Clinical documentation required for hip, knee, and shoulder prior authorizations

As you know, UPMC Health Plan requires certain clinical documentation/notes in support of a request for prior authorization for hip, knee, and shoulder procedures 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.

Our system has been updated to confirm the submission of such information before an authorization will be provided beginning July 24, 2025. 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 network manager or Physician Account Executive. 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.