Notification/Prior Authorization Requirements - Effective 4/1/2017 (PDF 300.79 KB)

UnitedHealthcare Community Plan Prior Authorization TN - Effective 1/1/2017 (PDF 261.44 KB)

UnitedHealthcare Community Plan Prior Authorization TN - Effective 10/1/2016 (PDF 263.37 KB)

UnitedHealthcare Medicare Solutions and UnitedHealthcare Community Plan Notification/Prior Authorization Requirements - Effective 10/1/2016 (PDF 277.31 KB)

UnitedHealthcare Community Plan Prior Authorization TN - Effective 7/1/2016 (PDF 224.58 KB)

UnitedHealthcare Medicare Solutions and UnitedHealthcare Community Plan Notification/Prior Authorization Requirements - Effective 7/1/2016 (PDF 266.74 KB)

UnitedHealthcare Medicare Solutions and UnitedHealthcare Community Plan Notification/Prior Authorization Requirements - Effective 5/1/2016 (PDF 251.42 KB)

UnitedHealthcare Community Plan Prior Authorization List - Effective 5/1/2016 (PDF 226.32 KB)

UnitedHealthcare Medicare Solutions Notification/Prior Authorization List - Effective 1/1/16 (PDF 249.77 KB)

Advanced Notification Requirements for TN - Effective 6/1/2015 (PDF 230.72 KB)

Advanced Notification Requirements for TN - Effective 1/1/2015 (PDF 504.89 KB)

 

UnitedHealthcare Community Plan Medical & Drug Policies and Coverage Determination Guidelines

UnitedHealthcare has developed Medical Policies, Medical Benefit Drug Policies and Coverage Determination Guidelines to assist us in administering health benefits. Dagitoy a pagalagadan ken pagannurotan ket maipaay para ti panangipakaammo a ranta, ken saan a mangbukel ti medikal a balakad.
View the guidelines

UnitedHealthcare Medicare Advantage Coverage Summaries

For policy guidance for Medicare Advantage plan members, view the UnitedHealthcare Medicare Advantage Coverage Summaries Manual and corresponding policy update bulletins here

Integridad ti Claims, Reports, ken Panangibagi iti Gobyerno

UnitedHealth Grupo ket dawatenna ti panagtungpal kadagiti dawdawaten ti pederal ken paglintegan ti estado nga mangiparit ti panagsumite ti palso a claims a maikamang iti pederal a programa ti pannakasalwad ti salun-at, pakairamanan ti Medicare ken Medicaid. 
View our policy (PDF 38.15 KB).

Panangilibak

If UHG policies conflict with provisions of a state contract or with state or federal law, the contractual / statutory / regulatory provisions shall prevail. Tapno makita ti pakaaamo a panagbalbaliw ti pagalagadan, pilien ti Pagwarnakan a seksiyon iti kanigid.