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The United Healthcare Military form is a crucial document within the TRICARE system, facilitating the referral and request processes for various medical services for military beneficiaries. This form is designed to streamline communication between healthcare providers, military treatment facilities, and UnitedHealthcare Military & Veterans. Key sections include beneficiary information, which captures essential demographics such as name, gender, date of birth, and contact information. The requesting provider's details are also documented, ensuring that necessary referrals originate from qualified professionals. Additionally, the servicing facility's information allows for accurate coordination and continuity of care. The form emphasizes the importance of medical necessity, requiring detailed explanations for services requested, along with diagnosis and procedure codes. It also delineates priorities for requests, categorizing them as either routine or urgent, and specifies the type of service being requested, including specialty referrals and various types of inpatient and outpatient care. Compliance with privacy regulations is highlighted, underscoring the need to handle personal health information with care. Ultimately, this form serves as a vital instrument in managing the healthcare needs of military personnel and their families, aiding in the delivery of timely and appropriate medical services.

United Healthcare Military Example

TRICARE Service Request/Notification

Fax referral to: UnitedHealthcare Military & Veterans at: 877-890-9309 Routine 877-890-8203 Urgent

The Military Treatment Facility (MTF) in your area may have Right of First Refusal for this service.

Beneficiary Information

Name: Last

First

M.I.

Gender

DOB: (mm/dd/yyyy)

 

 

 

 

_____ / _____ / ________

 

 

 

 

 

 

Address: Street

Apt. No.

City

 

State

ZIP Code

 

 

 

 

 

 

Contact Phone #:

 

Sponsor SSN:

 

 

 

 

 

 

 

 

 

Requesting Provider Information

 

 

 

 

 

 

 

 

 

 

 

Name:

NPI #:

Address: Street

City

State

ZIP Code

Contact Name: Last

First

Contact’s Department in Facility:

Office Phone #:

Office Fax #:

Provider Rendering Care (Physician/Facility/Agency/Vendor)

Name: (Physician/Facility/Agency/Vendor)

Provider NPI #: (mandatory on form)

Specialty:

 

 

Sub-specialty: (if applicable)

 

 

 

 

 

Reason for Sub-specialty Request:

 

 

Anticipated Date of Service/Admission Date: (mm/dd/yyyy)

 

 

 

_____ / _____ / ________

 

 

 

 

 

 

Address: Street

City

State

ZIP Code

Office Phone #:

Office Fax #:

Servicing Facility Information

Name:

TIN:

Address: Street

City

State

ZIP Code

 

 

 

 

Request Priority: (Please check one)

Routine Urgent

 

 

Service Type: (Please check one)

Specialty Referral Inpatient (Acute, SNF, RTC or Rehab)

 

 

Outpatient (Medical/Surgical or Behavioral Health)

DME, Home health

This document may contain personally identifiable information, including protected health information. Only those with a need to know should access or use this document. Access, use or disclosure of this document or its contents must comply with the MHS Notice of Privacy Practices, the HIPAA Privacy Rule and the DoD Privacy Program. If you received this document in error, please contact us immediately at 1-877-988-9378.

TRICARE West Region Customer Service: 1-877-988-9378 (WEST) • www.uhcmilitarywest.com

TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved.

 

 

Doc#: UHC2467w_20130328

OA100-9116RM1_256

© 2013 United HealthCare Services, Inc.

SR#: 10624774

 

Page 1 of 2

 

 

 

 

 

 

TRICARE Service Request/Notification

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Admission Type: (Please check one) ER

Direct Admit Elective

 

 

 

 

 

 

Diagnostic Information

 

 

 

 

 

 

 

 

 

Diagnosis:

 

 

ICD-9 Code:

 

 

 

 

 

 

Any Secondary Diagnosis:

 

 

ICD-9 Code:

 

 

 

 

 

Requested Procedures/Services:

 

CPT 4 Code/ HCPCS Code:

 

 

 

 

 

 

Frequency Requested: _____

Daily

Weekly Monthly Other

Duration: ______ Days

Weeks

Months

Number of Visits Requested:

If DME: Purchase Rental

Medical Necessity of Services (Reason for request and/or Explanation of Medical Necessity)

This document may contain personally identifiable information, including protected health information. Only those with a need to know should access or use this document. Access, use or disclosure of this document or its contents must comply with the MHS Notice of Privacy Practices, the HIPAA Privacy Rule and the DoD Privacy Program. If you received this document in error, please contact us immediately at 1-877-988-9378.

