The UCare Provider Manual was developed as a reference guide for UCare policies and procedures relating to our products.
The Public Programs Provider Manual and the UCare Medicare Programs Provider Manual are now combined into one manual. We believe that the combination of various materials into one manual will enable your clinic to run more efficiently when you encounter a UCare member.
If you have questions or concerns regarding this manual, please contact the Provider Assistance Center at 612-676-3300 or toll free at 1-888-531-1493.
Once you have used this manual, we would appreciate your feedback. Please use the Provider Feedback Form for your comments.
Table of Contents
› Chapter 1: Introduction to UCare (Revised January 2010)
› Chapter 2: Enrollment and Eligibility (Revised September 2006)
› Chapter 3: Sales and Marketing (Revised January 2010)
› Chapter 4: Benefits Comparison (Revised July 2008)
› Chapter 5: Prior Authorization and Notification (Revised January 2010)
› Chapter 6: Claims Submission Information (Revised February 2010)
› Chapter 7: Nursing Facility (Revised January 2010)
› Chapter 8: Home Care Services (Revised February 2010)
› Chapter 9: Public Health Services (Revised January 2009)
› Chapter 10: Hospital Services (Revised December 2009)
› Chapter 11: Interpreter Services (Revised November 2009)
› Chapter 12: Transportation (Revised February 2010)
› Chapter 13: Provider Resources for Child & Teen Checkups (C&TC) & Blood Lead Testing (Revised January 2010)
› Chapter 14: Obstetrics and Gynecology (Revised December 2009)
› Chapter 15: Comprehensive Outpatient Rehabilitation Facility Services (Revised January 2010)
› Chapter 16: Quality Management (Revised February 2010)
› Chapter 17: Provider Enrollment (Revised December 2009)
› Chapter 18: Member Complaints, Appeals, and Grievances (Revised January 2010)
› Chapter 19: Culturally Responsive Care (Revised January 2010)
› Chapter 20: Delegated Business Services (Revised January 2010)
› Chapter 21: Point-of-Service (POS) UCare for Seniors (Reviewed October 2008)
› Chapter 22: Fraud, Waste, and Abuse (Revised November 2009)
› Chapter 23: Medical Necessity Criteria (Revised September 2008)
› Chapter 24: Clinical Practice Guidelines (Revised March 2010)
› Chapter 25: Health Promotion Programs (Revised October 2009)
› Chapter 26: HCBS Waiver Services (Revised October 2008)
› Appendices
Chapter 1: Introduction to UCare (Revised January 2010)
About UCare
UCare's Mission
Minnesota Health Care Programs
Special Needs Plan
Medicare Advantage Plans
UCare's Telephone & Address Guide
UCare's Provider Network
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Chapter 2: Enrollment and Eligibility (Revised September 2006)
Eligibility
Enrollment
Primary Care Clinic Change
Member Verification
MN-ITS
Access UCare
Member Identification Cards
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Chapter 3: Sales and Marketing (Revised January 2010)
Guidelines for Provider Marketing Activities
Permitted Provider Marketing Activities
Prohibited Provider Marketing Activities
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Chapter 4: Benefits Comparison (Revised July 2008)
MA, GAMC, GHO, MSHO, and MnDHO Benefit Reference Sheet
MinnesotaCare Benefit Summary Reference Sheet
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Chapter 5: Prior Authorization and Notification (Revised January 2010)
Definitions of Terms
General Guidelines
What Services Require Prior Authorizations and Notifications?
How Do I Submit Prior Authorization and Notification Documentation?
