Skip to main content

Medical Prior Authorization and Physician Forms

Medical Prior Authorization and Physician Forms:

UPMC Health Plan requires a prior authorization request for specific procedures or treatments to determine whether coverage of a request will be approved or denied.

Providers may submit a request for prior authorization to the Clinical Operations/Utilization Management Department, including supporting documentation and the Certificate of Medical Necessity (CMN).

We occasionally require additional information when completing a clinical review. If additional information is required, we will notify the requesting provider through Provider OnLine regarding what information is needed.

If the requested information is not received in a timely manner, the request will be denied due to a lack of sufficient information for review. UPMC Health Plan will notify the requesting provider of its prior authorization decision through Provider OnLine.

Providers may contact the Clinical Operations/Utilization Management Department by calling 1-800-425-7800 if they have a question or need instructions on how to submit prior authorizations during system outages. Help is available from 8 a.m. to 4:30 p.m. Monday through Friday.

UPMC Health Plan Self-Registration Transparency for UPMC for Life Medicare Advantage credentialed providers

Peer-to-Peer Discussions:
Providers may request a peer-to-peer discussion with a UPMC Health Plan medical director regarding adverse benefit determinations based on medical necessity. Providers should contact Clinical Operations/Utilization Management at 412-454-2765 Monday through Friday from 8 a.m. to 5 p.m.

Patient Health Guidelines:

Physician Forms:

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.