Information by UCare Plan
UCare Individual & Family Plans
Commercial products for individual and family (IFP) coverage available through MNsure, including UCare Individual & Family Plans and UCare Individual & Family Plans with M Health Fairview.
UCare Medicare Plans, UCare Medicare Plans with M Health Fairview and North Memorial, UCare Medicare Group Plans, UCare Advocate Plans, EssentiaCare and UCare Your Choice Plans.
Medicare + Medical Assistance
UCare Connect + Medicare and Minnesota Senior Health Options (MSHO)
State Medical Assistance Programs
UCare Connect (Special Needs BasicCare), Minnesota Senior Care Plus (MSC Plus), MinnesotaCare (MnCare), Prepaid Medical Assistance Program (PMAP)
Resources & Information
Electronic Prior Authorization (ePA):
ePA is the preferred method to submit Prior Authorization requests to Express Scripts for pharmacy benefit drugs. Providers may use ePA through ExpressPAth, Surescripts, CoverMyMeds or through the Electronic Health Record.
Prior authorization requests for medical drugs administered in a doctor's office will be reviewed by Care Continuum, a subsidiary of Express Scripts. See information in Medical Injectable Drug Prior Authorization Resources.
Care Continuum reviews Medical Drug Prior Authorization requests for all UCare plans.
To submit an authorization request, use one of the following ways:
- Online (ePA) via the ExpressPAth Portal at www.express-path.com/. Providers can submit requests, check on the status of submitted requests, and submit an authorization renewal on the ExpressPAth Portal. The site also provides 24/7 access, potential for real-time approvals, and email notifications once a decision is reached.
- Fax an authorization form to Care Continuum at 1-877-266-1871.
- Call Care Continuum at 1-800-818-6747.
To request an adjustment to an existing prior authorization:
- Providers should contact Care Continuum for prior authorization changes.
- The authorization must be active.
- End date extensions can be completed due to scheduling issues or health reasons (ex: chemo delayed due to blood count) that may prevent the administration of the previously approved drug.
- Required information for these requests:
- Reason for extension.
- Revised end date.
- Adjustments are not approved for the reasons listed below. A new review/renewal is required.
- Additional drug is requested.
- The patient is due for a renewal.
Non-participating providers should send requests using this form:
- by fax to UCare Clinical Pharmacy Intake at 612-617-3948.
- or by mail to UCare, Attn: Pharmacy at P.O. Box 52, Minneapolis, MN 55440-0052.
Providers that received a claim denial due to no authorization in place will continue to work through the provider claims appeal process using the Provider Claim Reconsideration Request Form.
Our Medication Therapy Management (MTM) Program is a free service for eligible UCare members to optimize individual medication therapy, experience and outcomes. Members receive a one-on-one consultation with a pharmacist to review their entire medication regimen (including prescription, over-the-counter medications and herbal supplements) to help resolve any potential medication-related issues regarding indication, effectiveness, safety and convenience.
UCare partners with many pharmacists across the state of Minnesota and provides reimbursement for MTM services.
Following is a high-level overview of the MTM Program. Please refer to the MTM section of the provider manual for full program information including detailed topics such as eligibility, expectations, audits, billing and more.
- Most UCare plans with prescription drug coverage are eligible for MTM services and can receive these services with contracted local pharmacists.
- Internal UCare telephonic MTM services are only available to Medicare, Connect + Medicare, MSHO, and select Medicaid members.
UCare’s expectation is that MTM services will be billed using MTM CPT codes 99605, 99606 and 99607. Billing is based on complexity, not time, for all lines of business.
Important Time Sensitive Requirement Reminders
- Medicare members must be provided with CMS standardized format materials (including medication action plan and personalized medication list) within 14 days of the encounter.
- A Continuity of Care Document (CCD) must be submitted within 45 days of the original visit.
- Member opt-outs from the MTM program must be received within 30 days of member’s decision to opt-out.
Continuity of Care Document (CCD)
MTM providers are required to maintain and submit a CCD for all Medicare visits. It is acceptable to send information for non-Medicare members as well.
