Eligibility & Authorization

 

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


 

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
 
 

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

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.
  

•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. 

• Any medication, even on the formulary of covered drugs, requires prior authorization if the use is not supported by an FDA-approved indication. Use the exception request form and the contact information on our Formularies page.

 
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

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