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)
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)
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 Fax Support Plan Cover Sheet (Revised 6/1/2024)
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)
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 Fax Support Plan Cover Sheet (Revised 6/1/2024)
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)
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
Support Plan Signature Sheet - MnCHOICES (New 10/2/2023)
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 5/23/2024)
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 6/14/2024)
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 *Coming soon*
Consumer Directed Community Supports (CDCS) Policy Manual
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 1/24/2024)
- 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.