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Medical Prior Authorization

Prior Authorizations:

UPMC Health Plan will be implementing an expanded approach to prior authorizations in collaboration with HealthHelp for advanced radiology/imaging, cardiology, sleep, and musculoskeletal services. Our common goal is to reduce denials, improve patient quality and safety, and ensure patients get the right care, at the right time, at the right place.

This expanded approach is built on a foundation of evidence-based clinical guidelines and criteria and a collaborative process for determining optimal treatment. The process includes collecting relevant clinical information from the ordering/treating physician’s office; reviewing this information against current evidence-based guidelines; and, if necessary, providing physician-to-physician consultation to determine test appropriateness and discuss potential alternatives.

Ordering practitioners are required to obtain prior authorizations for the following procedures by logging in to Provider OnLine or accessing Provider OnLine through Navinet:

  • Advanced radiology/imaging: CT, CTA, MRI, MRA , PET, Cardiac nuclear medicine
  • Cardiology: Cardiac catheterization, cardiac implantable devices, and wearable cardiac devices (e.g., LifeVest)
  • Sleep: In-lab polysomnography
  • Musculoskeletal: Arthroplasty, arthroscopy, open joint surgery, arthrodesis, laminotomy, laminectomy, corpectomy, foraminotomy, discectomy, kyphoplasty, and vertebroplasty

Informational Materials

If you would like hard copies of these materials or have any additional questions, contact your physician account executive or call Provider Services at 1-866-918-1595.

Physician Certification Form for Child with Special Needs:

In Pennsylvania, children with certain permanent or temporary disabilities are eligible for a special category of Medical Assistance (MA) called PH95.