Care Coordination Resources
Minnesota Senior Health Options (MSHO)
Community Care Coordination Requirements Grid (Revised 11/1/2023)
Institutionalized Care Coordination Requirements Grid (Revised 11/1/2023)
MnCHOICES Community Care Coordination Requirements Grid (Revised 11/1/2023)
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 (Revised 8/18/2023)
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)
Additional or Substitute Home and Community Based Service Exception Request Form
Monthly Activity Log (Revised 3/1/2023)
Collaborative Care Plan - PDF | Collaborative Care Plan - Word (Revised 11/21/2022)
Customized Living Verification Code Form | Customized Living Verification Code Guidelines
Death Notification Form
Home Health Communication Form | Home Health Communication Form Example
Institutional Health Risk Assessment - Word (Revised 7/19/2023) | Institutional Health Risk Assessment Example - PDF (New 7/19/2023)
Nursing Home Face Sheet
Refusal Support Plan - Word (Revised 11/18/2022)
Refusal Support Plan - PDF (Revised 10/17/2023)
Release of Information Form
Request to Exceed Case Mix Cap
Support Plan Signature Sheet - MnCHOICES (New 10/2/2023)
Transfer Member Health Risk Assessment - PDF (Revised 10/31/2023)
Transfer Member Health Risk Assessment - Word (Revised 10/31/2023)
UTR Support Plan - Word (Revised 11/9/2022)
UTR Support Plan - PDF (Revised 7/10/2023)
Waiver Service Approval Form (Revised 6/1/2023) | T2029 Specialized Equipment and Supplies (New 6/1/2023)
- 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 10/25/2023)
- 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.