Decision Making on Requests
Authorization Grids for: GAMC and all other programs
Who to Contact
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Chapter 6: Claims Submission Information (Revised February 2010)
Electronic Data Interchange
Paper Claims/Attachments
CMS 1500 Paper Claim Form
CMS 1450/UB-04 Paper Claim Form
Common Submission Issues
Duplicate Claims Submission
Claims Payment
Chiropractic Claims
Dental Billing
Elderly Waivered Services
Waivered Services
Member Liability
Coordination of Benefits (COB) Claims
Primary Care Reimbursement
Denial/Termination/Reduction (DTR) of Services Notice
Claims Adjustments
Claims Auditing and Recovery Program
Coding
Ambulatory Payment Classification (APC)
Explanation of Payment (EOP) Reference Guide
ANSI Cross-Walk List including EX Codes
Forms
UCare Phone Numbers
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Chapter 7: Nursing Facility (Revised January 2010)
Skilled Nursing Facility Services - Medicare Programs
Skilled and Non-Skilled Nursing Facility Services - Minnesota Health Care Programs and Special Needs Plans
Denial and Discharge Notices
Facility Discharge Notices
Forms
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Chapter 8: Home Care Services (Revised February 2010)
Home Care Services Criteria
Billing Medicare Certified Home Care Services
New Enrollee Rights, New Provider Responsibilities in Medicare Advantage (UCare for Seniors)
Notice of Denial of Medical Coverage (NDMC) Process
Home IV Infusion Services
Personal Care Attendant (PCA) Provider Standards
PCA Individual Training and PCA Agency Training Requirements
PCA Authorization Process
PCA Billing Guidelines
PCA UMPI Numbers (additions/changes/deletions)
Qualified Professional (QP) Supervision Standards
PCA Supervision Responsibility
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Chapter 9: Public Health Services (Revised January 2009)
UCare Values Coordination with Public Health
Authorizations for Public Health Services
Population Health Improvement Collaboratives
References
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Chapter 10: Hospital Services (Revised December 2009)
Hospital Admission Notification Process
Daily Admission Report
Acute Rehabilitation Process and Guidelines
Notice of Discharge and Medicare Appeal Rights (NODMAR) Process
Care Transitions
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Chapter 11: Interpreter Services (Revised November 2009)
Access to Interpreter Services
Arranging for Interpreter Services
UCare Contracted Interpreter Service Agencies
Interpreter Requirements
Professional Standards for Interpreters
Guidelines for Working with Interpreters
Interpreter Services Performance Expectations
Service Reimbursement and Claims Processing
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Chapter 12: Transportation (Revised February 2010)
Types of Transportation Services
Eligible Members for Non-emergency Transportation
Benefits Grid
Transportation Provider Guidelines
Common Carrier Transportation
Common Carrier Provider Guidelines
Common Carrier Services Claim Submission Requirements
Common Carrier Coding Information
Billing Same Day Rides for STS and Common Carrier Services
Special Transportation Services (STS) Provider Guidelines
Special Transportation Services Claims Submission Requirements
Extended Transportation
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Chapter 13: Provider Resources for Child & Teen Checkups (C&TC) & Blood Lead Testing (Revised January 2010)
Resources List and Links
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Chapter 14: Obstetrics and Gynecology (Revised December 2009)
Family Planning Services
Sterilization
Abortion Services
UCare's Management of Maternity Services (M.O.M.S)
Billing Information
Prenatal Care Guidelines for Normal Pregnancy
Prenatal Care Guidelines for High Risk Pregnancy
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Chapter 15: Comprehensive Outpatient Rehabilitation Facility Services (Revised January 2010)
CORF Denial and Discharge Notices
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Chapter 16: Quality Management (Revised February 2010)
Program Overview
Quality Improvement Advisory and Credentialing Committee (QIACC)
Healthcare Effectiveness Data and Information Set (HEDIS)
Pay for Performance (P4P)
Medical Record Documentation Requirements
Member Medical Record Requirements for Providers Policy
Clinic Requirements for Quality Management
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Chapter 17: Provider Enrollment (Revised December 2009)
Practitioner Types that Require Credentialing
Practitioner Types that do not Require Credentialing
Facility Types that Require Credentialing
Credentialing Process
UCare's Credentialing Policy
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Chapter 18: Member Complaints, Appeals, and Grievances (Revised January 2010)
Medicare Advantage Member Appeal and Grievance Process
Medicare Part D Prescription Drug Benefit Appeal and Grievance Process
Special Needs Program (SNP) Integrated Appeals process (Coming in the future for implementation in 2008)
Minnesota Health Care Programs Member Appeal and Grievance Process
Quality of Care Reviews
Clinic Responsibilities: Complaints, Appeals, and Grievances
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Chapter 19: Culturally Responsive Care (Revised January 2010)
Background: What is Cultural Competence? Why is it Important?
