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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Key Points

Key Points are major highlights about a particular topic. These points are listed in bullet form for easy readability.

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Table of Contents

Welcome and Key Contacts – Effective Jan. 4, 2025
A.1	Chapter A Table of Contents
A.2	Welcome
A.3	UPMC Health Plan Website
A.4	Provider OnLine
A.6	How to Use This Manual
A.7	Key Contacts
A.8	Table A1 UPMC Health Plan Behavioral Health Services (BHS) Contacts
A.10	Table A2 UPMC Community HealthChoices Contacts
A.14	Table A3 UPMC for Kids (CHIP)
A.16	Table A4 UPMC for Life (Medicare)
A.19	Table A5 UPMC for You (Medical Assistance)
A.24	Table A6 UPMC Health Plan (Commercial)
A.27	Table A7 UPMC Medicare Special Needs Plans (SNP) Contacts
A.29	Table A8 Other Program & Government Contacts
Previous version of Chapter A (effective Jan. 1, 2024)
Provider Standards and Procedures – Effective Jan. 1, 2024
B.1	Chapter B Table of Contents
B.2	Provider Rights, Responsibilities, and Roles
B.16	Provider Standards and Requirements
B.26	Accessibility Standards
B.31	Referrals and Coordination of Care
B.37	Hospital Guidelines
B.41	Provider Disputes
B.47	Provider Credentialing
B.54	Medical Assistance Revalidation Requirements
B.56	Disclosure of Ownership and Control
B.58	Provider Sanctioning
B.60	Provider Termination
B.61	Integrated Denial Notice
Previous version of Chapter B (effective July 2, 2021)
UPMC Health Plan (Commercial) – Effective June 20, 2022
C.1	Chapter C Table of Contents
C.2	Employer Group Products at a Glance
C.4	Health Maintenance Organization (HMO)
C.6	Enhanced Access: Point-of-Service (POS)
C.8	Preferred Provider Organization (PPO)
C.10	Exclusive Provider Organization (EPO)
C.12	UPMC Consumer Advantage (Consumer Directed Health Care Plans)
C.14	UPMC HealthyU
C.15	UPMC Inside Advantage
C.16	Covered Benefits
C.26	Benefit Exclusions
C.27	Services That May Be Covered With Certain Restrictions
C.28	Complaints & Grievances
C.29	Complaint Procedures
C.31	Grievance Procedures
C.38	UPMC Individual Products
C.41	Covered Benefits for Individuals and Their Families
C.44	Benefit Exclusions for Individuals and Their Families
C.45	Complaints and Grievances for Individuals and Their Families
C.46	Complaint Procedures for Individuals and Their Families
C.47	Grievance Procedures for Individuals and Their Families
C.52	Nonemergency and Routine Health Care Problems
C.53	Preventive Guidelines
C.53	Guidelines for Medical Records Documentation
C.54	Accessing and Sharing Information
Previous version of Chapter C (effective May 30, 2020)
UPMC for Kids (CHIP) – Effective Sept. 16, 2024
D.1	Chapter D Table of Contents
D.2	At a Glance (UPMC for Kids)
D.5	Covered Benefits (UPMC for Kids)
D.21	Benefit Exclusions (UPMC for Kids)
D.22	Member Complaint & Grievance Procedures
D.29	Member Rights & Responsibilities
Previous version of Chapter D (effective Jan. 7, 2024)
UPMC for You (Medical Assistance) – Effective Sept. 1, 2024
E.1	Chapter E Table of Contents
E.2	At a Glance (UPMC for You)
E.3	Medical Assistance Managed Care in Pennsylvania
E.5	Covered Benefits (UPMC for You)
E.36	Other Services (UPMC for You)
E.38	Services Already Approved by Another MCO or Fee-for-Service (UPMC for You)
E.39	Services Not Covered (UPMC for You)
E.40	Program Exception Process (UPMC for You)
E.44	The EPSDT Program
E.54	Special Needs Unit
E.54	School-based and School-linked Services
E.55	MA Provider Compliance Hotline
E.56	Member Rights and Responsibilities
E.58	Member Complaint and Grievance Procedures
E.78	Appendix E.1 – Other Resources and Forms (UPMC for You)
E.81	Appendix E.2 – Copayment Schedule (UPMC for You)
Previous version of Chapter E (effective Oct. 15, 2022)
UPMC for Life (Medicare) – Effective Sept. 16, 2024
F.1	Chapter F Table of Contents
F.2	At a Glance (UPMC for Life)
F.3	UPMC for Life HMO
F.6	UPMC for Life PPO
F.9	UPMC Health Plan Medicare Select and Medicare Supplement
F.11	Benefits and Services for HMO and PPO Members
F.20	Services Not Covered (UPMC for Life)
F.21	Services Requiring Prior Authorization
F.22	Integrated Denial Service
F.24	Member Appeals and Grievances
Previous version of Chapter F (effective April 15, 2024)
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 Jan. 4, 2025
H.1	Chapter H Table of Contents
H.2	At a Glance (Claims Procedures)
H.5	Submission Guidelines
H.7	Provider OnLine
H.12	Timely Filing Requirements
H.16	Diagnosis Codes
H.20	Claims Documentation
H.32	Table H8 – Commonly used Place-of-Service Codes
H.33	Modifiers
H.42	Reimbursement
H.47	Denials and Appeals
H.48	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 Jan. 1, 2025
J.1	Chapter J Table of Contents
J.2	At a Glance (Pharmacy Services)
J.5	Pharmacy Policies
J.7	UPMC Health Plan (Commercial) Pharmacy Program
J.13	UPMC for Kids Pharmacy Program
J.15	UPMC Community HealthChoices (Medical Assistance) and UPMC for You (Medical Assistance) Pharmacy Program
J.20	UPMC for Life (Medicare) and UPMC for Life Special Needs Plans Pharmacy Program
J.26	Where to Obtain Prescriptions
Previous version of Provider Manual Chapter J (effective Oct. 15, 2022)
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 Sept. 16, 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 April 29, 2024)