TRICARE West Region Customer Service: 1-877-988-9378 (WEST) • www.uhcmilitarywest.com

TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved.

 

 

Doc#: UHC2467w_20130328

OA100-9116RM1_256

© 2013 United HealthCare Services, Inc.

SR#: 10624774

 

Page 2 of 2

 

Form Characteristics

Fact Name Fact Description
Referral Fax Numbers For service requests, use 877-890-9309 for routine referrals and 877-890-8203 for urgent cases.
Right of First Refusal The Military Treatment Facility (MTF) in the area may have the right to refuse services before another provider can intervene.
Privacy Compliance This document must comply with the MHS Notice of Privacy Practices and HIPAA Privacy Rule, ensuring that only authorized users can access it.
Contact for Errors If you inadvertently receive this document, contact the helpline at 1-877-988-9378 immediately for assistance.

Guidelines on Utilizing United Healthcare Military

Completing the United Healthcare Military form is an important process for ensuring your healthcare needs are properly documented and communicated. Follow these detailed steps to accurately fill out the form, ensuring that all required information is provided clearly to avoid delays in processing.

  1. Start with the Beneficiary Information section.
    - Fill in the last name, first name, and middle initial of the beneficiary.
    - Mark the beneficiary’s gender and provide the date of birth in the specified format (mm/dd/yyyy).
    - Enter the full address, including street, apartment number (if applicable), city, state, and ZIP code.
    - Include a contact phone number and the sponsor's Social Security Number (SSN).
  2. Move on to the Requesting Provider Information section.
    - Enter the provider's name and their National Provider Identifier (NPI) number.
    - Provide the address, including street, city, state, and ZIP code of the requesting provider.
    - List the contact person's details, including last name, first name, and their department in the facility.
    - Include the office phone number and fax number.
  3. Fill out the Provider Rendering Care section.
    - Enter the name of the physician, facility, agency, or vendor rendering the care.
    - Provide their NPI number, full specialty, and sub-specialty if applicable.
    - If a sub-specialty request is made, document the reason for the request.
    - Indicate the anticipated date of service or admission (mm/dd/yyyy).
    - Fill in the address and contact details as requested.
  4. Complete the Servicing Facility Information section.
    - Provide the name and Tax Identification Number (TIN) of the servicing facility.
    - Fill in the facility's address details.
    - Check the appropriate request priority (either Routine or Urgent) and service type (indicate Specialty Referral or others based on your needs).
  5. Specify the Admission Type by selecting ER, Direct Admit, or Elective.
  6. In the Diagnostic Information section, document the diagnosis and ICD-9 code, and any secondary diagnosis codes that apply.
  7. For Requested Procedures/Services, list the procedures and corresponding CPT 4 code or HCPCS code.
    - Indicate the frequency requested (Daily, Weekly, Monthly, or Other) and duration (Days, Weeks, or Months).
    - Specify the number of visits requested and whether any DME (Durable Medical Equipment) is needed, and if so, whether it should be purchased or rented.
  8. Lastly, provide a brief explanation of the medical necessity for the services requested.

Once you have completed the form, review all sections for any missing information or errors. Then, submit it via fax to the appropriate number listed on the form. By following these steps carefully, you ensure that your healthcare request is processed efficiently and accurately.

What You Should Know About This Form

What is the purpose of the United Healthcare Military form?

The United Healthcare Military form, specifically the TRICARE Service Request/Notification, is designed to facilitate referrals for medical services to beneficiaries of TRICARE. This form is utilized to request specialty care, inpatient services, outpatient services, or durable medical equipment (DME). Proper completion ensures that the necessary medical evaluations and treatments are issued without delay.

Who should fill out the Military form?

The form should be completed by the requesting provider who is seeking a referral for a patient. This can include a physician, facility, agency, or vendor. The beneficiary's information, including personal details and medical necessity for the requested services, must be accurately provided to avoid interruptions in care.

What information is required on the form?

The form requires several key pieces of information. This includes beneficiary details (name, gender, date of birth, address), requesting provider information (name, address, contact details), and specifics about the services being requested (medical necessity, diagnosis, anticipated date of service, etc.). Additionally, priority and service type must be indicated, such as whether the request is routine or urgent.

How do I submit the United Healthcare Military form?

The completed form should be faxed to the appropriate numbers provided based on the urgency of the request. Routine requests can be sent to 877-890-8203, while urgent requests should be faxed to 877-890-9309. Ensure that all required information is filled out to facilitate the referral process.

