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Provider Manual

This manual is for physicians, hospitals and other health care practitioners in the UPMC Health Plan network. Refer to it for quick guidance on the Health Plan's operational and medical management practices.

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Table of Contents

Welcome and Key Contacts – Effective Jan. 1, 2024
A.1Chapter A Table of Contents
A.3UPMC Health Plan Website
A.4Provider OnLine
A.6How to Use This Manual
A.7Key Contacts
A.8Table A1 UPMC Health Plan Behavioral Health Services (BHS) Contacts
A.10Table A2 UPMC Community HealthChoices Contacts
A.13Table A3 UPMC for Kids (CHIP)
A.15Table A4 UPMC for Life (Medicare)
A.18Table A5 UPMC for You (Medical Assistance)
A.23Table A6 UPMC Health Plan (Commercial)
A.25Table A7 UPMC Medicare Special Needs Plans (SNP) Contacts
A.27Table A8 Other Program & Government Contacts
Previous version of Chapter A (effective Oct. 15, 2022)
Provider Standards and Procedures – Effective Jan. 1, 2024
B.1Chapter B Table of Contents
B.2Provider Rights, Responsibilities, and Roles
B.16Provider Standards and Requirements
B.26Accessibility Standards
B.31Referrals and Coordination of Care
B.37Hospital Guidelines
B.41Provider Disputes
B.47Provider Credentialing
B.54Medical Assistance Revalidation Requirements
B.56Disclosure of Ownership and Control
B.58Provider Sanctioning
B.60Provider Termination
B.61Integrated Denial Notice
Previous version of Chapter B (effective July 2, 2021)
UPMC Health Plan (Commercial) – Effective June 20, 2022
C.1Chapter C Table of Contents
C.2Employer Group Products at a Glance
C.4Health Maintenance Organization (HMO)
C.6Enhanced Access: Point-of-Service (POS)
C.8Preferred Provider Organization (PPO)
C.10Exclusive Provider Organization (EPO)
C.12UPMC Consumer Advantage (Consumer Directed Health Care Plans)
C.14UPMC HealthyU
C.15UPMC Inside Advantage
C.16Covered Benefits
C.26Benefit Exclusions
C.27Services That May Be Covered With Certain Restrictions
C.28Complaints & Grievances
C.29Complaint Procedures
C.31Grievance Procedures
C.38UPMC Individual Products
C.41Covered Benefits for Individuals and Their Families
C.44Benefit Exclusions for Individuals and Their Families
C.45Complaints and Grievances for Individuals and Their Families
C.46Complaint Procedures for Individuals and Their Families
C.47Grievance Procedures for Individuals and Their Families
C.52Nonemergency and Routine Health Care Problems
C.53Preventive Guidelines
C.53Guidelines for Medical Records Documentation
C.54Accessing and Sharing Information
Previous version of Chapter C (effective May 30, 2020)
UPMC for Kids (CHIP) – Effective Jan. 7, 2024
D.1Chapter D Table of Contents
D.2At a Glance (UPMC for Kids)
D.5Covered Benefits (UPMC for Kids)
D.21Benefit Exclusions (UPMC for Kids)
D.22Member Complaint & Grievance Procedures
D.29Member Rights & Responsibilities
Previous version of Chapter D (effective April 1, 2021)
UPMC for You (Medical Assistance) – Effective Sept. 1, 2024
E.1Chapter E Table of Contents
E.2At a Glance (UPMC for You)
E.3Medical Assistance Managed Care in Pennsylvania
E.5Covered Benefits (UPMC for You)
E.36Other Services (UPMC for You)
E.38Services Already Approved by Another MCO or Fee-for-Service (UPMC for You)
E.39Services Not Covered (UPMC for You)
E.40Program Exception Process (UPMC for You)
E.44The EPSDT Program
E.54Special Needs Unit
E.54School-based and School-linked Services
E.55MA Provider Compliance Hotline
E.56Member Rights and Responsibilities
E.58Member Complaint and Grievance Procedures
E.78Appendix E.1 – Other Resources and Forms (UPMC for You)
E.81Appendix E.2 – Copayment Schedule (UPMC for You)
Previous version of Chapter E (effective Oct. 15, 2022)
UPMC for Life (Medicare) – Effective April 15, 2024
F.1Chapter F Table of Contents
F.2At a Glance (UPMC for Life)
F.3UPMC for Life HMO
F.6UPMC for Life PPO
F.9UPMC Health Plan Medicare Select and Medicare Supplement
F.11Benefits and Services for HMO and PPO Members
F.20Services Not Covered (UPMC for Life)
F.21Services Requiring Prior Authorization
F.22Integrated Denial Service
F.24Member Appeals and Grievances
Previous version of Chapter F (effective Oct. 15, 2022)
Utilization Management and Medical Management – Effective March 23, 2024
G.1 Chapter G Table of Contents
G.2 At a Glance
G.3 Procedures Requiring Prior Authorization
G.5 How to Contact or Notify Utilization Management
G.6 When to Notify Utilization Management
G.10 Case Management Services
G.13 Special Needs Services
G.15 Health Management Programs
G.17 Clinical and Preventive Health Care Guidelines
