UPMC Health Plan's claims processing system allows providers to take advantage of enhanced access to information, including the ability to immediately correct claims that have missing information, incorrect procedure codes, or other errors.
Electronically filed claims may be submitted in the following ways:
Individual claim entry
Individual claim entry, known as Prelog, is available to providers with established Health Plan online accounts. This feature allows direct submission of both professional (HCFA/CMS-1500) and institutional (UB-92) claims via a user-friendly interface, using the Internet's highest level of security to make the process safe and easy. The provider's office can enter claims and verify if they have been accepted and are ready for adjudication. If you choose this option for claims submission and you do not have a Provider OnLine account, complete this form (PDF) to sign up. If you have questions while you are completing the form, contact our Web Support Services at 1-800-937-0438.
Batch file submissions
UPMC Health Plan accepts electronic claims in data file transmissions.
Providers who have existing relationships with clearinghouses such as WebMD (UPMC Health Plan Payer ID: 23281), NDC, and HDS can continue to transmit claims in the format produced by their billing software. These clearinghouses are then responsible for reformatting these claims to meet HIPAA standards and passing the claims on to the Health Plan.
Providers are able to submit claims directly without incurring clearinghouse expenses. Claim files are transmitted using a secure FTP process that does not require data encryption prior to transmission. Providers may use the standard PGP encryption process in addition to the secure FTP, if additional data security is desired. These claims are loaded into batches and immediately posted in preparation for adjudication. Via the Provider OnLine EDI tools, these batches can be viewed in several standard report formats.
In order to submit EDI files directly to the Health Plan, providers must:
- Use billing software that allows the generation of a HIPAA-compliant 837 professional or institutional file
- Have a sample 837 file exported from their billing system containing only UPMC Health Plan claims
- Have a computer with Internet access
- Have the ability to download and install a free Active-X secure FTP add-on,
- Complete testing and become certified with UPMC Health Plan
UPMC Health Plan currently accepts dual provider identifiers. Please submit the National Provider Identifier (NPI), along with the tax ID and the provider ID as assigned by UPMC Health Plan. When care is coordinated, submit the referring provider NPI if available, as well as the name and UPIN. For member identification, submit the member's 11-digit ID number or the government-assigned identifiers for Medicare or Medical Assistance members.
If you are interested in HIPAA-compliant EDI file submission, please refer to the additional set-up documents on this website. You can follow up with additional questions to the HealthPlanEDI@upmc.edu distribution group.