Clinical Practice Guidelines

UCare’s clinical practice guidelines includes the primary source with a direct link to online content, modifications (if needed) for our unique populations, rationale for modifications and additional references if available.

MEDICAL

UCare, through the Quality Improvement Advisory and Credentialing Committee (QIACC), adopts medical clinical practice guidelines from nationally or locally recognized sources. Sources may include medical specialty societies and other professional organizations. The guidelines are based on reasonable medical evidence or a consensus on clinical treatment patterns by physicians in the selected field of practice.

Asthma, Diagnosis and Management
Primary Source: Global Initiative for Asthma

Diabetes, Type 2; Diagnosis and Management
Primary Source: American Diabetes Association

Management of Heart Failure in Adults
Primary Source: Journal of the American College of Cardiology (JACC)

Obesity in Adults; Prevention and Management
Primary Source: American Academy of Family Physicians

Prenatal Care
Primary Source: American Academy of Family Physicians

Preventive Services for Adults
Primary Source: American Academy of Family Physicians

Preventive Services for Children and Adolescents  (Approval Mar. 22, 2018) 
Primary Source: American Academy of Pediatrics Bright Futures (AAP)

 

BEHAVIORAL HEALTH

UCare adopted five behavioral health clinical practice guidelines to support good decision-making by patients and clinicians, improve member health outcomes and meet NCQA accreditation standards. Adult guidelines are adopted from American Psychiatric Association (APA). Child and adolescent guidelines are adopted from the Journal of the American Academy of Child Adolescent Psychiatry. 

Assessment and Treatment of Children and Adolescents with Attention-Deficit/Hyperactivity Disorder
Primary Source: American Academy of Child and Adolescent Psychiatry 

Assessment and Treatment of Children and Adolescents with Depressive Disorders
Primary Source: American Academy of Child and Adolescent Psychiatry 

Treatment of Patients with Major Depressive Disorder
Primary Source: American Psychiatric Association 

Treatment of Patients with Schizophrenia
Primary Source: American Psychiatric Association 

Treatment of Patients with Substance Use Disorders (SUD)
Primary Source: American Psychiatric Association

 

PHARMACY

UCare adopts the Minnesota Department of Human Services’(DHS) Preferred Drug List guidelines to ensure a more consistent drug benefit for our Medicaid line of business. This clinical practice guideline is developed by Minnesota DHS Drug Formulary Committee.
 
Minnesota Fee-for-Service Medicaid Preferred Drug List 
 

From 5 columns to 4

Service Category

Essentia Health Provider Requirements Other EssentiaCare Network Providers

Codes Requiring Authorization - CPT/HCPC Codes

 

Outpatient Therapy (PT, OT & ST)

Includes therapy in the home and outpatient therapy provided in a nursing facility.

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Physical Therapy - Authorization required beyond threshold of 20 visits per calendar year.

Occupational Therapy - Authorization required beyond threshold of 20 visits per calendar year.

Speech Therapy - Authorization required beyond threshold of 30 visits per calendar year.

Magellan Healthcare: 
PH 952-225-5700, 
1-888-660-4705 (toll free)

Physical Therapy - Authorization required beyond threshold of 20 visits per calendar year.

Occupational Therapy - Authorization required beyond threshold of 20 visits per calendar year.

Speech Therapy - Authorization required beyond threshold of 30 visits per calendar year.

Magellan Healthcare: 
PH 952-225-5700, 
1-888-660-4705 (toll free)

20560, 20561, 92507, 92508, 92526,
92606, 92630, 92633, 97012, 97014,
97016, 97018, 97022, 97024, 97026,
97028, 97032, 97033, 97034, 97035,
97036, 97039, 97110, 97112, 97113,
97116, 97124, 97139, 97140, 97150,
97164, 97168, 97530, 97533, 97535,
97537, 97542, 97750, 97755, 97760,
97761, 97799, G0151, G0152, G0153
       

 

 

Updated February 2020

Region

UCare Product

Eligibility

Service Area
(Minnesota Counties)

Narrow network?

North

UCare Medicare Plans (HMO-POS)

  • Essentials Rx
  • Total
  • Value
  • UCare Medicare Group Plans*
  • Must have Medicare Part A & Part B to enroll

    Do not have end-stage renal disease

    Aitkin, Becker, Beltrami, Carlton, Cass, Clay, Clearwater, Cook, Crow Wing, Douglas, Grant, Hubbard, Itasca, Kanabec, Kittson, Koochiching, Lake, Lake of the Woods, Mahnomen, Marshall, Morrison, Norman, Otter Tail, Pennington, Pine, Polk, Red Lake, Roseau, St. Louis, Todd, Wadena, Wilkin All UCare network providers
    North

    UCare Medicare Plans (HMO-POS)

  • Classic
  • Must have Medicare Part A & Part B

    Do not have end-stage renal disease

    Aitkin, Becker, Carlton, Cass, Clay, Cook, Crow Wing, Hubbard, Kanabec, Lake, Morrison, Pine and St. Louis All UCare network providers
    Metro

