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 Navitus Health Solutions for medications subject to clinical restrictions or to request a non-formulary exception. Practitioners may use ePA through N, 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 Navitus Health Solutions 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. For more information regarding medical drug coverage criteria and how these drugs are covered by the members medical benefit, please review the Medical Drug Policies on the provider website.

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 (PMAP) and MinnesotaCare members. Complex Case Management is also available to Connect and Connect+ members who are pregnant. You can refer a member to this program by completing the referral form on our website (under the “Authorizations” tab, 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 securely emailed to CCMteam@ucare.org or 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. Communications received after normal business hours are returned on the next business day and communications received after midnight on Monday-Friday are responded to on the same business day.

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 free of charge for members requesting language assistance 24 hours per day, seven days per week.

Members and practitioners may request a copy of Medical Necessity Criteria used to make UM determinations by completing the Medical Necessity Criteria Request Form. Additionally, Providers and members are able to access the criteria used for decision making via UCare's website: https://prod.ds.interqual.com/service/connect/transparency?tid=bb070c3e-d799-430d-acad-aaa0c1756b2c 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 actively supports and promotes behaviors, attitudes and policies that enable providers to deliver services in ways that meet the needs of consumers from diverse cultures. Check out the following information, resources, and training opportunities on equity, culturally congruent care, bias, diversity, and inclusion.

UCare's Language Profile

UCare integrates data from various sources to understand the language needs of its members. Nearly 90% of UCare members report speaking English, while U.S. Census data suggests the overall Minnesota population is approximately 88% English-speaking. UCare recognizes the importance of serving its linguistically diverse membership. Here's a breakdown of the top foreign languages spoken by UCare members: Spanish; Amharic, Somali or other Afro-Asiatic languages; Hmong, Vietnamese, and Chinese.

Cultural Care Connection: A Comprehensive Resource

Culture Care Connection is an online learning and resource center developed by Stratis Health with the support and partnership of UCare. It is designed to support healthcare providers in delivering culturally responsive care. Culture Care Connection offers a wealth of resources, including:

• Language Resources: This section provides patient-facing communication tools and educational materials specifically translated for the threshold languages spoken by a significant portion of UCare members (as defined by U.S. Census data).
• Training Resources: Culture Care Connection offers various training resources for healthcare professionals on effectively providing language services and delivering culturally competent care.
• Culturally Responsive Care: This section provides information, training opportunities, and resources to help providers understand and address the needs of patients from diverse cultural backgrounds.

Additional Resources to Enhance Communication

• Interpreter Services: UCare’s Provider Manual offers a dedicated chapter on Interpreter Services, including information on accessing interpreters, understanding professional standards for interpreters, and effectively working with them during patient interactions.
• Multilingual Health Resources Exchange: This partnership facilitates the exchange of information and resources related to health communication in multiple languages.
• Think Cultural Health: This website, sponsored by the Office of Minority Health, offers healthcare professionals a range of resources, including continuing education opportunities and information on providing culturally and linguistically appropriate services (CLAS).

Finding More Information

For further details, please visit:

• Culturally Congruent Care section in UCare’s Provider Manual
• Cultural Support Resources on UCare® - Policies and Resources webpage