Medical Prior Authorization and Physician Forms

Medical Prior Authorization and Physician Forms:

UPMC Health Plan requires a prior authorization request for specific procedures or treatments to determine whether coverage of a request will be approved or denied.

Providers may submit a request for prior authorization to the Clinical Operations/Utilization Management Department, including supporting documentation and the Certificate of Medical Necessity (CMN).

• To submit a request online, please visit Provider OnLine.

We occasionally require additional information when completing a clinical review. If additional information is required, we will notify the requesting provider through Provider OnLine regarding what information is needed.

If the requested information is not received in a timely manner, the request will be denied due to a lack of sufficient information for review. UPMC Health Plan will notify the requesting provider of its prior authorization decision through Provider OnLine.

Providers may contact the Clinical Operations/Utilization Management Department by calling 1-800-425-7800 if they have a question or need instructions on how to submit prior authorizations during system outages. Help is available from 8 a.m. to 4:30 p.m. Monday through Friday.

Peer-to-Peer Discussions:
Providers may request a peer-to-peer discussion with a UPMC Health Plan medical director regarding adverse benefit determinations based on medical necessity. Providers should contact Clinical Operations/Utilization Management at 412-454-2765 Monday through Friday from 8 a.m. to 5 p.m.

Patient Health Guidelines:

• Clinical Guidelines
• Preventive and Immunization Guidelines
• Medical Record Documentation Guidelines
• Utilization Management Clinical Criteria
• Prior Authorization List (Excel)

Physician Forms:

• Autism Treatment Plan
• MCO Shift Care Form
• Self-Audit Overpayment Form
• Personal Designation Form
• CardioMEMS Heart Failure Monitoring System
  • Medical Necessity Form (MNF) for CardioMEMS Heart Failure Monitoring System – MP.PA.103
• Home Accessibility
  • Medical Necessity Form (MNF) for Home Accessibility Durable Medical Equipment – CHC
  • Medical Necessity Form (MNF) for Home Accessibility Durable Medical Equipment – MA
• Long Term Services and Supports (LTSS) Nursing Services for UPMC CHC
  • Medical Necessity Form (MNF) Long Term Services and Support (LTSS) Nursing Services – CHC
• Nutritional Products
  • Medical Necessity Form (MNF) for Nutritional Products
• Obstetrical Needs Assessment
  • Instructions
  • Blank form
  • Example of a completed form
• Out-of-Network Service Requests
  • Medical Necessity Form (MNF) for Out-of-Network Requests
• Parenteral Nutrition
  • Medical Necessity Form (MNF) for Parenteral Nutrition
• Provider Consent Form to File a Fair Hearing on Behalf of a Member
• Provider Consent Form to File a Grievance for a Member
• Provider Consent Form to file a Grievance for a UPMC Community HealthChoices participant
• Private Duty Nursing
  • Medical Necessity Form (MNF) for Private Duty Nursing
  • Tip Sheet for Requesting Authorization of Shift Care Services
  • Concurrent Authorization Request Form
  • Agency Request Form to Transfer Shift Care Hours
  • Shift Care Services Additional Hours Form
• Provider Appeal Forms
  • Expedited Provider Appeal Certification Form
  • Provider Dispute/Appeal Cover Sheet
  • Provider Appeal on Behalf of a Member

Physician Certification Form for Child with Special Needs:

In Pennsylvania, children with certain permanent or temporary disabilities are eligible for a special category of Medical Assistance (MA) called PH95.

• Physician Certification Form and Instructions for Child with Special Needs
• Letter Addressed to Physician from Department