Provider Information

Welcome to Health Choice Generations Utah HMO SNP Provider Portal!

The Health Choice Generations Provider Portal has been designed with you in mind. Our goal for the site is twofold.

We want to assist you with reducing administrative burdens by streamlining processes and providing a one-stop-“resource shop” saving you time and money.

We want to provide you with the tools you need so you can make the best decisions for your patients.

Included in this site, and accessed through a secure portal, is patient data such as claims history and prior authorizations. In addition, you will find forms, newsletters, the Health Choice Generations Provider Manual, continuing education information and links to other medical and dental information.

Provider Portal Login Manual

Provider Portal


Problems? Questions? Comments? Suggestions?
Please contact the Provider Portal Coordinator at:

Health Choice Generations Account Holders

In an ongoing effort to improve Health Choice Generations on-line web-based services, we have designed and built a brand new “single sign on” secure Provider Portal that allows access to both our Medicare (Health Choice Generations – HCG) and Medicaid (Health Choice Utah – HCU) lines of business.

Currently registered Health Choice Utah (Medicaid) Account Holders will not need to re-register to use the new system for Health Choice Generations Utah HMO SNP; however, providers that were also account holders on our Medicaid website will need to follow the on screen prompts within the Provider Portal to initially register to view our Medicare information.

We hope that you enjoy the improvements we have made to our on-line services, and invite your comments and feedback.

Members, Providers, or Appointed Representatives

You can request a Pharmacy Coverage Determination or exception online by visiting our Prior Authorization/Pre-Certification Portal 2022 Provider Directory

Note: Pharmacy prior authorization ONLY. Medical prior authorization requests (including J-code) may be submitted via the Provider Portal.

Health Choice Generations Provider Escalation

Health Choice Generations is committed to ensuring that you have an open line of communication with us at all times. Should you ever feel the need to escalate an issue, your Provider Representative’s supervisor is:

Steven Baker
Director of Provider Services

The Provider Manual provides important information about Health Choice Generations.

Provider Manual   HCG UT Provider Manual

Provider Notices  Coming Soon

Prior Authorization Guidelines

Services Requiring Prior Authorization Effective 12/10/2021
Medical Services Prior Authorization Form
Pharmacy Medication Prior Authorization Form

Prior Authorization Matrix effective for dates of service beginning 2/01/2021
Prior Authorization Guidelines effective for dates of service from 5/01/2020 – 01/01/2021
Prior Authorization Guidelines effective for dates of service from 1/15/2020 – 4/30/2020
Prior Authorization Guidelines effective for dates of service from 8/1/2019 – 1/14/2020
Prior Authorization Guidelines effective for dates of service from 3/1/2019 – 7/31/2019
Prior Authorization Guidelines effective for dates of service from 1/1/2019 – 2/28/2019

Medicare Part B Step Therapy Program

Clinical Guidelines and Recommendations

Centers for Medicare and Medicaid Services – Medicare Coverage Database

Annual Medicare Model of Care Training

Annual Medicare Model of Care Training – 2018 – 2019

Health Choice Generations utilizes:

  • Inter-Qual
  • UpToDate

Adult Hypertention Management Guidelines (NHLBI)

JNC 7 Report on Prevention, Detection, Evaluation and Treatment of High Blood Pressure

Adult Obesity Management Guidelines (NHLBI and NIDDKD)

Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults

Asthma & COPD Management Guidelines (NHLBI)

Guidelines for the Diagnosis and Management of Asthma
COPD Guidelines

Cardiac and CVA Care Management (ACC/AACE)

NCEP III Guideline

Chronic Pain Management Guidelines (American Pain Society)

Clinical Practice Guidelines

Diabetes Management Guidelines (ADA)

Clinical Practice Guidelines

General Infections Disease Management Guidelines (IDSA)

Clinical Practice Guidelines

HIV Management Guidelines


Pediatric Obesity Management Guidelines (NHLBI and NIDDKD

Childhood Obesity

Smoking Cessation Guidelines (NIH)

Tobacco Cessation

Claim Submissions and Coordination of Benefits

Where should Plan Providers send their Claims?

