Prior authorization and notification requirements for UCare plans
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This document lists services that require prior authorization or notification across specified UCare commercial, Medicare, and Medicaid plans and describes auxiliary aids contact information. It affects providers and delegated entities submitting authorizations for members of the listed UCare products.
No material clinical or coverage changes in this revision.
Services Requiring Prior Authorization or Notification
Authorization/notification service lists by product
Services grouped by UCare product that require prior authorization or notification. Each item shows the service or service category and, when specified, the plan(s) to which the requirement applies.
ALL of the following
- Inpatient acute hospitalization
- Adult mental health crisis stabilization services (MSHO, UCare Connect + Medicare, PMAP, MSC+, MinnesotaCare only)
- Adult crisis stabilization (community) (MSHO, UCare Connect + Medicare, PMAP, MSC+, MinnesotaCare only)
- Bariatric surgery (weight-loss surgery)
- Spinal surgery (spine)
- Inpatient pediatric residential psychiatric care (UCare Connect + Medicare, PMAP, MSC+, MinnesotaCare only)
- Cosmetic surgery
- Neurostimulation of cranial nerves (vagus nerve and hypoglossal nerve stimulators)
- Durable medical equipment (DME) — rental and purchase
- Early Intensive Developmental and Behavioral Intervention (EIDBI) (UCare Connect + Medicare, PMAP, MSC+, MinnesotaCare only)
- Genetic and hereditary condition testing
- Home health nursing visits (formerly specialized duty nursing) (MSHO, UCare Connect + Medicare, UCare Connect only)
- Home health care (skilled nurse visits and medically necessary home health assistance) (MSHO, UCare Connect + Medicare, UCare Connect only)
- Intensive Residential Treatment Services (IRTS) (MSHO, UCare Connect + Medicare, PMAP, MSC+, MinnesotaCare only)
- Inpatient psychiatric residential placement
- Long-term acute care (LTAC)
ALL of the following
- Inpatient acute hospitalization
- Spinal surgery (spine)
- Bariatric surgery (weight-loss surgery)
- Durable medical equipment (DME) — rental and purchase
- Psychiatric residential treatment facilities for children (PRTF)
- Intensive Residential Treatment Services (IRTS)
- Long-term acute care (LTAC)
ALL of the following
- SNF admission or bed authorization (UCare's MSHO and UCare Connect + Medicare only)
- Spinal cord stimulation
- Transcranial magnetic stimulation (TMS)
- Prosthetic and orthotic devices — wheelchairs (rental and purchase)
- Wheelchair accessories and supplies (rental and purchase)
- Infusion devices
- Substance use disorder outpatient treatment and community-based treatment services (MSHO, UCare Connect + Medicare, PMAP, MSC+, MinnesotaCare only)
- Radiation therapy — proton beam
- Vascular surgery
- Vaccine products
ALL of the following
- Some items list plan-specific applicability in parentheses — follow the plan-specific notes when submitting authorization or notification requests.
Provider Requirements and Action Items
Medicare/Medicaid‑related plans: prior authorization/notification required
For members of UCare Medicare, MSHO, UCare Connect, PMAP, MSC+ and MinnesotaCare plans, providers must obtain prior authorization or provide notification to UCare for the services listed below; some services are plan‑specific as noted. Authorization is required for inpatient acute hospitalization, bariatric (weight-loss) surgery, spinal (back) surgery, durable medical equipment (DME) rental and purchase, long‑term acute care (LTAC), skilled nursing facility (SNF) admission, home health nursing visits and specialty behavioral health services (e.g., ARMHS, crisis stabilization, IRTS, PRTF) where noted. Providers should follow plan-specific applicability indicated in the list (for example ARMHS, crisis stabilization, EIDBI, home care nursing and EIDBI are limited to the plans called out).
- Inpatient acute hospitalization — prior authorization/notification required.
- Bariatric surgery — prior authorization required.
- Spinal surgery (back surgery) — prior authorization required.
- Durable medical equipment (DME) — rental and purchase require authorization.
- LTAC — prior authorization required.
- SNF admission and skilled nursing services — authorization required (see plan notes).
- Home health nursing visits / home health care — authorization required for specified plans.
- Adult rehabilitative mental health services (ARMHS) and adult crisis stabilization — authorization required for MSHO, UCare Connect + Medicare, PMAP, MSC+ and MinnesotaCare only.
- Early Intervention Developmental and Behavioral Intervention (EIDBI) and Intensive Residential Treatment Services (IRTS) — authorization required for specified plans.
- Partial list; follow plan-specific applicability in the source when submitting authorizations.
Individual & Family plans: prior authorization/notification required
For UCare Individual & Family plans, providers must obtain prior authorization or provide notification for a similar group of services. Examples requiring authorization include inpatient acute hospitalization, spinal/back surgery, bariatric surgery, durable medical equipment (rental and purchase), intensive residential behavioral health treatment (PRTF), IRTS, and LTAC. Providers should check plan applicability when submitting an authorization request.
- Inpatient acute hospitalization — prior authorization/notification required.
- Spinal (back) surgery — prior authorization required.
- Bariatric (weight‑loss) surgery — prior authorization required.
- Durable medical equipment (DME) — rental and purchase require authorization.
- PRTF and IRTS (behavioral health residential services) — authorization required.
- LTAC — prior authorization required.
UCare 2025: new authorization additions
Effective for 2025, UCare added additional authorization requirements for specific services and plans. These include SNF/bed authorization, spinal cord stimulation, transcranial magnetic stimulation (TMS), prosthetic/orthotic devices (wheelchairs and accessories, rental and purchase), infusion devices, certain substance use disorder treatment services, PRTF, and other items listed for specified plans (see plan notes).
- SNF admission or bed authorization (MSHO and UCare Connect + Medicare only).
- Spinal cord stimulation — prior authorization required.
- Transcranial magnetic stimulation (TMS) — prior authorization required.
- Wheelchairs and wheelchair accessories (rental and purchase) — authorization required.
- Infusion devices and prosthetic/orthotic devices — authorization required.
- Substance use disorder outpatient and residential treatment services — authorization required for MSHO, UCare Connect + Medicare, PMAP, MSC+ and MinnesotaCare where noted.
Coding / Code Listings
| No codes listed |
Key Definitions
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