Critical Business Reminders

Practitioners have the right to:

1. Review the information submitted in support of their credentialing applications excluding references, recommendations and other peer-review information.
2. Correct erroneous and/or discrepancy information that varies substantially from the information verified during the credentialing process by submitting a newly attested and corrected application within 14 days from the receipt of request for correction either by email (credentialinginfo@ucare.org), fax (612-884-2184), or mail (UCare - 500 Stinson Boulevard NE, Minneapolis, MN 55413).
3. Be informed, upon request, of the status of their credentialing application. Please send your status request to UCare’s Credentialing Department at credentialinginfo@ucare.org. They will respond to your request via email within three business days.

For more information on this process, refer to the Provider Credentialing (Credentialing and Recredentialing Application Submission Process) section of UCare’s Provider Manual.

To review UCare’s current formularies, exception process and pharmaceutical procedures, visit the Pharmacy page on the provider website. If you would like a copy of this information by fax, email or mail, contact our Provider Assistance Center at 612-676-3300 or 1-888-531-1493 (toll free).

The formularies list pharmaceuticals by class and preferred products, along with clinical restrictions (prior authorization, step therapy or quantity level limits), and those products that may be subject to limited availability or access. Electronic prior authorization (ePA) is the preferred method to submit a request to Express Scripts for medications subject to clinical restrictions or to request a non-formulary exception. Practitioners may use ePA through Express Scripts, SureScripts, CoverMyMeds or through the Electronic Health Record. The Minnesota Uniform Form for Prescription Drug Prior Authorization or Drug Coverage Determination Form may also be sent to Express Scripts for initial review with appropriate clinical documentation.

As a reminder, Minnesota is a mandatory generic substitution state per Minnesota Statute 151.21. Brand name products will automatically be dispensed with AB rated generic if available, unless otherwise specified by the practitioner. The FDA considers an AB rated medication to meet bioequivalence standards to the brand name product. Drugs administered in the provider’s office and billed through the medical benefit may need prior authorization. For a list of medical injectable drugs requiring prior authorization, please visit the Pharmacy page on the provider website, where you will find corresponding criteria and authorization forms. See detailed information by selecting a specific UCare Plan and reviewing Medical Injectable Drug Prior Authorization Resources.

We welcome individual member referrals from practitioners for this program. Other referral sources include medical management programs, discharge planners, caregivers and members. UCare also identifies members for enrollment into the Complex Case Management Program using predictive modeling. Referrals are screened for program eligibility and assigned to a complex case manager, if indicated.

UCare accepts all referrals for screening for our Complex Case Management Program. Participation in this program is voluntary and free for eligible UCare Medicare Plans, UCare Individual & Family Plans, UCare Individual & Family Plans with M Health Fairview, Prepaid Medical Assistance Program and MinnesotaCare members. You can refer a member to this program by completing the referral form on our website (click “Care/Case Management Referral Forms” and select appropriate form).

If you would like to discuss the Complex Case Management Program, need additional information or would like to receive a referral form, call 612-676-6538. Referrals and/or additional documentation should be faxed to 612-884-2284.

Utilization management (UM) decision-making is based on appropriateness of care, service and existence of coverage. UCare does not compensate practitioners or individuals for denials, does not offer incentives to encourage denials and does not encourage decisions that result in underutilization. UCare ensures independence and impartiality in making referral decisions that will not influence hiring, compensation, termination, promotion and any other similar matters.

UCare’s affirmative statement is located on our website’s Important Coverage Information page under “How UCare makes coverage decisions, manages care, and determines authorizations.”

UCare offers members and practitioners access to utilization review staff via local or toll free telephone lines and confidential voicemail from 8 am-5 pm, Monday through Friday, excluding holidays. Collect calls are accepted from both members and practitioners. After normal business hours, a confidential intake fax line (612-884-2499) and telephone line (612-676-6705) are available for submission of notifications, utilization requests, supporting clinical information and other documentation as needed.

A TTD/TTY line (612-676-6810 or 1-800-688-2534 (toll free) is available 24 hours per day, seven days per week for members or practitioners with speech difficulties or hearing impairment. Interpretation services are also available for members requesting language assistance 24 hours per day, seven days per week.

Practitioners may request a copy of Medical Necessity Criteria used to make UM determinations by completing the Medical Necessity Criteria Request Form. If you would like to receive a copy of the affirmative statement or the Medical Necessity Criteria Request Form by fax, email or mail, please contact the UM intake line at 612-676-6705, and we will send the information within five business days of receipt of the request.

UCare takes member rights and responsibilities seriously. Practitioners are expected to be familiar with the Member Rights and Responsibilities. Our members’ rights and responsibilities can be found in the Member Appeals & Grievances section of the Provider Manual. If you would like a copy of the Members’ Rights and Responsibilities statement by fax, email or mail, contact our Provider Assistance Center at 612-676-3300 or 1-888-531-1493 (toll free).

UCare is committed to helping practitioners work with UCare members who face decisions regarding next steps in their care. UCare’s goal is to empower members to work collaboratively with their practitioners. By doing so, they can make sure they are well informed on their options and make the right health decision for their personal needs.

The Informed Medical Decision-Making Foundation describes shared decision-making (SDM) as a collaborative process that allows patients and practitioners to make health care treatment decisions together, taking into account the best scientific evidence available, as well as the patient’s values and preferences. SDM honors the practitioner’s expert knowledge and the patient’s right to be fully informed of all care options and the potential harm and benefits. This process provides patients with the support they need to make the best individualized care decisions, while allowing practitioners to feel confident in the care they prescribe.

Shared Decision-Making resources can be found on the UCare Quality Initiatives website. If you would like a copy of these resources faxed, emailed or mailed, please contact our Provider Assistance Center at 612-676-3300 or 1-888-531-1493 (toll free).

UCare, through its Quality Improvement Advisory and Credentialing Council (QIACC), adopts and disseminates evidence- based clinical practice guidelines from nationally or locally recognized sources to support good decision-making by patients and clinicians and to improve health outcomes. At least every two years, QIACC reviews and approves the content of the guidelines.
UCare is working on improving the health of our members through a population health management wide focus. UCare annually reviews its population health strategy to analyze how health services are delivered and offered to meet the needs of the targeted population. Based on this analysis, UCare determines actionable categories and sub-categories to identify targeted populations and appropriate interventions. UCare assesses and reviews the characteristics and needs of its population including social determinants of health, subpopulations, child and adolescent members, disabilities and serious and persistent mental illness.

UCare’s medical clinical practice guidelines include Asthma, Diagnosis and Management; Care of the Older Adult; Diabetes in Adults, Type 2 Diagnosis and Management; Management of Heart Failure in Adults; Obesity in Adults, Management & Prevention; Prenatal Care, Routine; Preventive Services for Adults; and Preventive Services for Children and Adolescents.

UCare’s mental health and substance use disorder guidelines include Assessment and Treatment of Children and Adolescents with Attention-Deficit/Hyperactivity Disorder; Assessment and Treatment of Children and Adolescents with Depressive Disorders; Treatment of Patients with Major Depressive Disorder; Treatment of Patients with Schizophrenia; and Treatment of Patients with Substance Use Disorders (SUD).

Clinical Practice Guidelines can be found in the Clinical Support Resources section of the UCare Policies and Resources website. If you would like a copy of any of the guidelines faxed, emailed or mailed, contact our UM intake telephone line at 612-676- 6705.