Services Requiring Prior Authorization or Notification
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Lists medical services and items that require prior authorization or notification for specified UCare health plans in Minnesota; affects providers and facilities submitting authorization requests for members of those plans.
No material clinical or coverage changes in this revision.
Services Requiring Authorization or Notification
Authorization requirement (plan-specific lists)
Covered when prior authorization or notification is obtained per the plan-specific lists below.
See plan-specific lists below for which services require authorization
Plans and plan-specific lists
- UCare Medicare, EssentiaCare, MSHO, UCare Connect + Medicare, UCare Connect, PMAP, MSC+, MinnesotaCare: Services requiring authorization or notification for these plans include: inpatient rehabilitation for acute conditions; adult mental health rehabilitation services (ARMHS) (MSHO, UCare Connect + Medicare, PMAP, MSC+, MinnesotaCare only); adult crisis stabilization services in specialized facilities (MSHO, UCare Connect + Medicare, PMAP, MSC+, MinnesotaCare only); bariatric surgery (gastric bypass); spine surgery; treatment for children in specialty facilities (UCare Connect + Medicare, PMAP, MSC+, MinnesotaCare only); cosmetic procedures; cranial nerve stimulation (vagus and hypoglossal nerve stimulation); durable medical equipment (DME) rental and purchase; early intensive developmental and behavioral intervention (EIDBI) (UCare Connect + Medicare, PMAP, MSC+, MinnesotaCare only); genetic or molecular diagnostic tests; private duty nursing (formerly Private Duty Nursing) (MSHO, UCare Connect + Medicare, UCare Connect only); home health medical care (qualified nurse and home health aide visits) (MSHO, UCare Connect + Medicare, UCare Connect only); and intensive residential treatment services (IRTS).
Source: plan-specific list
- UCare's MSHO, UCare Connect + Medicare, PMAP, MSC+ and MinnesotaCare (2025 list): Additional services requiring authorization in 2025 for these plans include: inpatient hospitalization; long-term acute care (LTAC); placement in a skilled nursing facility (SNF) or nursing facility (as specified); personal care assistant (PCA) and community support services (CFSS) (MSHO and MSC+ only); proton beam therapy; psychiatric residential treatment facilities (PRTF) (MSHO, UCare Connect + Medicare, PMAP, MSC+, MinnesotaCare only); SNF or swing-bed post-acute transitions (MSHO and UCare Connect + Medicare only); spinal cord stimulation; outpatient substance use disorder treatment (MSHO, UCare Connect + Medicare, PMAP, MSC+, MinnesotaCare only); residential substance use disorder treatment (MSHO, UCare Connect + Medicare, PMAP, MSC+, MinnesotaCare only); transcranial magnetic stimulation (TMS); transplantation; venous procedures; power/manual wheelchair rental and purchase; and wheelchair accessories (rental and purchase).
Source: 2025 authorization list
- UCare Individual & Family and UCare Individual & Family with M Health Fairview: Services requiring authorization or notification for these individual plans include: inpatient rehabilitation for acute conditions; adult crisis stabilization services in specialized facilities; spine surgery; bariatric surgery (gastric bypass); treatment for children in specialty facilities; cosmetic procedures; cranial nerve stimulation (vagus and hypoglossal); DME (rental and purchase); genetic or molecular diagnostic tests (e.g., cancer panels); inpatient hospitalization; IRTS; LTAC; proton beam therapy; PRTF; SNF or specified post-acute transitions; spinal cord stimulation; residential substance use disorder treatment; TMS; transplantation; venous procedures; power/manual wheelchairs (rental and purchase); and wheelchair accessories (rental and purchase).
Source: individual plan list
Delegated services excluded from these lists
- Delegated items: Manual therapy services; dental services; pharmacy services.
These are managed via delegated organizations and are excluded from the lists requiring authorization
Providers must verify member plan and follow plan-specific authorization procedures
UCare delegates authorization management for certain service categories to contracted organizations; accordingly, these services are not included in the lists of services that require prior authorization or notification under this policy. Specifically, the excluded categories are: manual therapy services, dental services, and pharmacy services. These exclusions apply across the UCare plan lines shown in the source (including Medicare, EssentiaCare, MSHO, UCare Connect, PMAP, MSC+, MinnesotaCare, and UCare Individual & Family plans), where UCare works with delegated organizations to handle authorizations for those service types.
What Providers Must Do
Prior authorization/notification required for listed services
Prior authorization or advance notification is required for a defined list of services for members of specified UCare plans (see plan lists). Providers must obtain authorization or submit the required notification before delivering the listed services when indicated by the member's plan enrollment.
- Applies to UCare Medicare, EssentiaCare, UCare MSHO, UCare Connect + Medicare, UCare Connect, PMAP, MSC+, and MinnesotaCare (plan-specific lists differ).
- See the policy's service lists for items requiring prior authorization/notification (examples include inpatient rehabilitation for acute conditions, bariatric surgery, spine surgery, DME, transplant, proton therapy, and many others).
- Some services are listed only for certain plan groups (the 2025 list applies to MSHO, UCare Connect + Medicare, PMAP, MSC+ and MinnesotaCare).
Follow delegated-organization workflows for excluded services
Providers must follow the plan-specific authorization pathways UCare uses with delegated organizations: certain services (manual therapy, dental, and pharmacy services) are managed by delegated entities and therefore are excluded from this central authorization list.
- UCare works with delegated organizations for manual therapy services, dental services, and pharmacy — these are not included in the authorization-required lists.
Auxiliary aids and services available at no charge
UCare provides auxiliary aids and services (for example, qualified interpreters and information in accessible formats) at no charge to assist with communications related to authorizations and care.
- To request auxiliary aids or services, contact UCare at 612-676-3200 or 1-800-203-7225 (voice); TTY: 612-676-6810 or 1-800-688-2534.
Denial risk if authorization/notification is not obtained
Failure to obtain required prior authorization or to provide required notification for listed services may result in claim denial or the service being deemed non‑covered under plan rules.
- Examples of services with denial risk if authorization/notification is not obtained include inpatient rehabilitation for acute conditions, bariatric surgery, spine surgery, and DME purchases.
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