Utilization Management Criteria

UPMC Health Plan uses nationally recognized criteria, as well as Health Plan medical policies, to determine utilization management decisions. All criteria are reviewed and approved by physicians on the Quality Improvement Committee. UPMC Health Plan is currently using the following licensed proprietary criteria:

2007 InterQual

• Care Planning Criteria — Procedures
• Level of Care Criteria — Acute Adult
• Level of Care Criteria — Acute Pediatric
• Level of Care Criteria — Rehabilitation
• Level of Care Criteria — Subacute and SNF
• Level of Care Criteria — Long-Term Acute Care
• Level of Care Criteria — Behavioral Health
• Imaging and Procedures

The Medical Management Department applies criteria and guidelines on a case by case basis, taking into account each individual's unique circumstances. All denials of coverage that are based on medical necessity are made by a Health Plan Medical Director. A member or provider can obtain the criteria used for a specific review decision by notifying Medical Management at:

Medical Management Department
UPMC Health Plan
One Chatham Center
112 Washington Place
Pittsburgh, PA 15219

UPMC Health Plan policy ensures that a Medical Director is available to discuss utilization review decisions with the treating practitioner. If you would like to discuss a utilization decision that is based on medical necessity with a physician reviewer, please call the Medical Management Department at 1-800-425-7800. A nurse reviewer will arrange for you to speak with a Medical Director. All calls must be initiated within two business days from notification of the denial.