Care Coordination Resources
Minnesota Senior Health Options (MSHO)
Assessment Timelines (New 6/23/2022)
Community Care Coordination Requirements Grid (Revised 7/1/2022)
FTP Site Tip Sheet
Institutionalized Care Coordination Requirements Grid (Revised 7/1/2022)
SMART Goals (New 6/23/2022)
UCare’s Minnesota Senior Health Options (MSHO) Overview
Care Plan Letter (Revised 8/31/2022)
Care Plan Signature Letter (Revised 8/31/2022)
Change in Contact Info for Care Coordinator (Revised 8/26/2022)
Change of Care Coordinator Letter (Revised 8/26/2022)
Member Change Letter (Revised 8/26/2022)
PCP/ICT Care Plan FAX Cover Sheet (Revised 7/29/2022)
PCP/ICT Care Plan Cover Letter (Revised 7/29/2022)
Provider Care Plan Cover Letter
Provider Care Plan Summary Letter
Provider Engagement Letter (Revised 7/6/2022)
Refusal Letter (New 1/5/2022)
Unable to Reach Member Letter (Updated 9/8/2022)
Welcome Letter (Updated 8/2/2022)
Welcome Letter - Member in Nursing Home (Revised 8/26/2022)
Welcome Letter - Member on CAC, CADI, DD, or TBI (Updated 8/2/2022)
When to Contact Your Care Coordinator (New 7/27/2022)
Additional or Substitute Home and Community Based Service Exception Request Form
Care Coordination Appointment Reminder Form (Revised 1/1/2022)
Collaborative Care Plan - PDF | Collaborative Care Plan - Word | Collaborative Care Plan Instructions
Customized Living Verification Code Form | Customized Living Verification Code Guidelines
Death Notification Form
Dental Kit Form
Health Connect 360 Referral Form
Home Health Communication Form | Home Health Communication Form Example
How to Safely Dispose of Medication (Revised 1/1/2022)
Institutional Health Risk Assessment-PDF (Revised 8/17/2022)
Institutional Health Risk Assessment-WORD (Revised 8/17/2022)
Lutheran Social Service of Minnesota Community Companion Authorization Request Form-WORD
Lutheran Social Service of Minnesota Community Companion Authorization Request Form-PDF
MA Transportation Ride Request Form (New 7/6/2022)
Medication Toolkit Order Form
MOM’s Meals MSHO Supplemental Benefit Form
MSHO AA/NA Ride Request Form
MSHO Supplemental Benefit Form (Revised 7/62022)
Memory Kit Order Form
Individual Home Supports Form (Revised 2/16/2022)
Nursing Home Face Sheet
Assessment Log (formerly Part C) (Revised 1/1/2022) | MSHO Activity Reporting Log Tip Sheet (Part C Log) (Revised 2/24/2022) | MSHO Tips for Completing Part C Log
Reemo Smartwatch Order Form (Revised 8/17/2022) | Reemo Smartwatch Overview
Refusal Support Plan-WORD (Revised 7/1/2022)
Refusal Support Plan-PDF (Revised 7/1/2022)
Release of Information Form
Request to Exceed Case Mix Cap
Strong & Stable Kit Order Form
Transitional Health Risk Assessment Form - Word
Transitional Health Risk Assessment Form - PDF
UTR Support Plan-WORD (Revised 7/1/2022)
UTR Support Plan-PDF (Revised 7/1/2022)
Waiver Service Approval Form (Revised 7/29/2022)
- 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.
- 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.
- Used to request a transfer of a PCA Authorization from another health plan to UCare.