Mental Health & Substance Use Disorder 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
MH & SUD General Services Form
MH & SUD Inpatient & Residential Form
MH & SUD Out-of-Network Prior Authorization Form 

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

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