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 Assistance Center (PAC) Holiday Hours

UCare and the Provider Assistance Center (PAC)  team will be closed, Monday, 05/24/2019, for Memorial Day. We will open up at 8:00 a.m.

 

 

 

 

 

2017 Medical Services Authorization & Notification Grids:
 
 
 
 
2017 Behavioral Health Authorization & Notification Grids:
 
 
 
 
2017 Injectable Drugs Authorization & Notification Grids:
 
2017 Authorization Requirements - Injectable Drugs  – UCare for Seniors/EssentiaCare
 
 
 
2017 Authorization Requirements - Injectable Drugs  – UCare Choices/Fairview UCare Choices