Medical Services Authorizations

2025 Authorization and Notification Requirements (effective June 1, 2025):
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* | Institutional Special Needs Plans (I-SNP)
UCare Connect | MSC Plus | Prepaid Medical Assistance Plan (PMAP) | MinnesotaCare (MnCare)

*MultiPlan Providers should reference these Authorization Grids.

2025 Authorization and Notification Requirements (effective January - May 2025):
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* | 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.

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.

All Products
AIR/LTACH Admission Notification Form
Durable Medical Equipment/Supply Prior Authorization Form
General Prior Authorization Request Form (Not used for Medical Drug authorization requests)
Hospice Election Form
NICU Notification Form
Non-Emergent Air Ambulance
Rare Disease Prior Authorization Form
Transplant Prior Authorization Form
Universal Health Plan/Home Health Agency Prior Authorization Request Form

Only EssentiaCare and UCare Medicare Plans
Pre-Determination Request Form (Not used for Medical Drug Pre-Determination requests)

Only State Public Programs & Special Needs Plans
DHS Managed Care Service Authorization Request Process
Home Care Nursing/Private Duty Nursing Request Form

UCare partners with Carelon to perform utilization management review for genetic testing authorizations for members in all UCare products, except Medicare Supplement plans.

Contact Carelon for prior authorization:

• Provider portal - https://www.providerportal.com/ (registration with Carelon required)
• Phone number - 1-833-821-1954

For SNF Medically Necessary Private Room Requests, UCare will accept either the DHS Private Room Request Form found in the DHS Nursing Home portal or the necessary details added to the Nursing Home/Swing Bed Admission/Update Form.

Only Medicare and Individual & Family Plans
Skilled Nursing Home/Swing Bed Admission Notification Form

Only State Public Programs & Special Needs Plans
Nursing Home Authorization Information

Only MSHO, MSC+, UCare Connect and UCare Connect + Medicare Plans
Nursing Facility (NF) Communication Form

Only State Public Programs & Special Needs Plans
PCA/CFSS Assessment Request Form
PCA/CFSS Authorization Transfer Form
PCA/CFSS Provider Change Request Form

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:
For questions about 2025 services, contact DentaQuest. For questions about 2024 services, contact Delta Dental of Minnesota. 

Genetic Testing:
UCare partners with Carelon to perform utilization management review for genetic testing authorizations for members in all UCare products, except Medicare Supplement plans. Contact Carelon for prior authorization through their provider portal (registration with Carelon required) or call 1-833-821-1954 for more information.

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

Restricted Recipient Program
Restricted Recipient Reference Guide

Minnesota Restricted Recipient Program - State Public Programs & Special Needs Plans
Specialty Referral Form
Authorization for PCP Partners in Clinic
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

Special Transportation Services (STS) Certificate of Need (CON) Authorization Form

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

Universal Referral Form