Provider Forms & Documents | UniCare State Indemnity Plan

Provider Reference Sheet

Use this document as a convenient reference for member copays, notification requirements for preapprovals, and selected procedures for pre-review.

Please refer to the applicable member handbook, found in our member materials, for more information on plan benefits, conditions, limitations, and exclusions.

Download Provider Reference Sheet

Precertification Worksheets

Updated July 2020

Find out which procedures require preapproval and how much notice is required.

Note: Check our Provider Reference Sheet for a list of UniCare's precertification requirements and whether a service will be reviewed by Carelon Medical Benefits Management or by UniCare.

Outbound Fax Information Form for Utilization Management (UM) Decision Letters

Use this form to begin receiving UniCare utilization management decision letters for approvals, denials, and requests for information by fax.

Download Outbound Fax Information Form for UM Decision Letters

HealthCare Administrative Solutions (HCAS) Provider Enrollment Form

Use this form to enroll as a UniCare contracted provider. Please complete a separate page for all new providers in the group.

Download HCAS Provider Enrollment Form

Standardized Provider Information Change Form

If you're an existing UniCare contracted provider, use this form to let us know about changes to your practice, such as the names of new providers in your group.

Download Standardized Provider Information Change Form

Member ID Cards

View samples of the member ID cards for all four plans. UniCare ID cards show copay amounts and other plan information.

Provider Forms and Documents