2020 Authorization and Notification Requirements 
Mental Health & Substance Use Disorder Services


For the following health plans: UCare Medicare Plans | UCare Medicare with M Health Fairview & North Memorial | EssentiaCare

 

Return to UCare Medicare Authorization Forms & Information

Return to EssentiaCare Authorization Forms & Information


Important Information regarding 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 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, eligibility and licensure requirements must be met 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.

 

The following services require authorization or notification. (Click a topic for details.) 

 

Services 

Requirements

Code Requiring Authorization - CPT / HCPC Codes

Threshold Units

Diagnostic Assessment

back to top

Authorization required after threshold.

90791, 90792

4 sessions per calendar year

Inpatient Mental Health Admission

back to top

Notification required within 24 hours of admission.

Concurrent review for additional days.

Follow National Government Services Psychiatric Inpatient Hospitalization LCD L33624.  N/A

Inpatient Substance Use Disorder Admission

back to top

Notification required within 24 hours of admission.

Concurrent review for additional days.

Follow Medicare National Coverage Determinations 130.1 through 130.6.

N/A

Partial Hospitalization

back to top

Notification required within 24 hours of intake.

Concurrent review for additional days.

G0129, G0176, G0177, G0410, G0411

Follow National Government Services Partial Hospitalization Program LCD L33626.

N/A

Psychological & Neuropsychological Testing

back to top

Authorization required beyond threshold. 96136, 96137, 96138, 96139

15 cumulative hours per calendar year

Psychological & Neuropsychological Testing Administration and Scoring

back to top

Authorization required beyond threshold.  96146 5 sessions per calendar year

Psychotherapy Family

back to top

Authorization required beyond threshold.

90846, 90847, 90849

52 sessions per calendar year

Psychotherapy Individual & Group

back to top

Authorization required beyond threshold.

90832, 90834, 90837, 90853, 90875, 90876

104 sessions per calendar year

Transcranial Magnetic Stimulation

back to top

Authorization required prior to service. 

LCD L33398
90867, 90868, 90869

National Government services Transcranial Magnetic Stimulation

N/A

 

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

 

Phone

Call our toll-free helpline. You may remain anonymous. If we are unavailable when you call, please leave a message.
 
Phone:  1-877-826-6847

Postal Mail

Send us a letter and/or documents you would like us to review.
 
UCare
Attn: Special Investigation Unit
P.O. Box 52
Minneapolis, MN 55440-0052

Email

Send us an email message with your question or concern.
 

 

 

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