1. Download Contract Application Forms All types of suppliers must complete the following forms: UCare Contract Admission Form (XLS) Site/Practitioner List (XLS) Property Disclosure Form (PDF) Supplier Directory and Subdirectory Questionnaire (PDF) W-9 (PDF) Certificate of Insurance (COI): You must contact your insurance company for copies. Additional Forms for Medicare Certified Providers: FDR Certification (PDF) FDR Compliance Program Requirements (PDF) Additional Forms for Mental Health Providers: Behavioral Health Survey (XLS) Additional Forms for Transportation Service Providers: Current MNDOT Vehicle Certification: You will need a copy of your current Minnesota Department of Minnesota Vehicle Certification Transportation (MNDOT). 2. Attach all required contract application documents to an email and send them to providerapp@ucare.org. 3. If you have any questions regarding the contract application, please send an email to providerapp@ucare.org. Important Notes: This online tool allows UCare contract providers to view information stored with UCare and make changes as needed. Examples of changes that can be made include: If you are having trouble downloading contract forms, please send an email to providerapp@ucare.org with the subject line “Difficulty downloading forms”. UCare requires that all suppliers under contract with the National Supplier Identifier (NPI) or the Minnesota Unique Supplier Identifier (UMPI) be registered with the Minnesota Department of Human Services.

Registration information can be found on the MHCP Registered Suppliers page under “MHCP Supplier Requirements”. If you have any questions about the registration process or other questions for DHS, please call the DHS Information Office at 651-431-2000. You will not be able to see members until the effective date of the contract. The effective date of the contract is usually determined by UCare once the signed contract has been concluded by the supplier. Providing services to uCare members prior to entering into a contract may result in the rejection of claims. For providers who also need credentials, providing services to UCare members before they are both contracted and certified may result in claims being denied. Please note that each practitioner in your practice has their own approval date. This data may vary from practitioner to practitioner, even if it is part of the same practice. The date of approval of credentials with UCare cannot be changed retroactively or from the date indicated in the UCare approval letter. Services provided to Members prior to this approval date and the date of entry into force of the Agreement may result in the rejection of claims. Note: This application cannot be used to add new locations or changes to the facility or location, new practitioners, non-accredited practitioners, unless otherwise specified*.

Use the correct form in the drawers below to make these types of changes. * Specialties from non-recognized providers: audiologists, certified registered nurse anesthesiologists (ARNC), nutrition, occupational therapists, physiotherapists, speech-language pathologists, anesthesiology, hospital physicians (excluding hospital psychiatrists or hospital physicians) and radiologists. | Log in to the MN Uniform Practitioner Change Form user manual for non-online use. Send to: credentialinginfo@ucare.org or fax: 612-884-2184 If you are contracting with a third-party invoice issuer to call UCare on your behalf, we need a signed confirmation form that gives UCare permission to share information. Please use the form below to provide this information. Supplier notification / modification / update / termination Third party agreement Gantry data configuration (Portico employees only) Incomplete forms will be returned without processing. Please allow 30 calendar days until your application is completed. To check status, please contact the UCare Supplier Support Center at 612-676-3300 or toll-free at 1-888-531-1493.

Join our network FDR Attestation FDR Compliance Program Requirements Site/Practitioner List Provider Directory & Subdirectory Questionnaire UCare Contract Intake Form W-9 Incomplete forms will be returned without processing. Please allow 30 calendar days until your application is completed. You will receive a letter informing you of the completion. To check status, please contact the UCare Supplier Support Center at 612-676-3300 or toll-free at 1-888-531-1493. Personal Care Attendant Personal Care Attendant (BCP) Form Instructions ADD PCA UMPI Add a FORM PCA UMPI Amendment Form PCA UMPI ElderLy Waiver Form To be included in our claims processing system, you must complete the Form Add a configuration or location | Instructions To update your information, complete the appropriate form below: Change or update your Tax Investment Identification Number, legal name, address, NPI/UMPI | Delete an organization or close a | site statements Interpreter Interpreter Instructions – Add, Edit, Delete Transport NovusMED users – Add, remove, change NovusMED IP address – Add, remove providers who have logged out or are not enrolled in Medicare may not provide services to members enrolled in UCare Medicare plans. In addition, UCare follows the eligibility and billing policies of CMS and MHCP to determine service coverage. Providers eligible for Medicare coverage may opt out or not enroll in Medicare. However, for dual members, UCare does not reimburse services covered by Medicare but not billed because the provider has chosen not to enroll in Medicare. For more information on opt-out service providers, see the MN Ministry of Human Resources` Social Service Providers Manual to review the requirements of Medicare and other insurance companies. If a member has other primary insurance for UCare, it is the provider`s responsibility to charge all “TPL” liability payers and receive payment to the fullest extent possible prior to UCare billing. . .

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