    UCare Medicare Plans (HMO-POS)

  • Prime
  • Essentials Rx
  • Complete
  • Classic
  • Total
  • Value
  • UCare Medicare Group Plans*
  • Must have Medicare Part A & Part B

    Do not have end-stage renal disease

    Anoka, Benton, Carver, Chisago, Dakota, Hennepin, Isanti, Mille Lacs, Ramsey, Scott, Sherburne, Stearns, Washington, Wright All UCare network providers
    South

    UCare Medicare Plans (HMO-POS)

  • Standard
  • Complete
  • Total
  • Value
  • UCare Medicare Group Plans*
  • Have Medicare Part A & Part B

    Do not have end-stage renal disease

    Big Stone, Blue Earth, Brown, Chippewa, Cottonwood, Dodge, Faribault, Fillmore, Freeborn, Goodhue, Houston, Jackson, Kandiyohi, Lac qui Parle, Le Sueur, Lincoln, Lyon, Martin, McLeod, Meeker, Mower, Murray, Nicollet, Nobles, Olmsted, Pipestone, Pope, Redwood, Renville, Rice, Rock, Sibley, Steele, Stevens, Swift, Traverse, Wabasha, Waseca, Watonwan, Winona, Yellow Medicine All UCare network providers
    South

    UCare Medicare Plans (HMO-POS)

  • Classic
  • Have Medicare Part A & Part B

    Do not have end-stage renal disease

    Blue Earth, Dodge, Faribault, Fillmore, Freeborn, Goodhue, Houston, Le Sueur, Mower, Nicollet, Olmsted, Rice, Steele, Wabasha, Waseca, Watonwan, Winona All UCare network providers

    In-Network Services

    Primary Care Office Visits $0 copay $25 copay $0 copay $20 copay $0 copay $0 copay $0 copay
    Specialist Office Visits $35 copay $50 copay $20 copay $45 copay $40 copay $10 copay $35 copay
    Inpatient Hospital Care $400 copay per stay (not per day), then 100% coverage, unlimited days per admission $300 copay per day (days 1 - 5), then 100% coverage, unlimited days per admission $250 copay per stay (not per day), then 100% coverage, unlimited days per admission $300 copay per day (days 1 - 5), then 100% coverage, unlimited days per admission $500 copay per day (days 1 - 3), then 100% coverage, unlimited days per admission $100 copay per stay (not per day), then 100% coverage, unlimited days per admission $150 copay per day (days 1 - 5), then 100% coverage, unlimited days per admission
    Urgent Care $50 copay $45 copay $50 copay $50 copay $40 copay $0 copay $50 copay
    Worldwide Emergency Care $100 copay $90 copay $100 copay $100 copay $90 copay $100 copay $100 copay
    Medicare Part D Prescription Drug Coverage* No Prescription Drug Coverage $400 deductible | Copays based on drug tiers $200 deductible | Copays based on drug tiers $400 deductible | Copays based on drug tiers $400 deductible | Copays based on drug tiers Copays based on drug tiers $200 deductible | Copays based on drug tiers
    Preventive Dental Coverage Yes No Yes Yes Yes No No
    Vision Coverage-Routine Routine Eye Exam: 1 per year, $0 Copay Routine Eye Exam: Not Covered Routine Eye Exam: 1 per year, $0 Copay Routine Eye Exam: 1 per year, $0 Copay Routine Eye Exam: 1 per year, $0 Copay Routine Eye Exam: 1 per year, $0 Copay Routine Eye Exam: 1 per year, $0 Copay
    Vision Coverage-Diagnostic Diagnostic Eye Exam: $35 copay Diagnostic Eye Exam: $50 copay Diagnostic Eye Exam: $20 copay Diagnostic Eye Exam: $45 copay Diagnostic Eye Exam: $40 copay Diagnostic Eye Exam: $10 copay Diagnostic Eye Exam: $35 copay
    Hearing Services-Routine Routine Hearing Exam: 1 per year, $0 Copay Routine Hearing Exam: Not Covered Routine Hearing Exam: 1 per year, $0 Copay Routine Hearing Exam: 1 per year, $0 Copay Routine Hearing Exam: 1 per year, $0 Copay Routine Hearing Exam: 1 per year, $0 Copay; $500 allowed every 36 months for hearing aids Routine Hearing Exam: 1 per year, $0 Copay
    Hearing Services-Diagnostic Diagnostic Hearing Exam: $35 copay Diagnostic Hearing Exam: $50 copay Diagnostic Hearing Exam: $20 copay Diagnostic Hearing Exam: $45 copay Diagnostic Hearing Exam: $40 copay Diagnostic Hearing Exam: $10 copay Diagnostic Hearing Exam: $35 copay
    Out of Pocket Maximum $3,400 $5,000 $3,400 $3,400 $4,500 $3,000 $3,000

     

    * Part D deductible only applies to some drugs. See the Drug Formulary for details. 

    Pharmacy benefit information