AmeriChoice by United Healthcare (Tennessee) - UHC River Valley
AmeriChoice by United Healthcare (Tennessee) - UHC River Valley
AmeriChoice by United Healthcare (Tennessee) - UHC River Valley
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<strong>AmeriChoice</strong> <strong>by</strong> <strong>United</strong> <strong>Healthcare</strong> (<strong>Tennessee</strong>)<br />
Services that Require Prior Authorization<br />
Effective Feb 15, 2010<br />
WEST <strong>Tennessee</strong><br />
Service Areas<br />
EAST <strong>Tennessee</strong> Service<br />
Areas<br />
MEDICARE Special<br />
Needs Plan<br />
Service Needed<br />
MIDDLE <strong>Tennessee</strong><br />
Service Areas<br />
Behavioral Health and<br />
Substance Abuse-<br />
Ambulatory<br />
• Mental Health Case<br />
Management (Level I<br />
Team Approaches<br />
Only)<br />
• Intensive Outpatient<br />
• Outpatient<br />
Detoxification and<br />
Rehabilitation<br />
• Supported Housing<br />
• Psychological and<br />
Neuropsychological<br />
Testing<br />
• Applied Behavioral<br />
Analysis<br />
• Supported<br />
Employment<br />
• Electro Convulsive<br />
Therapy<br />
Call 800-690-1606 Fax<br />
888-735-1434 In case of<br />
an emergency, call the<br />
local Mobile Crisis Line<br />
Adults – Over 18 years old:<br />
1-800-809-9957 Under 18<br />
years old: Rural Middle<br />
<strong>Tennessee</strong> 1-866-791-<br />
9222 Nashville Region 1-<br />
866-791-9221 Upper<br />
Cumberland Region 1-866-<br />
791-9223<br />
Call 800-690-1606 Fax<br />
866-359-3770 In case of<br />
an emergency, call the<br />
local Mobile Crisis Line<br />
Adults – Over 18 years old:<br />
1-800-809-9957 Under 18<br />
years old: Memphis<br />
Region 1-866-791-9226<br />
Rural West <strong>Tennessee</strong> 1-<br />
866-791-9227<br />
Call 800-690-1606 Fax<br />
877-614-7141 In case of<br />
an emergency, call the<br />
local Mobile Crisis Line<br />
Adults – Over 18 years old:<br />
1-800-809-9957 Under 18<br />
years old: Southeast<br />
Region 1-866-791-9225<br />
Knoxville Region 1-866-<br />
791-9224 Northeast<br />
Region 1-866-791-9228<br />
Call 800-690-1606<br />
Middle TN Fax 888-735-<br />
1434 East TN Fax 877-<br />
614-7141 In case of an<br />
emergency, call the local<br />
Mobile Crisis Line (See<br />
TennCare business line<br />
for information)<br />
Cosmetic & Reconstructive<br />
Surgery<br />
Call 800-690-1606 Call 800-690-1606 Call 800-690-1606<br />
Call 800-690-1606 Fax -<br />
800-743-6829
Durable Medical Equipment<br />
and Supplies > $500 Per<br />
Item<br />
Call 800-690-1606 Call 800-690-1606 Call 800-690-1606<br />
Call 800-690-1606 Fax -<br />
800-743-6829<br />
Prosthetics and Orthotics ><br />
$500 Per Item<br />
Bariatric Surgery<br />
Evaluations and Bariatric<br />
Surgery<br />
Call 800-690-1606 Call 800-690-1606 Call 800-690-1606<br />
Call 800-690-1606 Call 800-690-1606 Call 800-690-1606<br />
Call 800-690-1606 Fax -<br />
800-743-6829<br />
Call 800-690-1606 Fax -<br />
800-743-6829<br />
Home Health Care Services<br />
(HHC)<br />
• Medication or Infusion<br />
• Therapy services provided<br />
in home<br />
• All Other<br />
Call 800-690-1606 Call 800-690-1606 Call 800-690-1606<br />
Call 800-690-1606 Fax -<br />
800-743-6829<br />
Hospice Services – Inpatient<br />
and Outpatient<br />
Hospital Services – Inpatient<br />
• Acute (Medical,<br />
Surgical, Level 2<br />
through Level 4<br />
Nursery, and<br />
Maternity)<br />
• Sub-acute,<br />
Rehabilitation and<br />
SNF<br />
Call 800-690-1606 Call 800-690-1606 Call 800-690-1606<br />
Call 800-690-1606 Call 800-690-1606 Call 800-690-1606<br />
Call 800-690-1606 Must<br />
Follow Medicare<br />
guidelines<br />
Call 800-690-1606 Fax -<br />
800-743-6829
Hospital Services –<br />
Behavioral Health and<br />
Substance Abuse<br />
Call 800-690-1606 or fax<br />
requests to 888-7351434<br />
• Inpatient<br />
• Detoxification<br />
• Rehabilitation<br />
