Clinical documentation required for medical policy prior authorizations
As you know, UPMC Health Plan requires certain clinical documentation/notes in support of a request for prior authorization for the listed procedures below in accordance with its established policies and procedures, in addition to CMS requirements that medical record documentation must support the medical necessity of the services requested.
Beginning on June 26, 2026, our system will be updated to confirm the submission of such information before an authorization will be provided for the following UPMC Health Plan policies.
- MP PA 142 – Radiation therapy, external beam (EBRT)
- MP.PA.143 – Radiation Therapy – SRS and SBRT
- MP PA 146 – Laparoscopic cholecystectomy
- MP.PA.144 – Sleep Medicine – Sleep Study
- MP.PA.135 – Lumbar Spinal decompression
- MP.PA. 137 – Cardiac Devices, Implantable Defibrillator and Pacemaker
As such, please be sure to submit all supporting clinical documentation at the time of your request in accordance with the applicable medical prior authorization policy to avoid delays or denials when reviewing your request.
To submit an authorization, please log in to the secure Provider OnLine website and select Auth Entry/Inquiry from the left-hand navigation to submit the authorization. Clinical documentation will need to be uploaded during the online submission process.
If you have any questions about this update, please contact your provider network liaison. You can also call Provider Services at 1-866-918-1595.
Providers are responsible for appropriate billing of services. An authorization is not a guarantee of payment for services rendered.