UnitedHealthcare Community Plan
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Please select the state where you practice.

You'll find all forms we currently use in the following list.

We're currently reviewing all forms in an effort to make it easier and simpler to work with us, so check back frequently to see what's changed.

IA Health Link

Abortion Necessity Certification Form (PDF 71.34 KB)

Adult HRA Form (PDF 512.53 KB)

Cardiology Prior Authorization QRG (PDF 248.37 KB)

Cardiology Prior Authorization FAQ (PDF 161.31 KB)

Child/Pediatric HRA Form (PDF 568.81 KB)

Consent for Sterilization Form (PDF 33.75 KB)

Critical Incident Reporting Form (PDF 121.77 KB) - 12.7.2015

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

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

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

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

Prior Authorization Request Form (PDF 238.17 KB) – 1.27.2016

Provider Formal Claim Dispute Form – coming soon

Provider Formal Claim Dispute Process – coming soon

Radiology Prior Authorization QRG (PDF 228.03 KB)

Radiology Prior Authorization FAQ (PDF 221.83 KB)

 

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.