• Partial Hospitalization<br />
• Residential Treatment<br />
Facility<br />
• Crisis Stabilization<br />
Call 800-690-1606 or fax<br />
requests to 888-7351434<br />
(inpatient and residential<br />
treatment) and 866-359-<br />
3770 for all other services<br />
Call 800-690-1606 or fax<br />
requests to 888-7351434<br />
(inpatient and residential<br />
treatment) and 877-614-<br />
7141 for all other services<br />
Call 800-690-1606<br />
Middle TN Fax 888-735-<br />
1434 East TN Fax 877-<br />
614-7141<br />
Hysterectomy** Call 800-690-1606 Call 800-690-1606 Call 800-690-1606<br />
Call 800-690-1606 Fax -<br />
800-743-6829<br />
MRI, MRA, PET Scans and<br />
Advanced Imaging<br />
Refer to Radiology Prior<br />
Authorization list<br />
(www.uhcrivervalley.com/10provid<br />
er/01americhoice - Radiology<br />
Program)<br />
• Call 866-889-8054,<br />
select prompt # 5,<br />
then select prompt #<br />
2<br />
• Fax 866-889-<br />
8061 via Radiology<br />
Clinical Certification<br />
Fax Request Form<br />
• <strong>AmeriChoice</strong>Online<br />
via<br />
www.<strong>AmeriChoice</strong>.co<br />
m<br />
• Call 866-889-8054,<br />
select prompt # 5,<br />
then select prompt #<br />
2<br />
• Fax 866-889-<br />
8061 via Radiology<br />
Clinical Certification<br />
Fax Request Form<br />
• <strong>AmeriChoice</strong>Online<br />
via<br />
www.<strong>AmeriChoice</strong>.co<br />
m<br />
• Call 866-889-8054,<br />
select prompt # 5,<br />
then select prompt #<br />
2<br />
• Fax 866-889-<br />
8061 via Radiology<br />
Clinical Certification<br />
Fax Request Form<br />
• <strong>AmeriChoice</strong>Online<br />
via<br />
www.<strong>AmeriChoice</strong>.co<br />
m<br />
• Call 866-889-8054,<br />
select prompt # 5,<br />
then select prompt<br />
# 2<br />
• Fax 866-889-<br />
8061 via Radiology<br />
Clinical Certification<br />
Fax Request Form<br />
• <strong>AmeriChoice</strong>Online<br />
via<br />
www.<strong>AmeriChoice</strong>.<br />
com<br />
Non-Contracted Provider<br />
Services (Hospital and<br />
Professional)<br />
Call 800-690-1606 Call 800-690-1606 Call 800-690-1606<br />
Call 800-690-1606 Fax -<br />
800-743-6829<br />
Occupational Therapy<br />
performed in an outpatient<br />
facility after the initial<br />
evaluation and 6 visits<br />
Call 800-690-1606 Call 800-690-1606 Call 800-690-1606<br />
Call 800-690-1606 Fax -<br />
800-743-6829
Pharmacy<br />
Call SXC 866-434-5524<br />
See SXC’s website at<br />
https://tnm.rxportal.sxc.co<br />
m/rxclaim/portal/preLogin<br />
Call SXC 866-434-5524<br />
See SXC’s website at<br />
https://tnm.rxportal.sxc.co<br />
m/rxclaim/portal/preLogin<br />
Call SXC 866-434-5524<br />
See SXC’s website at<br />
https://tnm.rxportal.sxc.co<br />
m/rxclaim/portal/preLogin<br />
Prescriptions Solutions –<br />
Phone: 800-711-4555<br />
Fax: 800-527-0531 See<br />
Formulary at<br />
https://www.uhcrivervalle<br />
y.com/SecurePlusCompl<br />
ete/Pharmacy.html<br />
Physical Therapy performed<br />
in an outpatient facility after<br />
the initial evaluation and 6<br />
visits<br />
Call 800-690-1606 Call 800-690-1606 Call 800-690-1606<br />
Call 800-690-1606 Fax -<br />
800-743-6829<br />
Skilled Nursing Facility<br />
Services<br />
Call 800-690-1606 Call 800-690-1606 Call 800-690-1606<br />
Call 800-690-1606 Fax -<br />
800-743-6829<br />
Speech Therapy performed<br />
in an outpatient facility after<br />
the initial evaluation and 6<br />
visits<br />
Call 800-690-1606 Call 800-690-1606 Call 800-690-1606<br />
Call 800-690-1606 Fax -<br />
800-743-6829<br />
Transplantation Evaluations Call 800-690-1606 Call 800-690-1606 Call 800-690-1606<br />
Call 800-690-1606 Fax -<br />
800-743-6829<br />
Transportation – Non-<br />
Emergent<br />
1-866-416-9209 1-866-405-0238<br />
1-866-725-6270<br />
Reservation - 866-277-<br />
8963<br />
Ride Assist - 866-418-<br />
9809
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