For any questions or inquiries regarding the MTM program at UCare, please contact us via email at firstname.lastname@example.org.
Additional Helpful Resources
November 15, 2022 - Pharmacy Formulary and Benefit Changes for 2023
November 15, 2022 - Medical Benefit Drug Prior Authorization for 2023
November 12, 2021 - Changes to 2022 Part D Vaccine Billing for MSHO and Connect + Medicare
November 18, 2020 - UCare Medicare Part D Vaccine Information
The Pharmacy and Therapeutics Committee, a group of practicing physicians and pharmacists, meets up to six times per year to recommend medication inclusion or exclusion to our formularies. The Pharmacy and Therapeutics Committee evaluates drugs based on clinical evidence and efficacy (drug monographs, peer reviewed literature, compendia resources), therapeutic guidelines, medication safety and comparable data to other therapeutic alternatives. This committee reviews all new drugs approved by the FDA, new generics, new dosage forms, new indications as well as regular therapeutic class reviews and annual review of all utilization management criteria.
View the September 2023 Pharmacy and Therapeutics Committee Decisions Here.
View the June 2023 Pharmacy and Therapeutics Committee Decisions Here.
View the April 2023 Pharmacy and Therapeutics Committee Decisions Here.
View the March 2023 Pharmacy and Therapeutics Committee Decisions Here.
View the January 2023 Pharmacy and Therapeutics Committee Decisions Here.
View the November 2022 Pharmacy and Therapeutics Committee Decisions Here.
View the September 2022 Pharmacy and Therapeutics Committee Decisions Here.
View the June 2022 Pharmacy and Therapeutics Committee Decisions Here.
View the April 2022 Pharmacy and Therapeutics Committee Decisions Here.
View the March 2022 Pharmacy and Therapeutics Committee Decisions Here.
View the January 2022 Pharmacy and Therapeutics Committee Decisions Here.
Pharmacy Benefit Prior Authorization
Express Scripts - State Medical Assistance Programs and UCare Individual & Family Plans
Express Scripts - Medicare, Medicare + Medical Assistance (dual eligibles)
Medical Injectable Drug Prior Authorization
Care Continuum, a subsidiary of Express Scripts
Online (ePA): ExpressPAth Portal at www.express-path.com/
UCare Clinical Services Intake
Specialty Pharmacy Contact Information
Fairview Specialty Pharmacy
Phone: 612-672-5260 or 1-800-595-7140 toll free
*exclusive network provider of specialty drugs for UCare Individual & Family Plans and State Medical Assistance Programs
Mail Order Contact Information
Express Scripts Mail Order Pharmacy
ePrescribing: Express Scripts Home Delivery Pharmacy
News & Alerts
Provider News Library
September 2023 Health Lines
Learn about the following: Flu Shot Season, UCare's Unclaimed Property Notices, September is Falls Prevention Awareness Month, Juniper® Health Management and Wellness Classes, Documentation Improvement: Sepsis, Medicare Supplement Reminders, Accurate Member Information is Key to Smooth Claim Submissions and Fraud, Waste and Abuse Reporting Reminder.
Early Intensive Development and Behavioral Intervention (EIDBI) Claims Payment Reminder
UCare follows Minnesota Department of Human Services (DHS) guidelines, found in the MHCP Provider Manual, for the rendering and billing of EIDBI services.
In accordance with DHS guidelines, the practitioner who provides the service must bill the service as the rendering provider. Only list a Qualified Supervising Professional (QSP) as the rendering provider if they personally performed the service. Otherwise, list the QSP as the person who is supervising the rendering provider in addition to the rendering provider.
UCare Provider Manual Updated for Q3 2023UCare’s 2023 Provider Manual contains critical information that providers need to know to effectively work with UCare and our members. It is important that providers reference the online manual regularly for up-to-date content. The Provider Manual has been updated to reflect current business practices.
Go to the Provider Manual.
Reminder: Complete the Disclosure of Ownership, Control and Management Information and Exclusions Statement for Providers Form
In June, UCare asked providers to complete and submit the Disclosure of Ownership (DOO), Control and Management Information and Exclusions Statement for Providers form. Providers who still need to submit their completed form should do so as soon as possible.
