UCare - Providers - Forms

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Provider Network Management

Online Forms
› Online Facility/Clinic Closing Form
› Instructions for Online Facility/Clinic Closing Form

› Online Facility Change Form-Demographic Change/Update
› Instructions for Online Facility Change Form

›  Quality Complaint Reporting Form

Paper Forms
›  Claim Recoupment or Adjustment Form (W/ Electronic Form Fields)
›  Discharge Summary Form for MH-TCM
›  Disclosure of Ownership, Business Transactions & Exclusions Statement for Providers
›  Facility Change/Update Form w/ W-9  - Paper format (for facility adds only)
›  Member Liability & Waiver Reference Sheet/Sample Waiver Form
›  Mental Health Targeted Case Management (MH-TCM) Form
›  NH Admission Notification Form

›  Provider Payment Election Form
›  Provider Payment Election Form Instructions

Provider Enrollment

›  Uniform Practitioner Change Form
›  Uniform Practitioner Change Form (Word Format)
›  Initial Uniform Credentialing Application
›  Uniform Re-Credentialing Application
›  Mental Health Credentialing Application January 2007 (Word Format)
›  Organizational Provider Assessment Application
›  Personal Care Attendant (PCA) UMPI Form

Credentialing forms can be sent via:
Fax to: 612-884-2184 or e-mail to: credentialinginfo@ucare.org

Non-credentialing forms can be sent via:
Fax to: 612-884-2072 or e-mail to: demographicupdates@ucare.org

›  Portico Data Set Up Form - To be used by Portico staff only effective 04/14/09.

Clinical Services

Disease Management:
›  Disease Management Programs Grid
›  Asthma Action Plan (AAP) (UCare encourages members with asthma and their provider to complete and/or review the Asthma Action Plan (AAP) on an annual basis.)
›  Heart Failure Management Program
›  Heart Failure Program Patient Enrollment Form
›  Heart Failure Action Plan

General Forms:
›  Notice for Potential Re-Insurance Cases
›  Birth Notification Form
›  Hospice Election Form
›  180 Day Tracking Form
›  Approval Letter for State and Federal Programs
›  Nursing Home Face Sheet
›  UR Communication Form
›  NH Admission Notification Form

Minnesota Senior Health Options (MSHO):
›  MSHO Care Coordination Contact List
›  MSHO Care Coordination Requirements
›  Care Coordination and Plan of Care Process Flow
›  MSHO Care Plan Signature Letter
›  MSHO Change of Care Coordinator Letter
›  MSHO Change of Liability Form
›  MSHO Collaborative Care Plan
›  MSHO Collaborative Care Plan (Instructions Sheet)
›  MSHO Unable to Contact Letter (Care Manager)
›  MSHO Universal Transfer Form
›  MSHO Welcome Letter
›  MSHO Strong & Stable Kit Order Form
›  Instructions for the ICCD Form
›  Institutional Care Coordination Documentation Form
› MSHO Nursing Home Welcome Letter

Minnesota Disability Health Options (MnDHO) - UCare Complete:
›  MnDHO Care Coordination Requirements
›  Care Coordination and Plan of Care Process Flow
›  Instructions for the ICCD Form
›  Institutional Care Coordination Documentation Form
›  MnDHO Collaborative Care Plan
›  MnDHO Collaborative Care Plan (Instructions Sheet)

Minnesota Senior Care Plus (MSC+):
›  MSC+ Case Management Contact List
›  MSC+ Case Management Requirements
›  Care Coordination and Plan of Care Process Flow
›  MSC+ Collaborative Care Plan
›  MSC+ Collaborative Care Plan (Instructions Sheet)
›  MSC+ Unable to Contact Letter
›  MSC+ Universal Transfer Form
›  MSC+ Welcome Letter
›  Instructions for the ICCD Form
›  Change in Case Manager Letter
›  Institutional Care Coordination Documentation Form
› MSC+ Nursing Home Welcome Letter
›  MSC+ Strong and Stable Kit Order Form

UCare for Seniors:
›  UCare for Seniors Telephonic Assessment Tool
›  UCare for Seniors Plan of Care
› UCare for Seniors Tracking Tool
›  UCare for Seniors Case Management Requirements

Special Needs Basic Care - UCare Connect:
›  UCare Connect Case Management Requirements
›  UCare Connect Interim Assessment Form
› UCare Connect Assessment Tool
›  UCare Connect Care Plan
› Michigan Alcohol Screening Test (MAST) - Member Version
› Michigan Alcohol Screening Test (MAST) - Professional Version
› CAGE Questionnaire - Member Version
› CAGE Questionnaire - Professional Version
› Patient Health Questionnaire - PHQ-9 for Depression
› Brief Mental Status Exam (MSE) Form
› Case Coordinator Welcome Letter
› Case Coordinator Unable to Reach Letter
› Connect to Fitness Kit Order Form
› Change in Case Coordinator Letter
› Change in Health Plan Navigator Letter
› Health Plan Navigator Welcome Letter

Service Authorization and Referral Forms:
›  PCA Assessment Request Form
›  Benefit Exception Request Form
›  Clinical Services Prior Authorization Request Form

Care Transition Form:
›  MCO Care Transition
›  Individual Transition Log
›  Individual Transition Log Instructions

Denial Forms:
* Note: Forms are specific to product and contain approval numbers that correspond with each product. Use ONLY the form that is listed under the product name.*

Medicare Advantage MINNESOTA: UCare for Seniors:
›  Notice of Medicare Non-Coverage (NOMNC) Form; "The Advance Notice" (Word Format) - MINNESOTA
›  Notice of Medicare Non-Coverage (NOMNC) Form Instructions
›  NOMNC Valid Delivery Documentation Form - MINNESOTA
›  Detailed Explanation of Non-Coverage (DENC) Form; "Detailed Notice"
›  Notice of Denial of Medical Coverage (NDMC) Form
›  Revised Detailed Notice of Discharge Form with Instructions