Changes to inpatient denial and OBS claim billing

We will soon transition to the Epic® platform. This change will align our claims processing with industry standards by adjudicating claims based on the level of care authorized. As this transition approaches, please keep the following areas in mind:

• Dates of service. Effective for dates of service on or after Dec. 1, 2026, if a request for an authorization for an inpatient stay is denied, the claim must be submitted as an observation (OBS) claim.
• Denied claims. UPMC Health Plan will no longer crosswalk an inpatient denied claim to your contracted OBS rate. If the authorization for an inpatient stay is denied, and an inpatient claim is submitted, the claim will deny with reason code: “Inpatient denied—rebill as OBS.” To obtain payment for observation, you must submit an observation claim for consideration and adjudication. As a reminder, claims billed as observation do not require authorization.

These changes are intended to help reduce administrative intervention in claim pricing and improve claims payment accuracy. Thank you for your continued commitment to providing excellent service to our members.

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