Medical Assistance and MinnesotaCare Disenrollments Begin Aug. 1
The Minnesota Department of Human Services (DHS) began the Medical Assistance and MinnesotaCare renewal process, and some UCare members are at risk to lose their coverage as early as Aug. 1. Members who didn’t renew their coverage, and believe they are still eligible, can still renew their coverage and may be eligible for retroactive coverage.
Updated Prior Authorization Criteria for Drugs on the IFP Formulary
Starting September 1, 2023, UCare is updating prior authorization criteria for two drugs that are on the UCare Individual & Family Plans and UCare Individual & Family Plans with M Health Fairview formulary.
Expedited Appeal Requests Reminder
UCare’s Appeals and Grievances Department has seen an uptick in appeals for FDA-approved weight-loss medications including Wegovy and Saxenda. Several of these requests are filed as expedited. Providers are encouraged to review the criteria for expedited appeal requests.
Children’s Residential Treatment Authorization and Notification Requirements Temporarily Changed for Individual and Family Plan Members
Effective June 12, 2023, to Dec. 31, 2023, UCare is temporarily waiving prior authorization requirements for UCare Individual and Family Plans and UCare Individual and Family Plans with M Health Fairview for children’s residential treatment facilities before admission.
Critical Business Reminders
UCare provides Critical Business Reminders annually to update our provider network on important business information. View our updated Critical Business Reminders webpage here. You'll find updates to the credentialing and recredentialing process, pharmacy section, Complex Case Management Program referral process, utilization management (UM), affirmative statement, how to request UM criteria and obtain access to UM staff, Member Rights and Responsibilities, links to shared decision-making (SDM) resources and links to training and resources on culturally congruent care.
Inpatient Hospital Readmission Payment Policy UpdatedUCare recently updated the Inpatient Hospital Readmission Payment Policy. As part of this policy update, UCare's third-party vendor, Optum, will conduct post-payment reviews of applicable inpatient hospital admissions to assess whether the multiple hospital stays should bundle into one hospital confinement. Audits will start with claims paid July 15, 2023, and later.
See the June 1 Provider Bulletin for details.
End to COVID-19 Public Health Emergency
The COVID-19 Public Health Emergency (PHE) ended on May 11, 2023. UCare has revised its COVID-19 guidance for providers. Review UCare COVID-19 Information for Providers page for more information regarding these changes.
Provider Enrollment With Minnesota Health Care ProgramsUCare providers who are contracted to provide services to Medicaid members will be expected to enroll with Minnesota Health Care Programs (MHCP) starting July 17, 2023. Resources are available to help prepare for the enrollment process. See the May 17 Provider Bulletin.
Temporarily Changes to Post-Acute Care Authorization and Notification Requirements
Effective May 12, 2023, to Dec. 31, 2023, UCare is waiving prior authorization requirements for all plans before admission for Long-Term Acute Care Hospital (LTACH) and Acute Inpatient Rehabilitation (AIR).
Redeterminations and Renewals
The Minnesota Department of Human Services (DHS) has reinstated Medicaid redeterminations (or renewals) for Medical Assistance members. The renewal process started with Medical Assistance members who have a renewal date of July 1, 2023. This is the first date members could lose coverage for failing to renew their eligibility with the state and county.
2023 Summer Camps Available for Young UCare Members
This summer, UCare will team up with Minnesota camps to offer opportunities for young UCare members in Prepaid Medical Assistance Program (PMAP) and MinnesotaCare plans.
Discussing a Pre-Service Denial With a Reviewer
Beginning May 1, 2023, practitioners will have 14 calendar days from the denial notice date of an authorization to initiate a discussion of a pre-service authorization denial decision.
Pharmacy Formulary and Benefit Changes for 2023
Information about the 2023 formularies and changes to benefits is now available.
Medical Benefit Drug Prior Authorization for 2023
Medical Benefit Drug Prior Authorization for 2023 and Preferred Product Step Therapy Information now available.