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.
Community Care Coordination Requirements Grid (Revised 7/1/2024)
Institutionalized Care Coordination Requirements Grid (Revised 7/1/2024)
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)
PCP/ICT Support Plan Fax Cover Sheet (Revised 6/25/2024)
Provider Engagement Letter (Revised 7/6/2022)
Support Plan Letter (Revised 6/14/2024)
Support Plan Signature Letter (Revised 6/14/2024) | Hmong | Somali | Spanish
Unable to Reach Member Letter - Support Staff (New 7/1/2024) | Hmong | Somali | Spanish
MSC+
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 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) | Hmong | Somali | Spanish
Welcome Letter - Member in Nursing Home (Revised 8/26/2022)
Welcome Letter - Member on CAC, CADI, DD, or TBI (Revised 8/2/2022)
MSHO
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 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) | Hmong | Somali | Spanish
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) | Word | PDF | Example
Refusal Support Plan (Revised 6/20/2024) | Word | PDF
Transfer Member Health Risk Assessment (Revised 10/31/2023) | Word | PDF
UTR Support Plan (Revised 6/20/2024) | 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 7/3/2024)
Support Plan Translation Request (New 7/1/2024)
Transitions of Care Log (Revised 12/30/22)
TOC Log Instructions (Revised 12/28/22)
Transition of Care (TOC) Notification to PCP (Revised 6/3/2024)
Transition of Care Talking Points
EW Service Authorization
Waiver Service Approval Form (Revised 7/9/2024)
Waiver Service Approval Form - T2029 (Revised 6/28/2024)
EW T2029 Equipment and Supplies Guide (New 6/28/2024)
EW T2029 Equipment and Supplies Coverage Process (New 6/28/2024)
Home Health Communication Form
Request to Exceed Case Mix Cap
EW Budget Tool (New 6/14/2024)
CBSM EW Conversion Rates
Elderly Waiver Capitation Dates
CDCS Toolkit
Care Coordinator CDCS Guidelines (NEW)
CC CDCS Plan Approval Checklist (NEW)
CDCS DHS 6532 CSP Change Form (coming soon)
CDCS Member Agreement and Checklist (NEW)
Consumer Directed Community Supports (CDCS) Policy Manual
Member Guide to CDCS Allowed Expenditures (coming soon)
Notice of Technical Assistance (NEW)
EW DTR Form and Instructions
Elderly Waiver DTR Form | Instructions (Revised 6/6/2024)
EW DTR Reason Code Tool (Revised 1/1/2024)
Home Health Communication Form | HHC Example
- 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 7/1/2024)
- 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
- Used to request a transfer of a PCA Authorization from another health plan to UCare.