UCare - Providers - Forms

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For RxAmerica (Pharmacy Benefit Management) Forms click here.

Provider Network Management

The new online Facility Change Form-Demographic Change/Update is now available for your convenience. Please click on the link below to submit facility changes (i.e. tax ID number, legal name, ownership, physical address, billing address, phone number, and/or fax number). For other changes, such as terminating and/or adding a facility, please fill out the Facility Change/Update Form (paper format) by clicking on the link below and send it in. We are currently creating other online forms that will include the termination and addition of a facility. Please look for these other online forms shortly.

› Instructions for Online Facility Change Form
› Online Facility Change Form-Demographic Change/Update *New online form*

›  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 and terms only)
›  Member Liability & Waiver Reference Sheet/Sample Waiver Form
›  Mental Health Targeted Case Management (MH-TCM) Form
›  NH Admission Notification Form
›  Provider Direct Deposit Instructions
›  Provider Direct Deposit Authorization Form
›  Quality Complaint Reporting Form *New online form*

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

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

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
›  MSHO Care Coordination Process Flow
›  MSHO Care Plan Signature Letter
›  MSHO Change of Care Coordinator Letter
›  MSHO Change of Liability Form
›  MSHO Comprehensive Care Plan Form
›  MSHO Institutional Care Coordination Documentation
›  MSHO Member Death Notification Form
›  MSHO Unable to Contact Letter (Care Manager)
›  MSHO Universal Transfer Form
›  MSHO Welcome Letter
›  MSHO Strong & Stable Kit Order Form
›  MSHO Interim Assessment Form
›  Instructions for the ICCD Form

Minnesota Disability Health Options (MnDHO) - UCare Complete:
›  MnDHO Institutional Care Coordination Documentation
›  MnDHO Care Coordination Requirements
›  MnDHO Interim Assessment Form
›  Instructions for the ICCD Form

Minnesota Senior Care Plus (MSC+):
›  MSC+ Case Management Contact List
›  MSC+ Case Management Requirements
›  MSC+ Case Management Process Flow
›  MSC+ Comprehensive Care Plan
›  MSC+ Institutional Care Coordination Documentation
›  MSC+ Unable to Contact Letter
›  MSC+ Universal Transfer Form
›  MSC+ Welcome Letter
›  MSC+ Interim Assessment Form
›  Instructions for the ICCD 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:
›  SNBC 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

UCare Secure:
› UCare Secure Care Management Requirements

Service Authorization and Referral Forms:
›  PCA Assessment Request Form
›  Statement of Need for Personal Care Assistant (PCA) Services Form
›  Benefit Exception Request Form
›  Clinical Services Prior Authorization Request Form

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, UCare Secure:
›  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