Quality Assurance

Documents you may need

If your patient's employer self-insures the group plan, the appeal process may vary slightly. Patients can contact their Health Care Concierge team at the number on the back of their ID card for more information.

• Complaint and Grievance Process
  • C&G Process – CM ASO 1
  • C&G Process – CM ASO 2
  • C&G Process – CM Fully Insured
  • C&G Process – CM St. Francis
  • C&G Process – FEHB
  • C&G Process – IND
• HIPAA Guidelines (Health Insurance Portability and Accountability Act)
• Member Rights and Responsibilities
  • UPMC Health Plan (Commercial)
  • UPMC for Life (Medicare)
  • UPMC Medicare Special Needs Plans (SNP)
  • UPMC for You (Medicaid)
  • UPMC for Kids (CHIP)
  • UPMC Community HealthChoices (CHC)
• Physician-Patient Communication Guidelines
• Provider Satisfaction Results
• Quality Improvement Program
• Quality and Safety

Minimum Data Set (MDS)

The MDS template serves as a guide for a facility case manager to include the relevant data points in the clinical reviews for submission to the Health Plan. The UPMC Health Plan nurse reviews the MDS and follows the standard UM process. Receipt of the MDS, including all relevant data, reduces the number of calls necessary to complete the review. Decisions are based on the initial submission, unless the caller indicates that additional information is forthcoming.

• Minimum Data Set (MDS)

Identifying and Reporting Fraud, Waste, and Abuse

As a part of UPMC Health Plan’s continuing provider education efforts, we have created an informational presentation to assist you and your staff in ways to identify and prevent fraud, waste, and abuse.

Provider Manual

Be sure to check our provider manual for guidance on topics including POA, serious preventable events process, and provider accessibility standards.

• View our provider manual