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Mangyaring piliin ang estado kung saan ka nagtatrabaho.

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

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 FAQs (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

Planong Pangkomunidad ng UnitedHealthcare
8 Cadillac Drive, Suite 100
Brentwood, TN 37027

Claims Address

Planong Pangkomunidad ng UnitedHealthcare
P.O. Box 5220
Kingston, NY 12402

Utilization Management Appeals Address

Planong Pangkomunidad ng UnitedHealthcare
P.O. Box 5220
Kingston, NY 12402

Claims Appeals Mailing Address

Part C Appeals and Grievance Department
Planong Pangkomunidad ng UnitedHealthcare
Paunawa: Complaint and Appeals Department
P.O. Box 31364
Salt Lake City, UT 84131-0364

 

Part D Appeals and Grievance Department
Paunawa: 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)

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). 

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:

Specialty na Botika ng Network

Numero ng Telepono

BriovaRx

855-427-4682

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

Specialty na Botika ng Network

Kategorya ng Gamot

Numero ng Telepono

Accredo (nursing services)

Kakulangan sa Enzyme

Gaucher's Disease

Immune Globulin

Pulmonary Hypertension

800-803-2523

 

Option Care (nursing services)

Kakulangan sa Enzyme

Gaucher's Disease

Hemophilia

Immune Globulin

Makena

866-827-8203

Specialty na Botika ng 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.

UnitedHealthcare Medicare Prior Authorization Requirements - Effective 1/1/2018  (PDF 282.37 KB)

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 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. Ang mga patakaran at alituntunin na ito ay ibinibigay para sa mga layunin ng pagbibigay-impormasyon, at hindi bumubuo ng isang payong medikal.
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 ng Mga Claim, Ulat, at Pagkakatawan sa Pamahalaan

Iniaatas ng UnitedHealth Group ang pagsunod sa mga batas pederal at batas ng estado na nagbabawal sa pagsusumite ng mga huwad na claim kaugnay sa mga pederal na programa ng pangangalaga sa kalusugan, kabilang na ang Medicare at Medicaid. 
View our policy (PDF 38.15 KB).

Disclaimer

If UHG policies conflict with provisions of a state contract or with state or federal law, the contractual / statutory / regulatory provisions shall prevail. Upang makita ang mga na-update na pagbabago sa patakaran, piliin ang seksyon ng Bulletin sa kaliwa.