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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.orgNon-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
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
Medicare Advantage WISCONSIN: UCare for Seniors: › Notice of Medicare Non-Coverage (NOMNC) Form; "The Advance Notice" (Word Format) - 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 and UCare Connect:› Notice of Medicare Non-Coverage (NOMNC) Form; "The Advance Notice" (Word Format) - 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› Denial, Termination, Reduction (DTR) Notification Form› Denial, Termination, Reduction (DTR) Form Instructions
UCare State Products: PMAP, Minnesota Care, GAMC, MSC+, and MnDHO :› Denial, Termination, Reduction (DTR) Notification Form› Denial, Termination, Reduction (DTR) Form Instructions
Non-Product Specific Forms: › Type Of Service Codes › Reason 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
Service Logs:› Dual Special Needs Plans NOMNC/DENC Denial Log› Medicare Advantage NOMNC/DENC Denial Log› Universal Service Approval Log› Universal Service Denial Log
Clinical Services Letters:› When To Call Your Care Manager› Senior Health Profile Care Manager Introductory Letter› Senior Health Profile Care Manager Follow-up Letter
Member Incentives
› Gift Certificate Voucher Guidelines › Immunization Voucher (24 Months)› Blood Lead Voucher (12 or 24 Months)› MOMS Prenatal Voucher › MOMS Postpartum Voucher › Mammogram Voucher › Mammogram Voucher - UCare for Seniors