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
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.
CPAP and BPAP (for Medicare members only)
DME: apnea, cardiac, uterine and oximetry monitors
DME: compression, medication, feeding, insulin and suction pumps
DME: hospital bed/special mattress
DME: stimulator/CPM machine/TENS unit
DME: General Precertification
Home Health Care
Hyperbaric Oxygen Therapy
Intensity Modulated Radiation Therapy (IMRT) (AIM review)
Meniscal Allograft Transplant
MRI of the Knee
Skilled Nursing Facility
Standardized Prior Authorization Form
This form was developed by the Massachusetts Health Care Administrative Simplification Collaborative in May 2012. You can use the prior authorization form to submit a prior authorization request to UniCare for review, but you will still need to submit the appropriate UniCare precertification worksheet to provide the necessary clinical documentation to support the request. (UniCare does not require providers to submit the standardized prior authorization form - only the appropriate UniCare precertification worksheet.)
Download Standardized Prior Authorization Form
Outbound Fax Information Form forUtilization 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 InformationChange 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.