Appointment of Representative

You can appoint a person to act on your behalf if any of the following situations apply to you. Click on the links below to learn more.

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Medical Coverage Decision

You can ask our plan to provide a medical coverage decision if you are in any of the following situations:
  • If you are not getting certain medical care you want, and you believe that this care is covered by our plan.
  • Our plan will not approve the medical care your doctor or other medical provider wants to give you, and you believe that this care is covered by the plan.
  • You are being told that coverage for certain medical care you have been getting that we previously approved will be reduced or stopped, and you believe that reducing or stopping this care could harm your health.
Please refer to your Evidence of Coverage for complete details. You can access your Evidence of Coverage online by clicking here and selecting your plan type.

If you would like to appoint a person to act in your behalf, print the form and complete the required fields. Fax or mail the completed form to us. We must receive this form, an equivalent written notice, or a photocopy of an original form in order to process your request. This document is only valid for one year after the date of the member’s signature for the request. Each time you submit a request you must fill out a new Appointment of Representative form, an equivalent notice, or a photocopy of an original form.

Fax: 412-454-2057
Mail: UPMC for Life
Clinical Operations, 11th Floor
600 Grant Street
Pittsburgh, PA 15219

Appointment of Representative Form

Medical Claim Reimbursement

You can request a medical claim reimbursement if you are a UPMC for Life member and have paid out-of-pocket for covered medical services. If you would like to appoint a person to act on your behalf, print the form below, complete the required fields, and fax or mail it to us. We must receive this form, an equivalent written notice, or a photocopy of an original form in order to process your request. This document is only valid for one year after the date of the member’s signature for the request. Each time you submit a request you must fill out a new Appointment of Representative form, an equivalent notice, or a photocopy of an original form. If you have any questions, please call our Member Services Department at 1-877-539-3080, from 8 a.m. to 8 p.m., seven days a week.* TTY users should call 711.*

Fax: 412-454-8519
Mail: UPMC Health Plan/UPMC Health Benefits
Claims Department
PO Box 2999
Pittsburgh, PA 15230

Appointment of Representative Form

Vision Claim Reimbursement

If you have paid out-of-pocket for seeing a non-network vision provider, you can request to be reimbursed up to the vision allowance amount of your plan. See your Summary of Benefits or Evidence of Coverage to confirm your routine vision allowance amount. You can access these documents online by clicking here and selecting your plan type.

If you would like to appoint a person to act on your behalf, print the form below, complete the required fields, and fax or mail it to us. We must receive this form, an equivalent written notice, or a photocopy of an original form in order to process your request. This document is only valid for one year after the date of the member’s signature for the request. Each time you submit a request you must fill out a new Appointment of Representative form, an equivalent notice, or a photocopy of an original form. If you have any questions, please call our Member Services Department at 1-877-539-3080, from 8 a.m. to 8 p.m., seven days a week.* TTY users should call 711.

Fax: 412-454-8519
Mail: UPMC Health Plan/UPMC Health Benefits
Claims Department
PO Box 2999
Pittsburgh, PA 15230

Appointment of Representative Form

Medicare Prescription Drug Determination/Exception

UPMC for Life members can request a coverage determination/exception for a Part D prescription drug. Click here to view the types of coverage determination requests.

If you would like to appoint a person to act on your behalf, print the form below, complete the required fields, and fax or mail it to us. We must receive this form, an equivalent written notice, or a photocopy of an original form in order to process your request. This document is only valid for one year after the date of the member’s signature for the request. Each time you submit a request you must fill out a new Appointment of Representative form, an equivalent notice, or a photocopy of an original form. If you have any questions, please call our Member Services Department at 1-877-539-3080, from 8 a.m. to 8 p.m., seven days a week.* TTY users should call 711.

Fax: 412-454-7722
Mail: UPMC Health Plan Pharmacy Department
U.S. Steel Tower, 12th Floor
600 Grant Street
Pittsburgh, PA 15219

Appointment of Representative Form

Redetermination (Appeal) Request

If UPMC for Life denied your request for coverage of (or payment for) a prescription drug, you have the right to ask us for a redetermination (appeal) of our decision.

If you would like to appoint a person to act on your behalf, print the form below, complete the required fields, and fax or mail it to us. We must receive this form, an equivalent written notice, or a photocopy of an original form in order to process your request. This document is only valid for one year after the date of the member’s signature for the request. Each time you submit a request you must fill out a new Appointment of Representative form, an equivalent notice, or a photocopy of an original form. If you have any questions, please call our Member Services Department at 1-877-539-3080, from 8 a.m. to 8 p.m., seven days a week.* TTY users should call 711.