Health Choice Generations
Attn: Claims Department
P.O. Box 45900
Salt Lake City, UT 84145

Which Provider ID # should be used on the Claim Form for Health Choice Generations

Providers may use their Medicare/UPIN number in Box 33.

All claims are required to be submitted with the NPI. More information on NPI is available at

How may I check Claims Status or Claims Inquiry?

Providers can visit the Health Choice Generations Provider Portal to review claims and check member eligibility. Providers must pre-register on-line prior to having access to this confidential information. After you have registered, you will be able to view only your member’s claim information. Should you have difficulty registering you may refer to the Provider Portal Log-in Manual.

Providers may also call Health Choice Generations Claims Customer Service or Member Services for eligibility at 1-844-457-8943 (TTY 711), 8 a.m. – 8 p.m., Monday – Friday (7 days a week, October – March).

Who is the Primary payor: Health Choice Generations or Health Choice Utah?

Health Choice Generations (Medicare) is the primary payor. If Health Choice Utah is not the secondary payor, then the primary EOB must be submitted to the secondary payor by the Provider.

Provider Accounts Receivable

Health Choice Generations does not reconcile accounts receivable for provider offices. It is the responsibility of the provider office to ensure that payments are properly posted and that claims are resubmitted with proper/requested information in a timely manner.

Certain benefits under the Health Choice Generations plan require prior authorization. PCPs are required to coordinate the member’s care by sending the member to a contracted Health Choice Generations specialist. If a member receives healthcare services from any physician, hospital or other healthcare provider without authorization in advance, if required, then the member may have to pay for these services. Please click on the “Find a Doctor” link for a complete listing of Health Choice Generations contracted providers.

The Health Choice Generations Summary of Benefits and Evidence of Coverage lists the benefits which are covered by our plan. The Prior Authorization Grid lists covered services that need prior authorization.

There are many services a member may obtain on their own, without prior approval from a provider or from Health Choice Generations.

The following services are covered as Preventive Care and do not require prior authorization.

  • Colorectal Screenings
  • Mammography screenings
  • Pap Smears, Pelvic Exams and Clinical Breast Exam
  • Prostate Cancer Screening exams
  • Cardiovascular Disease Testing
  • Physical exams
  • Outpatient substance abuse services
  • Emergency services
  • Urgently needed care
  • Physician services, including doctor office visits
  • Flu shots and pneumonia vaccinations
  • Renal dialysis services that are obtained when a member is temporarily outside the plan’s service area and for the first Renal Dialysis visit so the Health Choice Generations Case Management department is aware of the member’s dialysis needs and can coordinate follow-up care (along with the provider). Ongoing dialysis treatment does not require additional authorization(s).

In addition to any exclusions or limitations described in the Health Choice Generations Evidence of Coverage and Summary of Benefits, the following items in the list below are NOT covered except as indicated by Health Choice Generations.

Non-Covered Services include but are not limited to:

