Cotiviti collaboration aims to prevent payment errors and improve the reimbursement process
Sep. 2022Important Notices
"This month, UPMC Health Plan began collaborating with Cotiviti Inc. after its acquisition of Health Management Services’ payment integrity solutions. The collaboration is for the following periodic post-payment reviews of paid medical claims, which are similar to reviews previously conducted by Health Management Services:
- Retrospective Accuracy (RA) reviews. Cotiviti uses data from paid claims to conduct these reviews that help ensure appropriate coding. These reviews do not require additional documentation from the provider.
- Clinical Claim Validation (CCV) reviews. In these cases, Cotiviti reviews medical records to ensure appropriate billing. If a claim is identified for a CCV review, the provider will receive a letter that:
- Identifies the selected the claim(s).
- Requests detailed information on the selected the claim(s), including a required copy of the medical records, if UPMC Health Plan has not already received these medical records. Outlines the response guidelines and time frames.
Recent Announcements
Important announcement – Telehealth submissions
As of October 1, 2025, UPMC Health Plan continues to accept the submission of telehealth claims. Providers may conduct telehealth visits for UPMC Health Plan members in all UPMC Insurance products. UPMC Insurance products include UPMC Advantage group and individual products, UPMC for Life Medicare Advantage plans, UPMC for Kids CHIP plans, UPMC Community HealthChoices, and UPMC for You Medical Assistance plans.Sep. 2025Important Notices
October 2025 UPMC for You and UPMC Community HealthChoices Formulary Update
Effective October 1st, 2025, Xifaxan and Retin-A (cream, gel) will no longer be covered by UPMC for You and UPMC Community HealthChoices due to non-participation in the Medicaid Drug Rebate Program.Sep. 2025Pharmacy Updates
Biosimilar Medication Formulary Updates
Updates to formulary biosimilar medications for denosumab, eculizumab, and ustekinumab productsSep. 2025Pharmacy Updates