PHYSICIANS REFERRALS & INSTRUCTIONS
Choose a referral method button and be taken to the instructions on this page:
Fax Referral
TRICARE Portal: ST OT PT Referrals*
Log into your provider portal: Access provider self-service
Click Referral & Authorization Center link under “Referrals & Authorizations header
Click Submit a new request
Enter TRICARE ID and select the patient.
Select yes or no for OHI (other health insurance)
Select “no” for expedited care and click Next button on bottom right
SELECT SERVICE
SPEECH THERAPY REFERRAL
Provider Setting: select Health Care Professionals and Ancillary Services
Type of Service: select Speech Therapy - Speech eval & therapy visits
OCCUPATIONAL THERAPY REFERRAL
Provider Setting: select Outpatient Facility or ER Visit
Type of Service: select Occupational Therapy-Occupational Therapy
PHYSICAL THERAPY REFERRAL
Provider Setting: select Outpatient Facility or ER Visit
Type of Service: select Physical Therapy-Physical Therapy General
Select No specific date of service required and click Next *To backdate services select “Already Occured”
ENTER PROCEDURES: no changes; click Next
ENTER EXISTING AUTHS SUBMITTED FOR THIS PATIENT: review to ensure no duplicate speech therapy services and click Next
CONFIRM AUTHORIZATION IS REQUIRED: Click Continue
SELECT PROVIDER:
Select View Alternative Providers
Scroll to the bottom and click the Search for Additional Providers; enter any of the following
Provider name: Lively Speech and Language Therapy, 111 Nature Walk Pkwy Unit 108, St. Augustine, FL 32092
Provider Id: EIN/TIN: 813281928, NPI: 1912614488
Phone number: 904-328-7489
Click Select button on right side when our information pops up
Under Justification for Choosing an Alternative Provider enter: Provider specializes and has additional training working with pediatric patients with autism and other complex needs at their ABA centers/in clinic and click Next
Select Lively Speech and Language Therapy and select 111 Nature Walk Pkwy address from drop down box and click Next
ENTER DIAGNOSIS, PRESENTING SYMPTOMS, AND/OR REASON FOR REQUEST
Enter patient ICD-10 codes
Enter Clinical History and Findings narrative and click Next
CREATE A NEW REFERRAL OR AUTHORIZATION
Review information for accuracy and change any incorrect information
Click Submit Request button in on the bottom right
Upload any supporting clinical documentation
*Please note that we are not in-network with Tricare as the panel is closed in our region; however, we DO NOT charge overages to any Tricare Patients.
United Healthcare MEDICADE Referral Portal
WHERE TO GO:
Log in here: https://identity.onehealthcareid.com/oneapp/index.html#/login
On the home screen, choose Referrals/Authorizations
Select Create New Request.
Member Search
Enter the child’s UHC Medicaid ID or name and date of birth. Select the correct member.
WHAT TO ENTER
Member Search: enter child’s medical plan, id, name, dob, gender, and address
Request Type: Choose Outpatient Rehabilitation Services: Select the appropriate referral for speech, occupational, or physical therapy.
Referring Physician: enter your Physician’s NPI and match the name.
Rendering Provider: Enter one of the following and match the name:
Group NPI: 1912614488; Lively Speech and Language Therapy
Speech Therapy NPI: 1740721885; Sarah Lively, CCC-SLP
Occupational Therapy NPI: 1861232548; Jeanette Soricelli, OTR/L
Physical Therapy NPI: 1912554304; Kim McCandless, DPT
Evaluation Request Details 1 unit of evaluation for the following:
Speech Therapy CPT codes 1 unit:
92523 (speech/language)
92521 (stuttering)
Occupational Therapy CPT codes:
97165 (low complexity)
97166 (moderate complexity)
97167 (high complexity)
Physical Therapy CPT codes:
97161 (low complexity)
97162 (moderate complexity)
97163 (high complexity)
Enter start and end dates
Clinical Information: Upload any relevant clinical documentation
Patient ICD-10 Codes
Submit request