Mental Health & Substance Use Disorder Services 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.

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)

All Products
1115 Waiver Concurrent Review Substance Use Disorder Residential
Mental Health 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

Only State Public Programs and Special Needs Plans
Adult Rehabilitative Mental Health Services (ARMHS) Provider Notification/Change Request

Only Medicare
UCare Pre-Determination Request Form

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