Fax: 412-454-7920
Mail: UPMC Health Plan
ATTN: Appeals and Grievances
PO BOX 2939
Pittsburgh, PA 15230-2939

Appointment of Representative Form

Pharmacy Claim Reimbursement

UPMC for Life members can apply for reimbursement for Part D prescription drugs. View your plan’s Evidence of Coverage to learn more about when to ask us for reimbursement. You can access your Evidence of Coverage online by clicking here and selecting your plan type.

If you would like to appoint a person to act on your behalf, print the form below, complete the required fields, and fax or mail it to us. We must receive this form, an equivalent written notice, or a photocopy of an original form in order to process your request. This document is only valid for one year after the date of the member’s signature for the request. Each time you submit a request you must fill out a new Appointment of Representative form, an equivalent notice, or a photocopy of an original form. If you have any questions, please call our Member Services Department at 1-877-539-3080, from 8 a.m. to 8 p.m., seven days a week.* TTY users should call 711.

Fax: 412-454-7722
Mail: UPMC Health Plan Pharmacy Services Department
U.S. Steel Tower, 12th Floor
600 Grant Street
Pittsburgh, PA 15219

Appointment of Representative Form

Filing an Appeal or Grievance

UPMC for Life works hard to improve the quality of care and service that you get as a member. Let us know right away if you have questions or problems with covered services or the care you receive. You can call our Member Services Department at 1-877-539-3080 seven days a week from 8 a.m. to 8 p.m.* TTY users should call 711.

If you would like to file an appeal or grievance on behalf of the member, you and the member must complete the Appointment of Representative form below. Print the form below, complete the required fields, and fax or mail it to us. We must receive this form, an equivalent written notice, or a photocopy of an original form in order to process your request. This document is only valid for one year after the date of the member’s signature for the request. Each time you submit a request you must fill out a new Appointment of Representative form, an equivalent notice, or a photocopy of an original form. If you have any questions, please call our Member Services Department at 1-877-539-3080, from 8 a.m. to 8 p.m., seven days a week.* TTY users should call 711.

Fax: 412-454-7920
Mail: UPMC for Life
PO BOX 2939
Pittsburgh, PA 15230-2939

Appointment of Representative Form

Reinstatement Request for Non-Payment of Premium

A UPMC for Life member who has been disenrolled for non-payment of plan premiums can request to be reinstated by calling our Member Services Department at 1-877-539-3080, seven days a week from 8 a.m. to 8 p.m.* TTY users should call 711.

If you would like to request reinstatement on behalf of the member, you and the member must complete the Appointment of Representative form below. Print the form below, complete the required fields, and fax or mail it to us. We must receive this form, an equivalent written notice, or a photocopy of an original form in order to process your request. This document is only valid for one year after the date of the member’s signature for the request. Each time you submit a request you must fill out a new Appointment of Representative form, an equivalent notice, or a photocopy of an original form. If you have any questions, please call our Member Services Department at 1-877-539-3080, from 8 a.m. to 8 p.m., seven days a week.* TTY users should call 711.

Fax: 412-454-7520
Mail: UPMC for Life
PO BOX 2987
Pittsburgh, PA 15230-2987

Appointment of Representative Form

If you have any questions, please call our Member Services Department at 1-877-539-3080, from 8 a.m. to 8 p.m., seven days a week.* TTY users should call 711.

This information is not a complete description of benefits. Call 1-866-405-8762 (TTY: 711) for more information. Out-of-network/non-contracted providers are under no obligation to treat UPMC for Life members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services. Other physicians/providers are available in the UPMC for Life network.

This information is available for free in other languages. Please call our customer service number at 1-877-539-3080 (TTY: 711). We are available October 1 through March 31, seven days a week from 8 a.m. to 8 p.m. From April 1 through September 30, we are available Monday through Friday from 8 a.m. to 8 p.m. and Saturday from 8 a.m. to 3 p.m.

UPMC for Life has a contract with Medicare to provide HMO, HMO SNP, and PPO plans. The HMO SNP plan has a contract with the PA State Medical Assistance program. Enrollment in UPMC for Life depends on contract renewal. UPMC for Life is a product of and operated by UPMC Health Plan Inc., UPMC Health Network Inc., UPMC Health Benefits Inc., and UPMC for You Inc.

Tivity Health, SilverSneakers, SilverSneakers FLEX and SilverSneakers BOOM are registered trademarks or trademarks of Tivity Health, Inc. and/or its subsidiaries and/or affiliates in the USA and/or other countries. © 2018. All rights reserved

*Our hours of operation change twice a year.

You can call us:

October 1 through March 31:
seven days a week from 8 a.m. to 8 p.m.

April 1 through September 30:
Monday through Friday: 8 a.m. to 8 p.m.
Saturday: 8 a.m. to 3 p.m.

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Last Updated: 10/01/2018
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