Medical Services 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)*

*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.

UCare Medicare Plans and UCare Medicare with M Health Fairview & North Memorial
EssentiaCare
State Public Programs
Special Needs Plans
UCare Individual and Family Plans, UCare Individual and Family Plans with M Health Fairview

All Products
Durable Medical Equipment/Supply Prior Authorization Form
General Prior Authorization Request Form (Not used for Behavioral Health services)
Genetic Testing Prior Authorization Form
Hospice Election Form
Transplant Notification Form
Universal Health Plan/Home Health Agency Prior Authorization Request Form

Only EssentiaCare, UCare Medicare and UCare Medicare with M Health Fairview & North Memorial Plans
Pre-Determination Request Form

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

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
Nursing Home/Swing Bed Admission/Update 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 Assessment Request Form
PCA Authorization Transfer Form
PCA Provider Change Request Form

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

Acupuncture Authorization (Effective 8-8-22):
Direct Duals and State Public Program authorization submissions to UCare's delegate, Fulcrum Health, Inc., | Fax: 763-204-8572
Fulcrum Licensed Acupuncture Policy
Medicaid Acupuncture Prior Authorization Request Form

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

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

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