Utilization services provide valuable support

UPMC Health Plan employs a staff of physicians and nurses to serve our network providers with experienced support and decision-making. Our staff uses evidence-based medicine and well-established guidelines when consulting with physicians.

When a physician calls the Health Plan as a result of a utilization management decision, a Health Plan Medical Director will review and discuss the case with the physician.

The Health Plan uses evidence-based policies and guidelines as a part of its decision-making process.

Network physicians can be assured that all final determinations are made by a Medical Director, and only a Medical Director can deny a service. 

Medical Directors utilize various standardized guidelines, such as InterQual criteria, evidence-based medical policy guidelines, and Centers for Medicare & Medicaid Services (CMS) regulatory policies.

Guidelines are reviewed by specialty physicians who are practicing experts in that field and who will be utilizing the same guidelines.

The Health Plan has a Technology Assessment Committee composed of Medical Directors who use evidence-based criteria and feedback from specialty physicians in developing medical policies.

All criteria are reviewed and approved by physicians on our Quality Improvement Committee, which is composed of physicians from the community for various specialties and Health Plan Medical Directors and staff. Also, criteria are reviewed and approved by external agencies, including the Pennsylvania Department of Public Works’ Prior Authorization Review Panel.