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Welcome to the UnitedHealthcare Community Plan Health Professionals area for Tennessee providers.
Here, you will find the information and links you need to conduct business with UHC Community Plan. 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)
Outpatient Change for Contracted Providers (PDF 75.75 KB) - Posted 07.14.2017
New NPI Requirement for Medicaid Plans (PDF 41.98 KB) - Posted 05.04.07
TennCare Prescription Utilization Reviews (PDF 33.62 KB)
Budget Reductions/Impacts for July 1, 2016 (PDF 1.43 MB)
Updated Provider Administrative Guide Notice (PDF 47.27 KB)
TennCare Member Re-Verification Information (PDF 351 KB)
Click on the arrow above to view provider alerts from 2016 and earlier.
Take A Stand Immunization Workshop Opportunity (PDF 198.03 KB)
UnitedHealthcare Clinical Information Submission Protocol (PDF 82.05 KB)
External FAQ Clinical Submission Protocol (PDF 54.21 KB)
Budget Reductions/Impacts Effective July 1, 2015 (PDF 1.48 MB)
Change PCP Request Form (PDF 157 KB)
Transportation Alert (PDF 32.05 KB)
January 1, 2015 MCO Membership Transition Please click Here (PDF 73.21 KB) for important information.
New PCP Assignment Code: Lock In Your Doc (PDF 30.38 KB)
Lock in Your Doc FAQ's (PDF 33.87 KB)
TennCare Drug Safety Alert to Providers (PDF 64.1 KB)
2014 TN 1% Budget Reduction (PDF 308.71 KB)
Enhanced HIPAA Edits Applied to Claim Submissions (PDF 527.71 KB)
Facet Medial Branch Block Injection Certification Form Letter (PDF 140.93 KB)
Facet Medial Branch Injection Certification Form (PDF 282.73 KB)
DentalQuest Announcement (PDF 11.76 KB)
Provider Administrative Guide Notice (PDF 51.21 KB)
Budget Reduction Oct. 1, 2013 (PDF 201.78 KB)
Reimbursement and Member benefits changes
Attestation form (PDF 38.29 KB)
PCP Fee Schedule Increase FAQ (PDF 24.48 KB)
PCP Rate Increase Announcement Letter
(PDF 31.03 KB)Enhanced Rates Allergy and Immunology Clarification (PDF 110.66 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
- 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.
Click on the arrow above to view our contact information.
Provider Call Center
Postal Mailing Address
UnitedHealthcare Community Plan
UnitedHealthcare Community Plan
Utilization Management Appeals Address
UnitedHealthcare Community Plan
Claims Appeals Mailing Address
Part C Appeals and Grievance Department
Part D Appeals and Grievance Department
Click on the arrow above to view clinical information.
CHOICES (Long Term Care)
United Healthcare Community Plan (TennCare)
United Healthcare Dual Complete Preferred (HMO/SNP)
Click on the arrow above to view provider tools and resources.
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
E-Alert: Electronic Medical Records and Documentation of Seven (7) Required Components (PDF 18.58 KB)
Just for Teens website
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)
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)
COA Documentation Tool - Geriatric Form (PDF 249.7 KB)
Click on the arrow above to view provider manuals.
Tennessee Medicaid Administrative Manual (PDF 2.57 MB)
Tennessee UnitedHealthcare Dual Complete Care Provider Manual (PDF 1.08 MB)
Member Handbook (PDF 2.94 MB)
March Vision Provider Reference Guide (PDF 2.12 MB)
March Vision TN Specific Benefit Summary (PDF 142.96 KB)
Quick Reference Guide for the UnitedHealthcare Administrative Guides (PDF 112.23 KB)
CPT (Current Procedural Terminology) Codes
Radiology Prior Authorization List (PDF 242.17 KB)
Quality Improvement Program Description (PDF 297.65 KB)
Quality Improvement Program Evaluation (PDF 710 KB)
Click on the arrow above for behavioral health information and forms.
TN Health Link Provider Attestation Form (PDF 110.24 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 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)
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 Pre-Certification & Concurrent Review Fax Form
Tennessee Behavioral Health Quick Reference Guide (PDF 204.88 KB)
UHCCP Facility-Agency Site Audit Tools (PDF 118.07 KB)
UHCCP Member Record Audit Tool (PDF 331.31 KB)
UHCCP Provider Evaluation of Performance Plan (PDF 88.64 KB)
Click on the arrow above to view the behavioral health level of care guidelines.
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 & Neuropsychological Testing (PDF 98.95 KB)
Psychosocial Rehabilitation Community Support Services (PDF 60.61 KB)
Sub-Acute Inpatient treatment (PDF 65.19 KB)
Supported Housing and Enhanced Supported Housing (Combined) (PDF 109.28 KB)
Tennessee Health Link: Adults Medical Necessity Criteria (PDF 180.84 KB)
Transcranial Magnetic Stimulation (PDF 44.26 KB)
Click on the arrow above to view resource materials.
Home and Community Based Services Providers (PDF 103.84 KB)
Tennessee Health Care Innovation Initiative Project (PDF 93.88 KB)
Tennessee False Claims Act (PDF 1.63 MB)
Contractor Risk Agreement - TennCare East and West
Contractor Risk Agreement - TennCare Middle
Referral Provider Listing - West (PDF 742.4 KB)
Referral Provider Listing - East (PDF 1.17 MB)
Referral Provider Listing - Middle (PDF 1.21 MB)
Click on the arrow above to view information about medical injectables.
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:
Network Specialty Pharmacy
The following specialty pharmacies also provide certain types of specialty medications:
Network Specialty Pharmacy
Accredo (nursing services)
Option Care (nursing services)
CVS Caremark Specialty Pharmacy
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.
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
Click on the arrow above to view the prior authorization archive.
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. These policies and guidelines are provided for informational purposes, and do not constitute medical advice.
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.
Integrity of Claims, Reports, and Representations to the Government
UnitedHealth Group requires compliance with the requirements of federal and state laws that prohibit the submission of false claims in connection with federal health care programs, including Medicare and Medicaid.
View our policy (PDF 38.15 KB).
If UHG policies conflict with provisions of a state contract or with state or federal law, the contractual / statutory / regulatory provisions shall prevail. To see updated policy changes, select the Bulletin section at left.