UnitedHealthcare Community Plan
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Provider Forms 

You'll find all forms we currently use in the following list. Check back frequently to see what forms have been updated or changed.

 

UnitedHealthcare Community Plan

Abortion Necessity Certification Form (PDF 71.34 KB)

Adult HRA Form (PDF 600.36 KB) - 3.29.2017

Adult HRA Form Spanish (PDF 551.81 KB) - 8.11.2016

Case Activity Report (PDF 64.06 KB) - 2.22.2016

Child/Pediatric HRA Form (PDF 568.81 KB)

Child/Pediatric HRA Form Spanish (PDF 539.09 KB) - 8.11.2016

Claim Dispute Form (PDF 191.93 KB) – 2.22.2016

Claim Reconsideration Form (PDF 198.87 KB) – 2.22.2016

Claim for Targeted Medical Care Form - 4.01.2016

Consent for Sterilization Form (PDF 33.75 KB)

Consumer-Directed Attendant Care (CDAC) Daily Service Record (PDF 85.85 KB) - 5.15.2017

Critical Incident Reporting Form (effective January 1, 2017) (PDF 987.64 KB) - 12.19.2016 

Election of Hospice Benefit (PDF 14.79 KB) - 2.23.2016

Entity/Group Provider Disclosure of Ownership and Control of Interest Form (PDF 594.98 KB)

Health Homes Member Enrollment, Disenrollment Form (PDF 183.2 KB) - 10.3.2016

Individual Provider Disclosure of Ownership and Control of Interest Form (PDF 308 KB)

Medicaid Prenatal Risk Assessment (PDF 171.45 KB) - 3.2.2016

Member Appeal Form (English) (PDF 51.01 KB) – 12.20.2015

Member Appeal Form (Espanol) (PDF 52.45 KB) – 12.20.2015

PCP Change Form (PDF 65.23 KB) - hawk-i

PCP Change Form - IA Health Link (PDF 60.92 KB) - 4.15.2016

PCP Discharge Form - hawk-i (PDF 124.86 KB) - 8.8.2016 

PCP Discharge Form - IA Health Link (PDF 495.86 KB) - 8.8.2016

Person-Centered Treatment Plan Form (DOCX 222.85 KB) - 12.19.2016

Prior Authorization Request Form - Acute Medical  (PDF 139.44 KB) – 5.10.2016

Prior Authorization Request Form - Cardiology/Radiology - 5.16.2016

Revocation of Medicaid Hospice Benefit (PDF 10.33 KB) - 2.23.2016

 

Medical Injectables

Specialty pharmacy medications covered on the Medical Benefit may be provided through a variety of channels – home infusion provider, outpatient facility, physician, or specialty pharmacy.

For physicians who do not want to buy-and-bill a specialty pharmacy medication that is covered on the Medical Benefit, they may choose to source it through a network specialty pharmacy: 

Network Specialty Pharmacy

Phone Number

OptumRx

866-218-7398

BioScrip (offers nursing services)

 * also a National Home Infusion Provider for Medical Benefit medications

866-788-7710

The following specialty pharmacies may also provide specific categories of specialty pharmacy medications: 

Network Specialty Pharmacy

Medication Category

Phone Number

Accredo (offers nursing services)

Enzyme Deficiency

Gaucher’s Disease

Immune Globulin

Pulmonary Hypertension

888-296-4513

Walgreens Infusion Services (offers nursing services)

Cardiovascular/Heart Failure

Enzyme Deficiency

Gaucher’s Disease

Hemophilia

Immune Globulin

866-827-8203

CVS Caremark Specialty Pharmacy

Enzyme Deficiency

Gaucher’s Disease

Pulmonary Hypertension

800-237-2767

Coverage of the requested drug is dependent on the member’s benefits, and the availability of a specific drug from a network specialty pharmacy may vary.

The Specialty Pharmacy can deliver the medication to the healthcare practitioner’s office or another site (ex. patient’s home) upon request, and the Specialty Pharmacy will bill the patient’s health plan directly.

 

Utilization Guidelines

Utilization Guidelines, such as Milliman Utilization Care Guidelines, may be used as part of the prior authorization process. You may request a copy of a specific guideline by calling 1-888-650-3462.

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