Provider Relations & Contracting
Online Form
› Quality Complaint Reporting Form for Primary Care Clinics
Paper Forms
› Primary Care Clinic Change Fax Form New!
› Claim Recoupment or Adjustment Form
› Disclosure of Ownership, Business Transactions & Exclusions Statement for Providers
› Financial Report Designated Representative Form
› Member Liability & Waiver Reference Sheet/Sample Waiver Form
› NH Admission Notification Form
› Provider Payment/Remittance Advice Election Form
› Special Transportation Service (STS) Trip Form
› Interpreter Services Mileage Request Form
› Interpreter Change Form
Mental Health-Targeted Case Management (MH-TCM) Forms
› MH-TCM Approval Form
› MH-TCM DTR Notification Form
› MH-TCM Services Letter with Member Rights for SPP members
› MH-TCM Services Letter with Member Rights for MSHO members
› MH-TCM Services Letter with Member Rights for Connect members
› Change in MH-TCM Contracted Provider for SPP Member
› Change in MH-TCM Contracted Provider for MSHO Member
› Change in MH-TCM Contracted Provider for Connect Member
› Discharge Summary Form for MH-TCM
Mental Health Forms
› Dialectical Behavior Therapy (DBT) Intensive Outpatient Program (IOP) Prior Authorization Request Form New!
Provider Enrollment
Online Forms
› Credentialed Practitioner Add/Change Form
› Non-Credentialed Practitioner Change/Add Form
› Instructions for Non-Credentialed Practitioner Change/Add Form
› Personal Care Attendant (PCA) UMPI Form
› Instructions for the PCA UMPI Form
› Facility Location Add Form
› Instructions for Facility Location Add Form
› Facility/Clinic Closing Form
› Instructions for Online Facility/Clinic Closing Form
› Facility Change Form-Demographic Change/Update
› Instructions for Online Facility Change Form
› Portico Data Set Up Form - To be used by Portico staff only.
Paper Forms
› Initial Uniform Credentialing Application*
› Uniform Re-Credentialing Application
› Mental Health Credentialing Application
› Organizational Provider Assessment Application
› Organizational Provider Re-Assessment Application
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*Important Notice re: Credentialing
Effective Jan. 1, 2011, UCare will require all Minnesota contracted providers to submit Initial Minnesota Uniform Credentialing Applications electronically through the Minnesota Credentialing Collaborative's (MCC's) ApplySmart system.
For more information about the ApplySmart system, please vist the the MCC's home page at http://www.mncred.org/ and then select "FAQ." |
Credentialing forms can be sent via:
Fax to: 612-884-2184 or e-mail to: credentialinginfo@ucare.org
**If you receive a prompt to login after clicking on a form, please click "Cancel" to close out the login box.**
Clinical Services
Authorization and Referral Forms:
› Medical Referral Form for UCare Restricted Recipient
› Benefit Exception Request Form
› Dental Benefit Exception Request Form
› Clinical Services Prior Authorization Request Form
› PCA Assessment Request Form
› PCA Authorization Transfer Form
› PCA Provider Change Request Form
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 Program Patient Enrollment Form
› Heart Failure Program Provider Guide
› Fluid Retention Action Plan
General Forms:
› UR Communication Form
› NH Admission Notification Form
› MSHO Action Plan Talking Points for Diabetes, HF, and Cancer
› MSHO Mental Illness Resources Guide
› Care Management Referral Form
› 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
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
› MSHO Plan of Care (POC) Letter to Primary Care Provider (PCP)
› MSHO Care Coordinator/Case Management Check List
› Care Coordination/Case Management for Members on a CCDT Waiver
› MSHO Welcome Letter for Members on CAC, CADI, DD, or TBI Waiver
› CCDT Assessment Form
Minnesota Senior Care Plus (MSC+):
› MSC+ Case Management Contact List
› MSC+ Case Management Requirements
› MSC+ Care Plan Signature Letter
› 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
› MSC+ Change in Case Manager Letter
› Institutional Care Coordination Documentation Form
› MSC+ Nursing Home Welcome Letter
› MSC+ Strong and Stable Kit Order Form
› MSC+ Plan of Care (POC) Letter to Primary Care Provider (PCP)
› MSC+ Case Management/Care Coordinator Check List
› Care Coordination/Case Management for Members on a CCDT Waiver
› MSC+ Welcome Letter for Members on CAC, CADI, DD, or TBI Waiver
› CCDT Assessment 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 BasicCare - UCare Connect:
› UCare Connect Case Coordinator Contact List
› UCare Connect Universal Transfer Form
› 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
› UCare Connect Plan of Care (POC) Letter to Primary Care Provider (PCP)
› UCare Connect Welcome Letter for DUAL Members on a Waiver
› UCare Connect Welcome Letter for NON-DUAL Members on a Waiver
› UCare Connect Health Resource Letter
› UCare Connect Case Coordination Change Fax Form New!
