Authorization

2024 Authorization and Notification Requirements:
Minnesota Senior Health Options (MSHO) | Connect + Medicare
EssentiaCare (Essentia Health + UCare)*
UCare Individual & Family Plans (IFP) | UCare Individual & Family Plans with M Health Fairview
UCare Medicare Plans* | UCare Your Choice* | UCare Medicare Plans with M Health Fairview & North Memorial* | Institutional Special Needs Plans (I-SNP)
UCare Connect | MSC Plus | Prepaid Medical Assistance Plan (PMAP) | MinnesotaCare (MnCare)

*MultiPlan Providers should reference these Authorization Grids. 

Pharmacy
Please see the Pharmacy page for information regarding Medical Injectable Drug Authorizations.

2023 Medical Services:
Minnesota Senior Health Options (MSHO)** | Connect + Medicare**
EssentiaCare (Essentia Health + UCare)* **
UCare Individual & Family Plans (IFP)** | UCare Individual & Family Plans with M Health Fairview**
UCare Medicare Plans* **| UCare Your Choice* **| UCare Medicare Plans with M Health Fairview & North Memorial* **| Institutional Special Needs Plans (I-SNP)**
UCare Connect** | MSC Plus** | Prepaid Medical Assistance Plan (PMAP)** | MinnesotaCare (MnCare)**

2023 Mental Health and Substance Use Disorder Services:
Minnesota Senior Health Options (MSHO) | Connect + Medicare
EssentiaCare (Essentia Health + UCare)*
UCare Individual & Family Plans (IFP) | UCare Individual & Family Plans with M Health Fairview***
UCare Medicare Plans* | UCare Your Choice* | UCare Medicare Plans with M Health Fairview & North Memorial* | Institutional Special Needs Plans (I-SNP)
UCare Connect | MSC Plus | Prepaid Medical Assistance Plan (PMAP) | MinnesotaCare (MnCare)

*MultiPlan Providers should reference these Authorization Grids. 

**Effective 5/12/2023 through 12/31/2023, pre-admission review for LTACH and AIR will not be required. Please submit notification of the admission within 24 hours of admission.

***Effective 06/12/2023 through 12/31/2023, pre-admission review for Children’s Residential Treatment for will not be required for UCare Individual and Family Plans. Please submit notification of the admission within 1 business day of the admission.

Pharmacy
Please see the Pharmacy page for information regarding Medical Injectable Drug Authorizations.

The Behavioral Health Case Management Referral Form is completed when you have a UCare PMAP, MNCare, MSHO or MSC+ member who has a complex Behavioral Health condition.

Mental Health & Substance Use Disorder Case Management Referral Form (New 5.26.20)

The Care Management Referral form is completed when you have a member/patient who you feel would benefit from care coordination services and is actively enrolled in UCare Connect, UCare Connect + Medicare, PMAP (under 65), UCare Medicare Plans or Individual & Family Plans.

Care Management Referral Form - PDF
Care Management Referral Form - Word

The Complex Case Management Referral form is completed when you have a medically complex member/patient who you feel would benefit from short term / intensive medical case management. They typically have a new critical medical event, multiple medical diagnoses with challenges or high medical costs/utilization. This program is for UCare Medicare and Individual & Family Plans and PMAP/MNCare.

Complex Case Management Referral Form - PDF
Complex Case Management Referral Form - Word

UCare works with delegated organizations to handle the following types of authorization.

Chiropractic Authorization:

Direct all authorization questions to UCare's delegate, Fulcrum Health, Inc. | 1-877-886-4941 (toll free)

Dental Authorization:
Direct all authorization questions to UCare's delegate, Delta Dental of Minnesota

• UCare State Public Programs: 1-855-648-1415 (toll free) or 651-768-1415
  
• UCare Medicare Plans and Institutional/Equivalent Special Needs Plan (I E SNP) (Medicare Advantage): 1-855-648-1416 (toll free) or 651-768-1416
  
• UCare Individual & Family Plans / UCare Individual & Family Plans with M Health Fairview: 1-855-648-1417 (toll free) or 651-768-1417
• EssentiaCare: 1-855-648-1416 (toll free) or 651-768-1416

Medical Injectable Drug Authorization:
Direct all authorization requests to UCare’s delegate: Care Continuum, a subsidiary of Express Scripts Online (ePA) at www.express-path.com/ | Phone: 1-800-818-6747 (toll free) | Fax: 1-877-266-1871

In order for services to be eligible for payment by UCare, the services must meet UCare’s standards for coverage, including medical necessity criteria. Coverage and benefits vary significantly among different UCare plans. Medical Necessity Criteria has been added to the Medical Authorization and Notification grids.

InterQual^® Medical Necessity Criteria

Medical Necessity Criteria Request Form

Reconstructive and Cosmetic Health Services Policy

Restricted Recipient Program
Restricted Recipient Reference Guide

Minnesota Restricted Recipient Program - State Public Programs & Special Needs Plans
Specialty Referral Form
Prescribing Privileges for PCP Partners
Restricted Recipient Program Intake Form

Restricted Member Program - Individual & Family Plans
UCare Individual & Family Plans Medical Referral for UCare Restricted Member Enrollee
UCare Individual & Family Plans Prescribing Privileges for PCP Partners
UCare Individual & Family Plans Restricted Member Program Intake Form

All Products
This form is intended to communicate patient referrals between medical and behavioral health providers.

Universal Referral Form

See the Medical Injectable Drugs requiring prior authorization.

Review Medical Drug Policies.

Participating providers can submit prior authorization, authorization adjustment and pre-determination requests to Care Continuum one of the following ways:

• Online (ePA) via the ExpressPAth Portal at www.express-path.com/. Providers can submit requests, check on the status of submitted requests, and submit an authorization renewal on the ExpressPAth Portal. The site also provides 24/7 access, potential for real-time approvals and email notifications once a decision is reached.
• Fax an authorization request form to Care Continuum at 1-877-266-1871.
• Call Care Continuum at 1-800-818-6747.

Non-participating and MultiPlan providers can submit prior authorization, authorization adjustment and pre-determination requests to UCare one of the following ways:

• Fax an authorization request form to UCare Clinical Pharmacy Intake at 612-617-3948.
• By mail to UCare, Attn: Pharmacy at P.O. Box 52, Minneapolis, MN 55440-0052.

Providers that receive a claim denial will continue to work through the provider claims appeal process using the Provider Claim Reconsideration Request Form.