  • Services that are not covered under Original Medicare, unless such services are specifically listed as covered in Section 4.
  • Services that you get from non-plan providers, except for care for a medical emergency and urgently needed care, renal (kidney) dialysis services that you get when you are temporarily outside the plan’s service area, and care from non-plan providers that is arranged or approved by a plan provider. See other parts of this booklet (especially Sections 2 and 3) for information about using plan providers and the exceptions that apply.
  • Services that you get without a referral from your PCP, when a referral from your PCP is required for getting that service.
  • Services that you get without prior authorization, when prior authorization is required for getting that service. (Section 4 gives a definition of prior authorization and tells which services require prior authorization.)
  • Services that is not reasonable and necessary according to the standards of original Medicare unless these services are otherwise listed by Health Choice Generations as a covered service. As noted in Section 4, we provide all covered services according to Medicare guidelines.
  • Emergency facility services for non-authorized, routine conditions that do not appear to a reasonable person to be based on a medical emergency. (See Section 3 for more information about getting care for a medical emergency).
  • Experimental or investigational medical and surgical procedures, equipment and medications, unless covered by Original Medicare or unless services covered under an approved clinical trial. Experimental procedures and items are those items and procedures determined by Health Choice and Original Medicare that are not generally accepted by the medical community. See Section 7 for information about participation in clinical trials while you are a member of Health Choice Generations.
  • Surgical treatment of morbid obesity unless medically necessary and covered under Original Medicare.
  • Private room in a hospital, unless medically necessary.
  • Private duty nurses.
  • Personal convenience items, such as a telephone or television in your room at a hospital or skilled nursing facility.
  • Nursing care on a full-time basis in your home.
  • Custodial care is not covered by Health Choice Generations unless it is provided in conjunction with skilled nursing care and/or skilled rehabilitation services. “Custodial care” includes care that helps people with activities of daily living, like walking, getting in and out of bed, bathing, dressing, eating, and using the bathroom, preparation of special diets, and supervision of medication that is usually self-administered.
  • Homemaker services.
  • Charges imposed by immediate relatives or members of your household.
  • Meals delivered to your home.
  • Elective or voluntary enhancement procedures, services, supplies and medications including but not limited to: weight loss, hair growth, sexual performance, athletic performance, cosmetic purposes, anti-aging and mental performance unless medically necessary
  • Cosmetic surgery or procedures, unless it is needed because of accidental injury or to improve the function of a malformed part of the body. Breast surgery is covered for all stages of reconstruction for the breast on which a mastectomy was performed and, to produce a symmetrical appearance, surgery and reconstruction of the unaffected breast.
  • Routine dental care (such as cleanings, fillings, or dentures) or other dental services. Certain dental services that you get when you are in the hospital will be covered.
  • Chiropractic care is generally not covered under the plan, (with the exception of manual manipulation of the spine, as outlined in Section 4) and is limited according to Medicare guidelines.
  • Routine foot care is generally not covered under the plan and is limited according to Medicare guidelines.
  • Orthopedic shoes unless they are part of a leg brace and are included in the cost of the leg brace. There is an exception: Orthopedic or therapeutic shoes are covered for people with diabetic foot disease (as shown in Section 4, in the Benefits Chart under “Outpatient Medical Services”).
  • Supportive devices for the feet. There is an exception: orthopedic or therapeutic shoes are covered for people with diabetic foot disease (as shown in Section 4, in the Benefits Chart under “Outpatient Medical Services”).
  • Hearing aids and routine hearing examinations.
  • Routine eye examinations and eyeglasses (except after cataract surgery), radial keratotomy, LASIK surgery, vision therapy and other low vision aids and services.
  • Self-administered prescription medication for the treatment of sexual dysfunction, including erectile dysfunction, impotence, and anorgasmy or hyporgasmy.
  • Reversal of sterilization procedures, sex change operations, and non-prescription contraceptive supplies and devices. (Medically necessary services for infertility are covered according to Original Medicare guidelines.)
  • Acupuncture.
  • Naturopath services.
  • Services provided to veterans in Veteran’s Affairs (VA) facilities. However, in the case of emergency services received at a VA hospital, if the VA cost sharing is more than the cost sharing required under Health Choice Generations, we will reimburse veterans for the difference. Members are still responsible for the Health Choice Generations cost sharing amount.

Please refer to the Health Choice Generations Prior Authorization Grid for more information on what services are covered and not covered by the Health Choice Generations plan.

The above list of non-covered services is not all-inclusive therefore Providers must verify both eligibility and covered benefits prior to rendering non-emergency services by calling Member Services at 1-844-457-8943 (TTY 711), 8 a.m. – 8 p.m., Monday – Friday (7 days a week, October – March).

Last Updated on January 26, 2022