UCare Medicare Plans, UCare Medicare with M Health Fairview & North Memorial Health

 

 

*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.

 
 

Important Information for Medical Authorization & Notification

 
  • Submit authorization requests 14 calendar days prior to the start of the service for non-urgent conditions.
  • All services are subject to member eligibility and benefit coverage.
  • For services that require an authorization, failing to obtain the authorization in advance may result in a denied claim.
  • UCare reserves the right to review and verify medical necessity for all services.
  • UCare does not instruct providers on how to bill. The codes listed on the authorization grid are for informational purposes only to assist our providers in the authorization process.       

 

  • InterQual Decision Support tool and Medicare National Coverage Determinations (NCD), Local Coverage Determinations (LCD), Local Coverage Articles and MHCP coverage policies are used as appropriate for medical necessity determinations. You may request a copy of the criteria used to make a medical necessity determination.
  • Contact UCare Provider Assistance Center (612-676-3000 or 1-888-531-1493) for additional information on thresholds.

 

  • Check whether Medicare is the primary insurance for members of UCare’s Minnesota Senior Care Plus and UCare Connect, by checking the Minnesota DHS-MN-ITS site. If Medicare is the primary coverage, it must be used for all Medicare-eligible/covered services or equipment.
  • UCare is the authorizing entity for all services, unless noted otherwise.
  • Clinical criteria may vary by UCare plan.
  • Authorization is not required for orthotics and prosthetics.

Authorization Contact Information

 

UCare Clinical Services

Phone (local): 612-676-6705

Phone (toll free): 1-877-447-4384

Fax: 612-884-2499

Magellan HealthCare: Therapy - PT, OT, ST

Phone (local): 952-225-5700

Phone (toll free): 1-888-660-4705

Fax: 1-888-656-1952

Check Authorization Status

Login to check the status of an 
authorization request.

LOG IN

Forms & Information

For SNF Medically Necessary Private Room Requests, UCare will accept either the DHS Private Room Request Form found in the DHS Nursing Home portal or the necessary details added to the Nursing Home/Swing Bed Admission/Update Form.

 

Nursing Home/Swing Bed Admission/Update Form

UCare has partnered with Magellan to manage the utilization and quality of its members’ outpatient and in-home rehabilitative and habilitative therapy services. You must register to access functionality that will help you with your UCare Therapy Authorizations.
 
Direct all authorization questions to Magellan Healthcare:
Phone (local): 952-225-5700 
Phone (toll free): 1-888-660-4705 
Fax: 1-888-656-1952

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

UCare Medicare Plans, UCare Medicare with M Health Fairview & North Memorial Health

 

 

*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.

 

Authorization Contact Information

 

UCare Behavioral Health
 

Phone:

612-676-6705
1-877-447-4384 toll free
 

Fax:

612-884-2033
1-855-260-9710 toll free

Check Authorization Status

Login to check the status of an 
authorization request.

LOG IN

 

Forms & Information

  • Submit authorization requests 14 calendar days prior to the start of the service for non-urgent conditions.
  • All services are subject to member eligibility and benefit coverage.
  • For services that require an authorization, failing to obtain the authorization in advance may result in a denied claim.
  • UCare reserves the right to review and verify medical necessity for all services.       
  • UCare does not instruct providers on how to bill. The codes listed on the authorization grid are for informational purposes only to assist our providers in the authorization process.
  • InterQual Decision Support tool and Medicare National Coverage Determinations (NCD), Local Coverage Determinations (LCD), Local Coverage Articles are used for medical necessity determinations. You may request a copy of the criteria used to make a medical necessity determination.
  • Medicare Provider of Service qualifications and licensure requirements must be met in order to provide services and submit claims to UCare.
  • Threshold limits are cumulative and can be exceeded when a member has seen multiple providers for the same service within a calendar year. Once threshold limits are exceeded, an authorization is required.
  • Contact UCare Provider Assistance Center (612-676-3000 or 1-888-531-1493) for additional information on thresholds.
  • Court-ordered mental health and substance use disorder services must be a covered benefit and meet Medicare coverage guidelines.
  • EssentiaCare: Out of network providers are not required to obtain an authorization for services. Medicare provider qualifications and benefits rules apply when an out of network provider is utilized.

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

UCare Medicare Plans, UCare Medicare Group Plans, UCare Medicare with M Health Fairview & North Memorial Health, EssentiaCare

 

Find Medical Injectable Drug Prior Authorization Resources for Medicare health plans and forms to request authorizations on our  Pharmacy page.

 

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.

back to top

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