What happens if I submit the form with incomplete information?

Submitting the form with incomplete information can result in delays in processing the referral. If the form lacks necessary details, United Healthcare may request additional information, which can prolong the time before services are rendered. It is crucial to verify all entries for accuracy and completeness before submission.

Who do I contact if I have questions about the form?

If you have questions regarding the form or its submission process, you can contact TRICARE West Region Customer Service at 1-877-988-9378. They can provide assistance and clarification on how to properly fill out the form and address any concerns you may have.

What is the importance of medical necessity in this form?

Medical necessity is a critical component of the United Healthcare Military form. It provides justification for the requested services or procedures. The explanation of medical necessity should clearly outline why the specialized care is needed based on the patient’s diagnosis and treatment plan. This helps in securing approval for the referral and ensures that the patient's healthcare needs are met adequately.

What privacy measures are in place for the information provided?

The form contains personally identifiable information and protected health information. Access to this information is limited to individuals who have a legitimate need to know. Compliance with privacy regulations, such as the HIPAA Privacy Rule and the DoD Privacy Program, is mandatory. If the form is received by an unintended recipient, they should contact United Healthcare at 1-877-988-9378 immediately to rectify the situation.

Common mistakes

Filling out the United Healthcare Military form can be a complex task. Many individuals inadvertently make mistakes that can delay their healthcare services. One common error is inaccurate beneficiary information. It is crucial to ensure that the name, date of birth, and Social Security Number are correct. A small typo can create significant issues in processing the request.

Another frequent mistake involves the omission of mandatory fields. The form includes several sections that require complete information, such as the provider's NPI number. Failure to include this or similar critical details often results in rejection of the entire referral or request.

Many people forget the necessary details regarding the medical necessity of services. The explanation provided for this section must be clear and thorough. Vague descriptions can lead to denials, as the reviewing party may not understand the urgency or need for the service requested.

Additionally, individuals may incorrectly select the request priority and service type. It is essential to carefully read all options and choose the appropriate categories. Misclassifying a request as 'routine' instead of 'urgent' could significantly delay treatment.

Finally, not double-checking contact information can lead to communication problems. Ensuring that the phone number and address are accurate aids in facilitating timely responses from the healthcare provider. Surgery or treatment delays can often be traced back to simple oversights in this area.

Documents used along the form

The process for obtaining medical services under the United Healthcare Military form involves several other documents that can facilitate the approval and management of care. Each of these forms plays a significant role in ensuring a smooth transition through the healthcare system for military beneficiaries.

  • TRICARE Authorization Request Form: This document requests authorization for specific medical services, including consultations and surgical procedures. It assists in determining coverage before services are rendered.
  • Patient Health History Form: Patients provide detailed medical histories, including previous illnesses, surgeries, and current medications. This information helps healthcare providers make informed treatment decisions.
  • Referral Letter: Issued by a primary care physician, this letter outlines the need for specialist care. It is essential for ensuring that the patient receives the appropriate services.
  • Claim Form: This document allows healthcare providers to submit payment requests to TRICARE or the military insurance provider after services have been provided, thereby facilitating reimbursement.
  • Patient Consent Form: Patients sign this form to grant permission for the use of their medical information and to acknowledge understanding of the treatment being proposed.
  • Medical Necessity Letter: This document typically accompanies a referral or authorization request. It details why a specific service or procedure is necessary for the patient's diagnosis or treatment.
  • Continuity of Care Form: Used when a patient transitions from one provider to another, this form ensures that the new provider has access to essential information about ongoing treatment and care plans.
  • Billing Information Form: Patients complete this form to provide insurance and billing details, which helps in processing claims accurately and efficiently.

Each of these documents serves a unique purpose in the healthcare process, ensuring that beneficiaries receive the services they need while maintaining compliance with necessary regulations. Understanding these forms can significantly help in navigating the TRICARE system smoothly.

