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Mental Health & Substance Use Disorder Services Authorizations

UCare Individual & Family Plans and UCare Individual & Family Plans with M Health Fairview

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Medical Services Authorizations

Medical Injectable Drug Authorizations

Authorizations and Notifications Requirements

Review UCare Individual & Family Plans Requirements:

View All 2020 MH & SUD Services Requirements (PDF)
View All 2021 MH & SUD Services Requirements (PDF)

Forms & Information

Authorization Forms

Mental Health Outpatient
Substance Use Disorder Treatment Outpatient
Prior Authorization Form for Out-of-Network Providers
Prior Authorization Form for Early Intensive Developmental & Behavioral Intervention (EIDBI)
Prior Authorization Form for Psychiatric Residential Treatment Facilities (PRTF)
Notice of Admission Form for Mental Health Inpatient or Residential
Notice of Admission Form for Substance Use Disorder Inpatient or Residential
Notice of Admission Form for Withdrawal Management
Concurrent Review Form for Withdrawal Management
Rule 25 Assessment and Placement Summary Form

Restricted Member Forms and Information

The forms below may be used when referring members to the UCare Individual & Family Plans Restricted Member Program:

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

Universal Referral Form

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

Universal Referral Form

Authorization Contact Information

UCare Mental Health and Substance Use Disorder Services

Phone (local): 612-676-6533
Phone (toll free): 1-833-276-1185
Fax (local): 612-884-2033
Fax (toll free): 1-855-260-9710

Provider Resources

Policies & Resources

Provider Manual
Medical Necessity Guidelines
Payment Policies

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*UCare Medicare Plans include Aware, Classic, Complete, Essentials Rx, Prime, Standard, Value and Value Plus,
Advocate Choice, Advocate Choice Plus and UCare Medicare Supplement.
UCare Individual & Family Plans include Core, Bronze, Bronze HSA, Silver, Silver HSA and Gold; and
UCare Individual & Family Plans with M Health Fairview Bronze, Bronze HSA, Silver, Silver HSA and Gold.