Obtain PA for non‑emergent fixed‑wing air ambulance

Prior authorization is required prior to non‑emergent fixed‑wing air ambulance transport; emergent air transport does not require authorization.

Obtain PA before lumbar/SI fusion and related spine procedures

Prior authorization is required prior to lumbar spinal fusion, sacroiliac joint fusion, and related spine procedures except for listed emergency indications.

• Emergency indications that do not require PA include trauma, acute transverse myelopathy, tumors, and cervical/thoracic back surgery.

Obtain PA for bariatric (gastric bypass) surgery

Prior authorization is required prior to bariatric (gastric bypass) surgery.

Obtain PA for cranial nerve stimulation (VNS/HNS)

Prior authorization is required prior to cranial nerve stimulation procedures, including vagus and hypoglossal nerve stimulation; mental‑health related VNS requests should be sent to the Mental Health and Substance Use Disorders fax line per the policy.

Obtain PA for DME deliveries; authorize E1399 > $1,500

Prior authorization is required before delivery or dispensing of DME items that require authorization; miscellaneous HCPCS code E1399 requires authorization when billed charges exceed $1,500.

• UCare may determine rental versus purchase; repair/replacement of rental equipment is the provider's responsibility.

Obtain PA for EIDBI services

Prior authorization is required prior to Early Intensive Developmental and Behavioral Intervention (EIDBI) services.

Obtain PA for formula/nutritional services (unless via feeding tube)

Prior authorization is required prior to formula or nutritional services; authorization is not required if the formula is administered through a feeding tube.

Obtain PA for listed genetic/molecular diagnostic tests; Carelon delegation 7/1/25

Prior authorization is required prior to ordering specified genetic or molecular diagnostic tests for the listed cancers. Genetic testing is delegated to Carelon as of 7/1/25—refer to the Carelon provider portal for authorizations after that date.

• Applies to tests for breast, ovarian, colorectal (excluding fecal DNA), pancreatic, prostate cancer and to cancer panels.

Confirm PA requirement for EIDBI

Prior authorization is required prior to EIDBI services (duplicate listing confirming requirement).

Confirm PA for formula/nutritional services

Prior authorization is required for formula or nutritional services (authorization not required if administered via feeding tube).

Genetic/molecular diagnostic test PA (Carelon delegation 7/1/25)

Prior authorization is required for the listed genetic or molecular diagnostic tests; beginning 7/1/25 these authorizations are delegated to Carelon—use the Carelon portal after that date.

Notify/obtain PA for home health, home care nursing; PA before first home care nursing visit

Providers must notify or obtain authorization for home health skilled nurse visits, home health aide services, and home care nursing per program specifics; home care nursing requires prior authorization prior to the first visit.

• For CADI waiver home health services, contact the CADI case manager who must submit DHS‑5841‑ENG to UCare prior to the first date of service.

Obtain PA for IRTS when treatment >90 days

Treatment in Intensive Residential Treatment Services (IRTS) exceeding 90 days requires authorization; readmission within 15 days counts toward the 90‑day total.

Obtain PA before LTAC admission; concurrent review for extensions

Prior authorization is required prior to admission for Long‑Term Acute Care (LTAC); concurrent review is required for additional days and a discharge summary must be sent upon discharge.

Obtain PA for microprocessor lower limb prostheses

Prior authorization is required prior to service for microprocessor‑controlled lower limb prostheses.

Obtain PA and complete in‑person assessment for PCA/CFSS

Prior authorization is required for Personal Care Assistant (PCA) and Community First Services and Supports (CFSS); an in‑person assessment by a UCare care coordinator, waiver case manager, or contracted agency is required before approval.

• Note: PCA/CFSS are not a covered benefit through UCare Connect + Medicare and may instead be covered by Medicaid Fee‑for‑Service—contact the member's county.

Obtain PA for Proton Beam Therapy

Prior authorization is required before Proton Beam Therapy services.