Similar forms

  • Physician Referral Form: Similar to the United Healthcare Military form, this document outlines the need for a specialist's services. It gathers patient information and the reason for the referral, ensuring all necessary details are submitted for processing.
  • Authorization Request Form: This form is used by doctors to seek approval for specific medical services or procedures. Like the military form, it requires patient information and the anticipated date of service, thus facilitating a streamlined request process.
  • Insurance Claim Form: Healthcare providers submit this form to claim reimbursement for services rendered. Both documents involve extensive patient information and detail the type of care provided, establishing a parallel in function and importance.
  • Prior Authorization Form: Used in both private and public healthcare systems, this form seeks pre-approval for medical services. Each requires a valid reason for the service, along with supporting documentation to justify the medical necessity.
  • Continuity of Care Document (CCD): This document contains a summary of patient health information. It serves a similar purpose in terms of providing critical patient information to healthcare providers to ensure informed decision-making.
  • Referral for Specialty Care: Much like the United Healthcare Military form, this referral requests specific treatments from specialist providers. It must include clinical detail and justification for care, underscoring its importance in patient management.
  • Home Health Care Request Form: This document is necessary for patients who require home health services. Similar to the military form, it details the medical necessity, type of care needed, and logistics to ensure proper service delivery.
  • Emergency Services Request Form: This form is completed when emergency medical services are required. Both forms capture urgent care needs, along with pertinent patient details to expedite the request process.
  • Disability Services Request Form: Used to apply for medical services for individuals with disabilities, this form shares similar characteristics with the United Healthcare Military form in that it requires a thorough explanation of the care needed and the justification for it.
  • Mental Health Referral Form: As with the military form, this referral is crucial for obtaining psychological evaluations and treatments. It requires articulate reasons for the referral and detailed patient information, ensuring continuity in care.

Dos and Don'ts

When filling out the United Healthcare Military form, it’s essential to ensure accuracy and clarity. Here’s a helpful list of dos and don’ts to guide you through the process.

  • Do double-check all personal information for accuracy.
  • Don’t leave any required fields blank; incomplete forms can delay processing.
  • Do use clear and legible handwriting if filling out the form by hand.
  • Don’t use abbreviations or jargon that may not be understood by the reviewing team.
  • Do provide a specific reason for any specialty requests to ensure proper approval.
  • Don’t forget to include your contact information in case further details are needed.
  • Do ensure the doctor’s NPI number is included, as this is mandatory.
  • Don’t submit the form without confirming the request priority (routine or urgent).
  • Do check the coding for diagnoses and procedures, as these are crucial for processing.
  • Don’t ignore the instructions regarding confidentiality; protect personal health information at all costs.

Misconceptions

  • Misconception: The United Healthcare Military form is only for emergency situations. Many believe that this form is only necessary for urgent care, but it can also be used for routine services. Both routine and urgent cases can be addressed.
  • Misconception: The form is only for veterans. This form is intended for active duty personnel and their family members, as well as veterans. The services provided cover both active duty and veteran needs.
  • Misconception: You can submit the form without a physician's input. A healthcare provider must complete significant parts of this form. Their input is crucial for accurate medical necessity and proper processing of requests.
  • Misconception: Submitting the form guarantees service approval. Approval is not guaranteed upon submission. The request will be evaluated based on medical necessity and guidelines set forth by TRICARE.
  • Misconception: The form can be submitted via any means. There are specific fax numbers listed for submitting the form. Using the right number ensures the request reaches the appropriate department quickly.
  • Misconception: Personal information on the form is unprotected. The form contains sensitive information and is subject to strict privacy regulations. It must be handled with care to protect personal health information.
  • Misconception: Only the service member needs to fill out the form. Family members and providers also need to provide their information. The form requires details from multiple parties to process a request smoothly.
  • Misconception: You don't need to follow up after submitting the form. Following up is recommended. This ensures that the request is being processed and any issues can be addressed promptly.

Key takeaways

Filling out and using the United Healthcare Military form effectively is crucial for ensuring timely and appropriate healthcare services for military beneficiaries. Here are key takeaways to keep in mind:

  • Double-check contact information: Ensure that both the beneficiary and provider contact details are accurate. This is vital for follow-up communications.
  • Understand referral types: The form allows you to request various types of services. Remember to check the appropriate box for routine or urgent requests.
  • Include all required identifiers: When filling out the form, provide complete information, including the requesting provider's NPI number. This is mandatory for processing.
  • Specify the type of service: Clearly indicate whether the request is for specialty referral, inpatient care, outpatient services, or home health. Misidentification can delay care.
  • Address medical necessity: Clearly explain the medical necessity of the requested services. Insufficient information can lead to denial of care.
  • Familiarize yourself with submission guidelines: Fax the completed form to the appropriate United Healthcare Military & Veterans number. Use the correct fax line depending on urgency.
  • Contact customer service if needed: If questions arise or assistance is required, do not hesitate to call TRICARE West Region Customer Service at 1-877-988-9378.

Filling out this form accurately and completely will significantly expedite the processing of your healthcare requests.