ACA Risk Adjustment Claims Submission Announcement

Jan. 2026Important Notices

Notice: Submit your claims for ACA members

This is a reminder that all network providers must submit outstanding calendar year (CY) 2025 claims for ACA members (Platinum, Gold, Silver, and Bronze plans) no later than April 1, 2026. The U.S. Department of Health and Human Services requires issuers to submit their CY claims to the EDGE server by April 30 every year to provide a complete and accurate picture of each patient’s health status.

Claims adjudicated after the deadline will not be included for EDGE data submission.

You can submit claims through Provider OnLine at upmchealthplan.com/providers/medical. If you have any questions about this matter, please contact Provider Services or your physician account executive.

Recent Announcements

Bridging Smiles and Systems: Collaborative Care for Children with Chronic Conditions

Please join us for a live, CME-accredited and CEU-accredited webinar on May 13 from noon to 1p.m., that will explore the critical connection between oral health and pediatric chronic conditions such as diabetes, asthma, congenital heart disease, and ADHD.
Feb. 2026Education/Webinars

February 2026 UPMC for You and UPMC Community HealthChoices formulary update

Pulmicort Flexhaler has a new distributor, Rubicon Holding. National Drug Codes (NDCs) for Pulmicort Flexhaler from Rubicon Holding are not included in the Medicaid Drug Rebate program and are not covered under the Medicaid Prescription Drug Program. Pulmicort Flexhaler NDCs from the previous manufacturer, H2 Pharma, have been discontinued but may be billed/dispensed until supplies are exhausted.
Feb. 2026Pharmacy Updates

CME Webinar: American Foundation for Suicide Prevention’s ‘Talk Saves Lives’ Program

Please join us on Tuesday, April 28, from noon to 1 p.m. for “Talk Saves Lives: An Introduction to Suicide Prevention.” This live, CME-accredited webinar is the American Foundation for Suicide Prevention’s flagship suicide prevention education program. It covers the scope of this leading cause of death, warning signs and risk factors for suicide, and strategies to prevent it.
Feb. 2026Education/Webinars