Pause in Prior Authorization Policies
On April 1, 2025, we announced that UPMC Health Plan would start requiring prior authorization for certain services. Please note that we are delaying or changing the implementation of prior authorization for some of these services, as described below.
For policy MP.PA.144 Sleep Medicine – Sleep Study, UPMC Health Plan will no longer require the prior authorization requirement for certain codes, effective May 1.
The affected procedures and associated procedure codes are 95800, 95801, 95805, 98506, G0398, G0399, G0400.
Effective May 1, UPMC Health Plan is suspending the prior authorization requirement for the following policies until June 1, 2025:
- MP.PA.143 (Radiation Therapy - SRS and SBRT)
- MP.PA.139 (Brachytherapy)
- MP.PA.142 (Radiation Therapy, External Beam and Intensity-Modulated)
On May 1, 2025, we announced that UPMC Health Plan would start requiring prior authorization for MP.PA.147 - Diagnostic and Surveillance Colonoscopy, 18 years of age and older. Effective May 1, UPMC Health Plan is suspending the prior authorization requirement for this policy until July 1, 2025.
Updated medical policies will be available on UPMC Health Plan's Policies and Procedures Manual webpage at upmchp.us/policiesandprocedures. Authorization coding documentation is available at upmchp.us/PriorAuth and on the authorization entry/inquiry page of Provider OnLine.
If you have any questions or concerns about this matter, please contact your physician account executive or call Provider Services at 1-866-918-1595.
Providers are responsible for the appropriate billing of services. These suggested codes are not intended to provide or supersede clinical judgment. An authorization is not a guarantee of payment for services rendered.
25PV5432500