› UCare Connect Navigator Assignment New!
› UCare Connect Navigator Assignment Regional Map New!
Prepaid Medical Assistance Program (PMAP):
› PMAP Welcome Letter
› PMAP Unable to Contact Letter
› PMAP Health Resource Letter
Conversion Rates:
› DHS Bulletin #09-25-05C: Corrected Bulletin #09-25-05 Annual Increase for Maintenance Needs Allowance and Elderly Waiver Conversion Rates
› Attachment C
› Attachment D
**If you receive a prompt to login after clicking on a form, please click "Cancel" to close out the login box.**
Care Transition Form:
› Individual Transition Log
› Individual Transition Log Instructions
› MSHO/MSC+/Connect Care Transition Notification to PCP
Care System or County PCC/Care Coordination Change Process:
› PCC Changes within the same Care System
› Care System or County PCC/Care Coordination Change Process
› MSHO, MSC+, and UCare for Seniors PCC/Care Coordination Change Request Form
› UCare Connect Primary Care Clinic (PCC) Change Request Form
› UCare Connect Primary Care Clinic (PCC) Change Process
› UCare Connect Disability Type Change Request Form
› UCare Connect Disability Type Process
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" - 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
Medicare Advantage WISCONSIN - UCare for Seniors:
› Notice of Medicare Non-Coverage (NOMNC) Form; "The Advance Notice" - WISCONSIN
› Notice of Medicare Non-Coverage (NOMNC) Form Instructions
› NOMNC Valid Delivery Documentation Form - WISCONSIN
› 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
Dual Special Needs Plans (Dual SNPs) - MSHO:
› Notice of Medicare Non-Coverage (NOMNC) Form; "The Advance Notice" - DSNP
› Detailed Explanation of Non-Coverage (DENC) Form; "Detailed Notice" - DSNP
› NOMNC Valid Delivery Documentation Form - MINNESOTA
› Notice of Medicare Non-Coverage (NOMNC) Form Instructions
› Notice of Denial of Medical Coverage (NDMC) Form - DSNP
Non-Product Specific Forms:
› Denial, Termination, Reduction (DTR) Notification Form
› Denial, Termination, Reduction (DTR) Form Instructions
› Denial, Termination, Reduction (DTR) Reminders & Scenarios
› Type Of Service Codes
› Reason Codes with Usage Examples
› DTR Reason Decision Tree
› DTR Service Decision Tree
› Denial Notices - General Information
› Denial Forms Grid by Product
› Member Death Notification Form
› Waiver Service Approval Form
› List of Pended EW Codes Without a Fee Attached
› Location Codes
› Member Bill of Rights
› Part C Reporting Log
› DHS eDocs Link - Please click on "DHS eDocs Link" and you will be redirected to DHS' web site. There, you will be able to obtain these current forms:
- Minnesota Long-Term Care Consultation (LTCC) Services Assessment.
- LTC Screening Document.
- LTCC Program OBRA 1 Criteria.
- Case Manager/Financial Worker Communication.
- Managed Care Organization/County/Lead Agency Communication Form - Recommendation for Authorization of MA Home Care Services.
- MHCP Request for Payment of Long-Term Care Services.
**If you receive a prompt to login after clicking on a form, please click "Cancel" to close out the login box.**
Service Logs:
› Universal Service Approval Log
› Universal Service Denial Log
Clinical Services Letters:
› When To Call Your Care Manager
› UCare for Seniors Care Manager Introductory Letter
› UCare for Seniors Care Manager Follow-up Letter
Member Incentives
› Gift Certificate Voucher Guidelines
› Immunization Voucher (24 Months)
› Blood Lead Voucher (12 or 24 Months)
› Prenatal Care Incentive Voucher
› Postpartum Care Incentive Voucher
› Mammogram Voucher - MHCP and SNP members
› Mammogram Voucher - UCare for Seniors members