G.18 Member and Provider Surveys and Assessments
G.21 Quality Improvement Program
Previous version of Chapter G (effective Nov. 18, 2023)
Claims Procedures – Effective Dec. 5, 2021
H.1Chapter H Table of Contents
H.2 At a Glance (Claims Procedures)
H.4 Submission Guidelines
H.6 Provider OnLine
H.10 Timely Filing Requirements
H.14 Diagnosis Codes
H.18 Claims Documentation
H.30 Table H8 – Commonly used Place-of-Service Codes
H.31 Modifiers
H.40 Reimbursement
H.45 Denials and Appeals
H.46 False Claims
Previous version of Chapter H (effective Jan. 1, 2021)
Member Administration – Effective Sept. 9, 2024
I.1 Chapter I Table of Contents
I.2 Member Identification Cards
I.12 Provider and Member Rights and Responsibilities
I.13 Identifying Members and Verifying Eligibility
I.18 Determining Primary Insurance Coverage
I.26 Selecting or Changing a Primary Care Provider
I.30 Removing a Member from a Provider's Practice
Previous version of Chapter I (effective Nov. 1, 2021)
Pharmacy Services – Effective Oct. 15, 2022
J.1 Chapter J Table of Contents
J.2 At a Glance (Pharmacy Services)
J.4 Pharmacy Policies
J.6 UPMC Health Plan (Commercial) Pharmacy Program
J.12 UPMC for Kids Pharmacy Program
J.14 UPMC Community HealthChoices (Medical Assistance) and UPMC for You (Medical Assistance) Pharmacy Program
J.19 UPMC for Life (Medicare) and UPMC for Life Special Needs Plans Pharmacy Program
J.23 Where to Obtain Prescriptions
Previous version of Provider Manual Chapter J (effective July 2, 2021)
Glossary and Abbreviations – Effective Jan. 1, 2021
K.1 Chapter K Table of Contents
K.2 Glossary of Health Care Terms
K.12 Glossary of Behavioral Health Terms
K.17 Abbreviations
Previous version of Chapter K (effective June 7, 2020)
Behavioral Health Services – Effective May 15, 2023
L.1 Chapter L Table of Contents
L.2 At a Glance (Behavioral Health Services)
L.3 Providing Behavioral Health Services to UPMC Health Plan members
L.17 Provider Availability Standards
L.20 Coordination of Care, Referrals, and Transition of Care to Other Providers
L.22 Referral Assistance Given to Members in Selecting Behavioral Health Providers
L.23 Statement of UPMC Health Plan’s Policy on Incentives
L.23 Clinical Practice Guidelines for Common Behavioral Health Disorders
L.24 UPMC Health Plan Pharmacy Formulary Information
L.24 Member Rights and Responsibilities
L.26 About Being a UPMC Health Plan Behavioral Health Services Network Provider
L.35 Facility/Organization Assessment, Contracting, and Reassessment
L.40 Termination of Provider from the UPMC Health Plan Behavioral Health Services’ Network
L.42 Record Keeping Standards
L.46 Provider Cultural Competency
L.47 Provider Performance Tracking
L.47 Provider Satisfaction
L.48 Provider Disputes
L.48 Provider Education
L.48 Provider Advisory Committee
L.48 New Technology
L.49 Case Management Programs
L.51 Quality Improvement Overview
L.53 Fraud and Abuse Reporting
L.54 UPMC Health Plan Claims Procedures
Previous version of Chapter L (effective Jan. 1, 2021)
UPMC Medicare Special Needs Plans – Effective Feb. 29, 2024
M.1 Chapter M Table of Contents
M.2 At a Glance (UPMC Medicare Special Needs Plans)
M.6 Covered Benefits and Services
M.15 Services Not Covered (UPMC Medicare Special Needs Plans)
M.18 Member Appeals and Grievances
M.22 UPMC Special Needs Plans Model of Care
M.27 UPMC Special Needs Plans – Model of Care — Case Management
M.31 Appendix A: Integrated Denial Notice
M.33 Appendix B: Other Resources
Previous version of Chapter M (effective April 1, 2021)
UPMC Community HealthChoices (Medical Assistance) –
Effective April 29, 2024
N.1 Chapter N Table of Contents
N.2 At a Glance (UPMC Community HealthChoices)
N.3 Community HealthChoices Managed Care in Pennsylvania
N.4 Population Served
N.6 Coordination Between Medicare and UPMC Community HealthChoices
N.7 Covered Benefits
N.13 Service Descriptions
N.34 Other Services
N.36 Cultural, Linguistic, and Disability Competency
N.39 Alzheimer's Disease and Other Dementias (UPMC Community HealthChoices)
N.40 Services Already Approved by Another MCO or Fee-for-Service
N.41 Services Not Covered
N.42 Program Exception Process
N.46 Service Coordination
N.52 Participant Complaint and Grievance Procedures
N.54 Provider Critical Incident Reporting Requirements
N.59 Nursing Facility Quality of Care Review Preventable Serious Adverse Event Reporting
N.61 Medical Assistance Provider Compliance Hotline
N.62 Provider Monitoring
N.65 Additional Provider Requirements
N.66 Electronic Visit Verification
N.67 Other Resources and Forms
N.68 Copayment Schedule
Previous version of Chapter N (effective June 16, 2023)