UCare prior authorization and notification requirements (2025)
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Lists services that require prior authorization or notification for various UCare health plan lines (Medicare, Medicaid, Individual & Family) and which services are excluded because delegated organizations handle them. Affects providers and delegated organizations contracting with UCare in Minnesota.
No material clinical or coverage changes in this revision.
Authorization criteria by service group
Authorization criteria sets by service group
Services listed below require prior authorization or notification as specified by plan/program.
Service groups
Selected services (require prior authorization or notification)
- Acute inpatient rehabilitative therapy
- Adult Rehabilitative Mental Health Services (ARMHS) — only for listed programs (MSHO, UCare Connect + Medicare, PMAP, MSC+, MinnesotaCare)
- Post-crisis stabilization inpatient treatment for adults — only for listed programs (MSHO, UCare Connect + Medicare, PMAP, MSC+, MinnesotaCare)
- Bariatric surgery (gastric bypass)
- Spine surgery
- Inpatient pediatric treatment — only for listed programs (UCare Connect + Medicare, PMAP, MSC+, MinnesotaCare)
- Cosmetic surgery
- Cranial nerve stimulation (vagus and hypoglossal)
- Durable medical equipment (DME) — rental and purchase
- Early Intensive Developmental and Behavioral Interventions (EIDBI) — only for listed programs (UCare Connect + Medicare, PMAP, MSC+, MinnesotaCare)
- Diagnostic genetic or molecular testing
Additional services (require prior authorization or notification)
- Home-based nursing services (formerly personal care) — only for listed programs (MSHO, UCare Connect + Medicare, UCare Connect)
- Home health visits (skilled nursing and supportive home health services) — only for listed programs (MSHO, UCare Connect + Medicare, UCare Connect)
- Intensive Residential Treatment Services (IRTS) — only for listed programs (MSHO, UCare Connect + Medicare, PMAP, MSC+, MinnesotaCare)
- Inpatient hospitalization
- Long-term acute care (LTAC)
- Care in institutional settings (inpatient facility-based care) — only for listed programs (MSHO, UCare Connect + Medicare, UCare Connect, MSC+)
UCare authorization-required services for 2025
- Personal Care Attendant (PCA) and Consumer Directed Community Supports (CDCS/CFSS) — only for MSHO and MSC+
- Proton beam therapy
- Psychiatric Residential Treatment Facility (PRTF) — only for listed programs (MSHO, UCare Connect + Medicare, PMAP, MSC+, MinnesotaCare)
- Skilled nursing facility (SNF) or skilled beds — only for listed programs (MSHO, UCare Connect + Medicare)
- Spinal cord stimulation
- Outpatient stimulant use disorder treatment — only for listed programs (MSHO, UCare Connect + Medicare, PMAP, MSC+, MinnesotaCare)
- Inpatient stimulant use disorder treatment — only for listed programs (MSHO, UCare Connect + Medicare, PMAP, MSC+, MinnesotaCare)
- Transcranial Magnetic Stimulation (TMS)
- Transplants
- Vascular procedures
- Wheelchairs — rental and purchase
- Wheelchair accessories — rental and purchase
Individual & Family plan (authorization highlights)
- Proton beam therapy
- PRTF (psychiatric residential treatment)
- SNF or skilled beds
- Spinal cord stimulation
- Inpatient substance use disorder treatment
- TMS
- Transplants
- Vascular procedures
- Wheelchairs and wheelchair accessories — rental and purchase
Coding and effective year
Actions providers must take (prior authorization / notification)
Obtain prior authorization/notify UCare for selected high‑acuity services
Providers must obtain prior authorization or notify UCare for the following services: acute inpatient rehabilitative therapy; Adult Rehabilitative Mental Health Services (ARMHS) for listed programs (MSHO, UCare Connect + Medicare, PMAP, MSC+, MinnesotaCare); post‑crisis stabilization inpatient treatment for adults (same listed programs); bariatric (gastric bypass) surgery; spine surgery; inpatient pediatric treatment for listed programs; cosmetic surgery; cranial nerve stimulation (vagus and hypoglossal); durable medical equipment (rental and purchase); Early Intervention for Determined Behavioral Intervention (EIDBI) for listed programs; and diagnostic genetic or molecular testing.
- ARMHS and post‑crisis stabilization inpatient treatment: authorization applies only to specified programs (MSHO, UCare Connect + Medicare, PMAP, MSC+, MinnesotaCare).
- EIDBI and inpatient pediatric treatment: authorization applies to specified programs (UCare Connect + Medicare, PMAP, MSC+, MinnesotaCare).
Authorize additional home‑ and facility‑based services before delivery
Providers must obtain prior authorization or notify UCare for the following additional services: home‑based nursing (personal care previously referenced as private duty nursing) for listed programs; in‑home health visits (nurse visits and home health support) for listed programs; Intensive Residential Treatment Services (IRTS) for listed programs; inpatient hospitalization; long‑term acute care (LTAC); and institutional/guarded care facility stays for listed programs.
- Home‑based nursing and in‑home health visits authorization applies to UCare's MSHO, UCare Connect + Medicare, and UCare Connect programs.
- IRTS, inpatient hospitalization, LTAC, and institutional care authorization applies to the listed programs as specified in the source.
2025 UCare services requiring authorization
For 2025, providers must obtain UCare authorization for these services: personal care assistant (PCA) and Community First Services and Supports (CFSS) for MSHO and MSC+ members; proton beam therapy; psychiatric residential treatment facility (PRTF) services for listed programs; skilled nursing facility (SNF) or skilled beds for listed programs; spinal cord stimulation; outpatient and inpatient stimulant use disorder treatment for listed programs; transcranial magnetic stimulation (TMS); transplants; vascular procedures; wheelchairs and wheelchair accessories (rental and purchase).
- PCA and CFSS authorization applies only to UCare's MSHO and MSC+.
- Many items (PRTF, SNF/skilled beds, stimulant use disorder treatment) are limited to specified programs (MSHO, UCare Connect + Medicare, PMAP, MSC+, MinnesotaCare) — confirm program applicability when submitting requests.
Individual & Family plan authorization requirements (2025)
For UCare Individual & Family plans, providers must obtain prior authorization for a similar set of services including proton beam therapy, PRTF, SNF care, spinal cord stimulation, and inpatient substance use disorder treatment; additionally, TMS, transplants, vascular procedures, wheelchairs and wheelchair accessories require authorization in 2025.
- Verify plan type (Individual & Family) and confirm that authorization requirements match those listed for 2025.
- Contact UCare for plan‑specific authorization rules and the appropriate submission process.
Definitions and delegated responsibilities
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