Eligibility & Authorization

 

 

*UCare Medicare Plans include Prime, Value, Essentials Rx, Standard, Complete, Classic and Total.
UCare Individual & Family Plans include Bronze, Bronze HSA, Silver, Silver HSA, Core, Gold and
UCare Individual & Family Plans with M Health Fairview Bronze, Bronze HSA, Silver, Silver HSA.

Resources & Information

2020 Medical Services Authorization & Notification Grids:

Medical Services for State Public Programs, Special Needs Plans, UCare Medicare Plans and UCare Medicare with       M Health Fairview & North Memorial
 
EssentiaCare
 
UCare Individual and Family Plans, 
UCare Individual and Family Plans with M Health Fairview
 
2020 Behavioral Health Authorization & Notification Grids:
 
Medicare
 
Medical Assistance
 
UCare Individual and Family Plans, 
UCare Individual and Family Plans with M Health Fairview
 

2020 Medical Injectable Drug Authorization & Notification Requirements:

2020 Medical Injectable Drug Authorization List

Find medical injectable drug prior authorization resources and forms to request authorizations on our Pharmacy page for all UCare health plans. 

 

2019 Medical Services Authorization & Notification Grids:

Medical Services
 
EssentiaCare
 
UCare Medicare Plans with Fairview and North Memorial
 
UCare Individual and Family Plans, 
UCare Individual and Family Plans with Fairview
 
2019 Behavioral Health Authorization & Notification Grids:
 
Medicare
 
Medical Assistance
 
UCare Individual and Family Plans, 
UCare Individual and Family Plans with Fairview
 
2019 Injectable Drugs Authorization & Notification Grids:
 
UCare Medicare Plans/EssentiaCare
 
SNP/MSHO
 
SPP
 

The Behavioral Health Case Management Referral Form is completed when you have a UCare PMAP, MNCare, MSHO or MSC+ member who has a complex Behavioral Health condition. 

Behavioral Health Case Management Referral Form  (New 10.11.19)

The Care Management Referral form is completed when you have a member/patient who you feel would benefit from care coordination services and is actively enrolled in UCare Connect, UCare Connect + Medicare, PMAP (under 65), UCare Medicare Plans or Individual & Family Plans. 

Care Management Referral Form-PDF

Care Management Referral Form-WORD

The Complex Case Management Referral form is completed when you have a medically complex member/patient who you feel would benefit from short term / intensive medical case management. They typically have a new critical medical event, multiple medical diagnoses with challenges or high medical costs/utilization. This program is for UCare Medicare and Individual & Family Plans only at this time. 

Complex Case Management Referral Form - PDF

Complex Case Management Referral Form-WORD

 

UCare works with delegated organizations to handle the following types of authorization.

Chiropractic Authorization:
Direct all authorization questions to UCare's delegate, Fulcrum Health, Inc. | 1-877-886-4941

Dental Authorization:
Direct all authorization questions to UCare's delegate, Delta Dental of Minnesota 

UCare State Public Programs: 1-855-648-1415 toll free or 651-768-1415
UCare Medicare Plans (Medicare Advantage): 1-855-648-1416 toll free or 651-768-1416
UCare Individual & Family Plans / UCare Individual & Family Plans with M Health Fairview: 1-855-648-1417 toll free or 651-768-1417  
EssentiaCare: 1-855-648-1416 toll free or 651-768-1416

Medical Injectable Drug Authorizations:
Direct all authorization requests to UCare’s delegate: Care Continuum, a subsidiary of Express Scripts Online (ePA) at www.express-path.com/ | Phone: 1-800-818-6747 | Fax: 1-877-266-1871 

Therapy - PT, OT, ST Authorization:
Direct all authorization questions to UCare's delegate, Magellan Healthcare, Inc. | 952-225-5700, 1-888-660-4705 | 1-888-656-1952 (fax)

In order for services to be eligible for payment by UCare, the services must meet UCare’s standards for coverage, including medical necessity criteria. Coverage and benefits vary significantly among different UCare plans. Member Handbook or Member Contracts specific to the member’s UCare plan.

Medical Necessity Criteria

Medical Necessity Criteria Request Forrn

Find drug coverage for each UCare health plan and forms to request exceptions or authorizations on our Pharmacy page.

Find medical injectable drug prior authorization information for each UCare health plan and forms to request authorizations on our Pharmacy page.

The Formularies page on the UCare provider website shows which drugs are covered, as well as everything you need to request exceptions or prior authorization. 

 
Minnesota Restricted Recipient Program - State Public Programs
The forms below may be used when referring members to the UCare Restricted Recipient Program:
 
 
Restricted Member Program - Individual & Family Plans 
The forms below may be used when referring members to the Individual & Family Plans Restricted Member Program:

This form is intended to communicate patient referrals between medical and behavioral health providers.

Universal Referral Form

If you have other questions, contact the Provider Assistance Center:

612-676-3300 or 1-888-531-1493
Hours:  8 a.m. to 5 p.m.,  Monday through Friday

Newsletters & Alerts

 

 

 

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

    Q4 Update to UCare's Provider Manual

    UCare has updated the following chapters of the Provider Manual: Working with UCare, Sales & Marketing by Providers, Provider Credentialing, Behavioral Health and Nursing Facility Services. Specific updates are called out in the Appendix.

    See the Q4 October 2019 Provider Manual