Provider Administration Manual
Prior authorization information
Prior authorization is required for certain types of care. For detailed information, please see the Provider Administration Manual.
BlueCare Tennessee Provider Administration Manual
Prior Authorization Requests
You can submit prior authorization requests for all lines of business 24/7 at Availity.com.
Authorizations & Appeals
Requesting approval for services
Review services that require special approval
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Services Requiring Authorization
- BlueCare Tennessee/CoverKids Prior Authorization List
- High-Cost Lab Prior Authorization List
- Ventilator Weaning and Sub-Acute Tracheal Suctioning Request
- Bariatric Surgery Authorization Request Form
- Complex Rehabilitation Technology DME Authorization Request
- Durable Medical Equipment Request Form
- Initial Member/Caregiver Training Checklist
- Private Duty Nursing/Home Health Plan of Care
- Private Duty Nursing Home Plan of Care Agreement
- Recertification Member/Caregiver Training Checklist
- Provider-Administered Specialty Pharmacy Products
- Prior Authorization Request Form
- Request Out of Network Benefits
- Skilled Nursing Facility and Inpatient Rehabilitation Fax Form
- Transplant Fax Form
- MCG Site Guideline Transparency
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Program-Specific Prior Authorization
Behavioral Health
- Behavioral Health Out of Network Request Form
- Mental Health Inpatient Request Form
- Mental Health Outpatient Request Form
- Psychiatric Residential Treatment Request Form
- Psychological Testing Form
- Provider Discharge Form
- Referral for Applied Behavioral Analysis (ABA)
Advanced Imaging
Advanced imaging includes many diagnostic tools, like CT, MRA, MRI and PET, that require prior authorization for BlueCareSM patients. Please request authorization in Availity® or by calling 1-888-423-0131.
In-network providers caring for TennCareSelect members don’t have to get prior authorization. If you’re not an in-network provider, please contact our Utilization Management department at 1-800-711-4104.
High-Tech Imaging
Pharmacy
Authorization Policies and Process
Appeals process
We’re committed to providing quality and cost-effective health care services to our members. Our decisions are based only on existence of coverage and appropriateness of care.
Before beginning the reconsideration and appeals process, treating providers can request a peer-to-peer discussion with a doctor to review details of the member’s condition and care options.
Parts of our authorization appeals process
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Request a Reconsideration
If you disagree with a decision we’ve made or if you need to provide additional information that may affect the decision, please submit a Provider Reconsideration Form to us within 18 months of the initial denial.
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Appeal the Reconsideration
Please refer to the BlueCare Tennessee Provider Administration Manual for information on filing a formal appeal for TennCare-covered services.
You may file a formal appeal by submitting the Provider Appeals Form to us.
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Expedited Appeals
Expedited Appeals are available for members who are at a more urgent risk for severe health issues without the previously requested care or service.* To request an expedited appeal, please call Utilization Management at the appropriate number below. You can reach us Monday through Friday, 8 a.m. to 6 p.m. ET.
*Any care or service already provided isn’t considered for an expedited appeal.
- BlueCare Utilization Management: 1-888-423-0131
- TennCareSelect Utilization Management: 1-800-711-4104
- CoverKids Utilization Management: 1-800-924-7141
- CHOICES/ECF CHOICES: 1-888-747-8955
You can also submit a Treating Provider's Certificate: Expedited TennCare Appeal to the Division of TennCare at any point during the appeals process.
For information about filing an appeal for a value-based program, please see our Quality Care Initiatives page.
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Division of TennCare Member Appeal
If your patient has received a denial for services, your office can file an appeal for your patient to the Division of TennCare. Please note you must have approval from your patient, in writing, giving you permission to file the appeal.
Please submit written requests within 60 days of the denial by mail or fax:
TennCare Solutions Medical Appeals
P.O. Box 593
Nashville, TN 37202-0593
Fax: 1-888-345-5575