UCare's Medical Policy Disclaimer

UCare has developed medical policies to assist in the determination of coverage for certain clinical services (procedure, therapy, diagnostic test, medical device, etc.) where coverage requires determination of medical necessity.
 
UCare medical policies are published on this website for informational purposes and do not constitute medical advice, explanation of benefits or guarantee of payment.
 
In addition to to using UCare authored medical policies, UCare determines medical necessity using clinical criteria and guidelines developed by authoritative external sources, such as InterQual®, Magellan care guidelines, and the National Comprehensive Cancer Network. These criteria and guidelines are not a substitute for clinical judgment by a qualified healthcare professional and do not constitute the practice of medicine or medical advice. The treating healthcare professional remains responsible for diagnosis and treatment. Patients should always consult their treating healthcare professional before making decisions about medical care.
 

How Medical Policies are Developed

 

UCare’s medical policies are developed using credible evidence, such as peer-reviewed medical literature, national consensus statements, and clinical practice guidelines from recognized national sources.

UCare’s medical policies are developed, reviewed and approved by the medical policy committee. Pharmaceutical-related policies are reviewed and approved by UCare’s Pharmacy and Therapeutics Committee. Pharmaceutical policies can be found on the Pharmacy page.of this website. 

Medical policies are revised and updated every two years; however, policies may be reviewed prior to their scheduled review date if new scientific evidence that would alter the policy criteria becomes available sooner.

 

How Medical Policies are Used 

 
When making coverage decisions, UCare staff apply the benefits associated with that member’s enrollment and eligibility, according to federal and state regulation, and the member specific Evidence of Coverage (EOC), Member Contract or Member Handbook. If a determination of medical necessity is required and criteria are not specified in benefits or regulation, then UCare applies clinical criteria, which may be UCare medical policy or externally-sourced (e.g., InterQual®, Magellan Clinical Guidelines, or National Comprehensive Cancer Network).
 
 
If you understand and agree with the terms and conditions stated above, please click "I Agree."
 
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Provider Portal Unavailable

We are currently experiencing a technical issue on our provider portal. We are working on a resolution. We apologize for the inconvenience.

 

 

 

 

 

 

 

 

UCare Provider Manual Has Been Updated

2018 Provider Manual updates were made to Working with UCare's Delegated Business Services  Claims & Payment, Clinical Practice Guidelines, Member Appeals and Grievances, Home & Community Based Services, Public Health and Transportation Services. A change table in the Appendix links to specified changes in the manual. 
 

See the Provider Manual

 

 

Provider Assistance Center Phone Update

Our phone service is working, we’re continuing to monitor for any ongoing issues, please be aware we anticipate higher volumes as people catch up so we may experience longer wait times, especially on Monday. For faster assistance, please use the Provider Portal for claims, eligibility and authorization inquiries. We apologize for the inconvenience.