Obtain PA for spinal cord stimulation trial and permanent placement

Prior authorization is required prior to trial and prior to permanent placement for spinal cord stimulation.

Obtain PA when SUD outpatient care exceeds daily/weekly hour limits

If Substance Use Disorder outpatient treatment exceeds six hours in a day or 30 hours in a seven‑day rolling span, prior authorization is required; authorizations may be issued for up to 28 days.

• Hours are calculated using a rolling seven‑day time span.

Obtain PA for TMS

Prior authorization is required for Transcranial Magnetic Stimulation (TMS) prior to service.

Obtain PA for transplant evaluation/listing; notify within 24 hours of transplant admission

Prior authorization is required prior to evaluation or listing for the specified transplant types; notify UCare within 24 hours of admission for the transplant procedure.

• PA required for evaluation and listing; notification within 24 hours is required for transplant procedure admissions.

Obtain PA for vein procedures

Prior authorization is required prior to vein procedures.

Obtain PA for wheelchair accessories, rentals, and purchases; authorize K0108/K0669 > $1,500

Prior authorization is required before delivering or dispensing wheelchair accessories, rentals, or purchases for items that require authorization; miscellaneous codes K0108 and K0669 require authorization if billed charges exceed $1,500, and all rental months must be authorized.

• UCare may determine rental versus purchase and may require authorization prior to purchase of K0005‑K0007 and E1161 and all power‑operated vehicles/power wheelchairs.

PA and coverage note for PCA/CFSS (in‑person assessment required)

PCA and CFSS services require prior authorization and an in‑person assessment; PCA/CFSS may not be covered through UCare Connect + Medicare and may be covered by Medicaid FFS—contact the member's county.

Follow Medical Drug Policy library for injectable drug PA and step therapy

Medical injectable drugs and other medical drug policies that require prior authorization are listed in the Medical Drug Policy library; step therapy specifics are contained in those respective policies.

Apply InterQual and Medicare NCD/LCD criteria for genetic testing PA

Genetic testing authorizations and medical necessity criteria will follow the appropriate InterQual subsets and Medicare NCD/LCD as applicable; the specific criteria applied depends on the requested test.

Submit completed request form with supporting clinical documentation

Complete the appropriate authorization request form and submit it with supporting clinical documentation by fax or email to UCare using the return information on each form.

Notify within 24 hours of inpatient admission (if not in EAS) and send discharge summary within 72 hours

For inpatient admissions, notify UCare within 24 hours if you are not enrolled in the UCare Encounter Alert System (EAS), and send the discharge summary within 72 hours of discharge.

Send discharge summaries for LTAC, PRTF, SNF/Swing Bed, and SUD Residential; concurrent review for extensions

Discharge summaries are required to be sent upon discharge for LTAC, PRTF, SNF/Swing Bed, and Substance Use Disorder Residential Treatment; concurrent review is required for additional days.

Contact CADI case manager and ensure DHS‑5841‑ENG submission before CADI home health services

For CADI waiver home health services, providers must contact the CADI case manager who is required to submit DHS‑5841‑ENG to UCare; notification is required prior to the first date of service within the member's CADI waiver approval span.

Risk of denial if required PA is not obtained in advance

Failing to obtain a required prior authorization in advance may result in a denied claim.

Authorize E1399 when billed charges > $1,500 to avoid denial

DME miscellaneous code E1399 requires authorization when billed charges exceed $1,500; failure to obtain authorization for such charges may risk claim denial.

Notify within 24 hours of nursing facility admission and report RUGS changes/transfers/discharge

Notify UCare within 24 hours of Nursing Facility admission and update UCare upon Minnesota RUGS changes, facility transfers, or discharge; failure to do so may result in non‑compliance with notification requirements.

Notify within 24 hours of SNF/Swing Bed admission and provide concurrent review/discharge summary

Notify UCare within 24 hours of Skilled Nursing Facility (SNF) or Swing Bed admission and provide concurrent review and a discharge summary as required; failure to notify or provide required concurrent review/discharge summary may result in non‑compliance.