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Welcome UCare Providers

Care Coordination Resources 

Minnesota Senior Care Plus (MSC+) and Minnesota Senior Health Options (MSHO)

Care Coordinators foster ongoing primary and preventative care, create a person-centered support plan and assist with communication between all members of the interdisciplinary care team.

To find product-specific tools and forms, select the desired plan from the "Please select" drop-down and click "Select Plan" to explore each category and its contents.

Please select an option

MSC+ and MSHO
Appointment Reminder Letter (New 5/20/2024)
EW Provider Support Plan Cover Letter (Revised 3/4/2024)
EW Provider Support Plan Summary Letter (Revised 3/4/2024)
Provider Engagement Letter (Revised 7/6/2022)

MSC+
Care Plan Letter (Revised 8/31/2022)
Care Plan Signature Letter (Revised 8/31/2022) | Hmong | Somali | Spanish
Change in Care Coordinator Letter (Revised 8/26/2022)
Change in Contact Info for Care Coordinator (Revised 8/26/2022)
Member Elderly Waiver Service Change Letter
PCP/ICT Fax Support Plan Cover Sheet (Revised 3/4/2024)
PCP/ICT Support Plan Cover Letter (Revised 3/4/2024)
Refusal Letter (Revised 8/18/2023)
Unable to Reach Letter (Revised 9/8/2022) | Hmong | Somali | Spanish
Welcome Letter (Revised 8/2/2022)
Welcome Letter - Member in Nursing Home (Revised 8/26/2022)
Welcome Letter - Member on CAC, CADI, DD, or TBI (Revised 8/2/2022)

MSHO
Care Plan Letter (Revised 8/31/2022)
Care Plan Signature Letter (Revised 8/31/2022) | Hmong | Somali | Spanish
Change in Care Coordinator Letter (Revised 8/26/2022) | Hmong | Somali | Spanish
Change in Contact Info for Care Coordinator (Revised 8/26/2022)
Member Elderly Waiver Service Change Letter
PCP/ICT Fax Support Plan Cover Sheet (Revised 3/4/2024)
PCP/ICT Support Plan Cover Letter (Revised 6/5/2024)
Refusal Letter (Revised 8/18/2023)
Unable to Reach Member Letter (Revised 1/1/2024) | Hmong | Somali | Spanish
Welcome Letter (Revised 8/2/2022)
Welcome Letter - Member in Nursing Home (Revised 8/26/2022)
Welcome Letter - Member on CAC, CADI, DD, or TBI (Revised 8/2/2022)

Assessment and Support Plan Forms
2024 Monthly Activity Log (Revised 1/30/2024)
Collaborative Care Plan (Revised 11/21/2022) | Word | PDF
Institutional Health Risk Assessment  (New 1/1/2024) | Word  | PDF | Example
Institutional Support Plan  (New 1/1/2024) | WordPDF | Example
Refusal Support Plan (Revised 1/1/2024) | Word | PDF
Support Plan Signature Sheet - MnCHOICES (New 10/2/2023)
Transfer Member Health Risk Assessment (Revised 10/31/2023) | Word  | PDF
UTR Support Plan (Revised 1/1/2024) | Word | PDF

Other Forms
Additional or Substitute Home and Community Based Service Exception Request
Death Notification Form (Revised 3/27/2024)
Nursing Facility Coverage Guide (Revised 1/1/2024)
PCC Change Form | Process Flow
Release of Information Form (Revised 5/23/2024)

EW Service Authorization
Waiver Service Approval Form (Revised 4/8/2024)
Waiver Service Approval Form - T2029 (New 6/1/2023)
EW T2029 Equipment and Supplies Guide *Coming soon*
EW T2029 Equipment and Supplies Coverage Process *Coming soon*
Home Health Communication Form
Request to Exceed Case Mix Cap
EW Rate Calculations *Coming soon*
CBSM EW Conversion Rates

CDCS Toolkit *Coming soon* 

EW DTR Form and Instructions
Elderly Waiver DTR Form | Instructions (Revised 5/13/2024)
EW DTR Reason Code Tool (Revised 1/1/2024)
Home Health Communication Form | HHC Example

PCA Assessment Request Form

  • Used by the PCA agency when a member is due for their annual PCA assessment and must send it 60 prior to the end of the PCA authorizations.

PCA Communications Form (Revised 1/24/2024)  

  • Used when a DTR needs to be issued for services or an assessment (i.e., Early assessment, Refusal or Unable to reach).
  • Member has selected a PCA provider agency.
  • Used to approve or DTR extended PCA services.
  • Used when the CC is reporting a change or new PCA provider agency
  • Approve 45 day temp start/Increase of PCA services.

PCA Coverage Policy   (The PCA provider agency is required to notify UCare of a provider change however, the care coordinator may report this information to UCare in behalf of the provider).

  • Used by providers when a member changes to a different PCA provider agency.
  • Used by providers when a member previously had not selected a PCA provider agency at the time of the assessment but has now made their selection.

PCA Provider Change Request Form

PCA Transfer Form

  • Used to request a transfer of a PCA Authorization from another health plan to UCare.