Cultural Competence Self-Assessment Tool
Resources: Web Sites, Local Resources, and Health Care Options for the Uninsured and Underinsured Patients
National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care
Top 10 Innovations in Culturally and Linguistically Appropriate Services (CLAS) from UCare
Guidelines for Working with Interpreters
LEARN: Process for Improved Communication
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Chapter 20: Delegated Business Services (Revised January 2010)
Express Scripts, Inc.
Behavioral Healthcare Providers (BHP)
Mayo Management Services, Inc. (MMSI)
DentaQuest
Chiropractic Care of Minnesota, Inc. (ChiroCare)
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Chapter 21: Point-of-Service (POS) UCare for Seniors (Reviewed October 2008)
Point-of-Service Benefits
Coordination of Care When the POS Benefit is Used
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Chapter 22: Fraud, Waste, and Abuse (Revised November 2009)
Preventing Healthcare Fraud
What is UCare doing about it?
Common Examples of Fraud
How can you help avoid and prevent healthcare fraud?
Contacting UCare
UCare's Code of Conduct
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Chapter 23: Medical Necessity Criteria (Revised September 2008)
Legislated Utilization Requirements
Bariatric Surgery
Blepharoplasty
Circumcision
Electric Wheelchair and Scooters
ENT Surgery (Septoplasty, Rhinoplasty)
Orthoptic/Pleoptic Therapy (Vision Therapy)
Panniculectomy
Reduction Mammoplasty
Rehabilitative Services - Physical, Occupational, or Speech Therapy
Synagis (palivizumab) Injections
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Chapter 24: Clinical Practice Guidelines (Revised March 2010)
Clinical Practice Guidelines
Preventive Services for Adults Guideline
Preventive Services for Children and Adolescence Guideline
Prenatal Care, Routine Guideline
Diabetes, Type 2 Diagnosis and Management Guideline
Asthma, Diagnosis and Outpatient Management Guideline
Pressure Ulcer, Preventive and Treatment Guideline
Obesity, Preventive and Management Guideline
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Chapter 25: Health Promotion Programs (Revised October 2009)
ActiveU
Diabetes and Asthma Camps
Seats, Education, And Travel Safety (S.E.A.T.S.) Program
Gold Star Gift Certificates
Community Education Classes
Mammogram Reward
Management of Maternity Services (M.O.M.S.) Program
Pregnancy and Childbirth Education Classes
Senior Wellness Program
Smoking and Tobacco Cessation Programs
Important Phone Numbers
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Chapter 26: HCBS Waiver Services (Revised October 2008)
2009 Home and Community Based Services Provider Directory
Background for Home and Community Based Service (HCBS) Waivers and Highlights for Waiver Services
UCare products that may include an HCBS Waiver
UCare products that DO NOT include an HCBS Waiver
Approvals for HCBS Waivers - Working with the Member's Care Coordinator
Coding Information for Waiver Service Providers
Elderly Waiver Billing Information
Waiver Obligations - Important Notice for Elderly Waiver Providers
For Additional Information from DHS Regarding Waiver Services
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Appendices
› UCare for Seniors Evidence of Coverage - Value Plus and Classic
› UCare for Seniors Evidence of Coverage - Value
› UCare's Minnesota Senior Health Options (MSHO) Certificate of Coverage
› UCare Complete Certificate of Coverage
› UCare Connect Certificate of Coverage (Dual Eligible)
› UCare Connect Certificate of Coverage (Members with Medical Assistance only)
› Minnesota Senior Care Plus (MSC+) Certificate of Coverage
› Prepaid Medical Assistance Program/Prepaid General Assistance
Medical Care Certificate of Coverage
› MinnesotaCare Certificate of Coverage
Back to top >>