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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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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 December 10, 2019
A.3Provider OnLine
A.4UPMC Health Plan Website
A.5How to Use This Manual
A.6Key Contacts
A.7Table A1 UPMC Health Plan Behavioral Health Services (BHS) Contacts
A.9Table A2 UPMC Community HealthChoices Contacts
A.14Table A3 UPMC for Kids (CHIP)
A.16Table 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 January 1, 2018)
Provider Standards and Procedures – Effective December 9, 2018
B.2Provider Rights, Responsibilities, and Roles
B.17Provider Standards and Requirements
B.28Accessibility Standards
B.33Referrals and Coordination of Care
B.39Hospital Guidelines
B.43Provider Disputes
B.49Provider Credentialing
B.55Medical Assistance Revalidation Requirements
B.57Provider Sanctioning
B.59Provider Termination
B.60Integrated Denial Notice
Printable PDF
UPMC Health Plan (Commercial) – Effective July 26, 2014
C.2Employer Group Products at a Glance
C.5Health Maintenance Organization (HMO)
C.7Enhanced Access: Point-of-Service (POS)
C.9Preferred Provider Organization (PPO)
C.11Exclusive Provider Organization (EPO)
C.13UPMC Consumer Advantage (Consumer Directed Health Care Plans)
C.15UPMC HealthyU
C.16UPMC Inside Advantage
C.18Covered Benefits
C.29Benefit Exclusions
C.30Services That May Be Covered With Certain Restrictions
C.31Complaints & Grievances
C.32Complaint Procedures
C.34Grievance Procedures
C.41UPMC Individual Products
C.45Covered Benefits for Individuals and Their Families
C.48Benefit Exclusions for Individuals and Their Families
C.49Complaints and Grievances for Individuals and Their Families
C.50Complaint Procedures for Individuals and Their Families
C.52Grievance Procedures for Individuals and Their Families
C.58Other Resources and Links
C.59Preventive Guidelines
C.59Quick Reference Guide
Printable PDF
UPMC for Kids (CHIP) – Effective March 10, 2020
D.2At a Glance (UPMC for Kids)
D.4Covered Benefits (UPMC for Kids)
D.17Benefit Exclusions (UPMC for Kids)
D.16Member Complaint & Grievance Procedures
D.18Member Rights & Responsibilities
D.25UPMC for Kids Quick Reference Guide (UPMC for Kids)
Previous version of Chapter D (effective February 3, 2019)
UPMC for You (Medical Assistance) – Effective July 16, 2019
E.2At a Glance (UPMC for You)
E.3Medical Assistance Managed Care in Pennsylvania
E.4Covered Benefits (UPMC for You)
E.30Other Services (UPMC for You)
E.32Services Already Approved by Another MCO or Fee-for-Service (UPMC for You)
E.33Services Not Covered (UPMC for You)
E.34Program Exception Process (UPMC for You)
E.38The EPSDT Program
E.46Member Complaint and Grievance Procedures
E.67Other Resources and Forms (UPMC for You)
E.68Copayment Schedule (UPMC for You)
Previous version of Chapter E (effective July 1, 2018)
UPMC for Life (Medicare) – Effective April 10, 2014
F.2At a Glance (UPMC for Life)
F.3UPMC for Life HMO
F.5UPMC for Life PPO
F.7UPMC Health Plan Medicare Select and Medicare Supplement
F.8Benefits & Services for HMO and PPO Members
F.16Services Not Covered (UPMC for Life)
F.17Services Requiring Prior Authorization
F.18Appeals & Grievances
F.21Quick Reference Guide (UPMC for Life)
Printable PDF
Medical Management – Effective January 1, 2018
G.2 At a Glance (Medical Management)
G.2 Procedures Requiring Prior Authorization
G.3 How to Contact or Notify Medical Management
G.4 When to Notify Medical Management Case Management Services
G.7 Case Management Services
G.10 Special Needs Services
G.12 Health Management Programs
G.14 Clinical and Preventive Health Care Guidelines
G.15 Member and Provider Surveys and Assessments
G.17 Quality Improvement Program
Printable PDF
Claims Procedures – Effective January 1, 2018
H.2 At a Glance (Claims Procedures)
H.4 Submission Guidelines
H.12 Claims Documentation
H.24 Codes & Modifiers
H.30 Reimbursement
H.32 Denials & Appeals
H.32 False Claims
Printable PDF
Member Administration – Effective January 1, 2018
I.2 Member Identification Cards
I.5 Provider and Member Rights and Responsibilities
I.6 Identifying Members and Verifying Eligibility
I.9 Determining Primary Insurance Coverage
I.16 Selecting or Changing a Primary Care Provider
I.21 Removing a Member from a Provider's Practice
Printable PDF
Pharmacy Services – Effective May 27, 2019
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 for You (Medical Assistance) Pharmacy Program
J.18 UPMC for Life (Medicare) and UPMC for Life Special Needs Plans Pharmacy Program
J.22 Where to Obtain Prescriptions
Printable PDF
Glossary and Abbreviations – Effective January 1, 2018
K.2 Glossary of Health Care Terms
K.13 Glossary of Behavioral Health Terms
K.18 Abbreviations
Printable PDF
Behavioral Health Services
L.1 At a Glance (Behavioral Health Services)
L.3 Providing Behavioral Health Services to UPMC Health Plan members
L.13 About Being a Network Behavioral Health Provider
L.38 Overview of Quality Improvement
L.41 Fraud and Abuse Reporting
L.42 Information about UPMC Health Plan Claims Procedures
L.43 Glossary of Terms and Abbreviations Prepared for Behavioral Health Providers
Printable PDF
UPMC Medicare Special Needs Plans – Effective June 15, 2019
M.2 At a Glance (UPMC Medicare Special Needs Plans)
M.7 Covered Benefits and Services
M.15 Services Not Covered (UPMC Medicare Special Needs Plans)
M.17 Member Appeals and Grievances
M.20 UPMC Special Needs Plans Model of Care
M.25 UPMC Special Needs Plans – Model of Care — Case Management
M.30 Quick Reference Guide (UPMC Medicare Special Needs Plans)
Printable PDF
UPMC Community HealthChoices (Medical Assistance) –
Effective February 17, 2020
N.2 At a Glance (UPMC Community HealthChoices)
N.3 Community HealthChoices Managed Care in Pennsylvania
N.4 Population Served
N.5 Coordination Between Medicare and UPMC Community HealthChoices
N.6 Covered Benefits
N.28 Linguistic and Disability Competency
N.30 Alzheimer's Disease and Other Dementias
N.31 Other Services (UPMC Community HealthChoices)
N.33 Services Already Approved by Another MCO or Fee-for-Service (UPMC Community HealthChoices)
N.34 Services Not Covered (UPMC Community HealthChoices)
N.35 Program Exception Process (UPMC Community HealthChoices)
N.38 Service Coordination
N.43 Provider Critical Incident Reporting Requirements
N.47 MA Provider Compliance Hotline
N.48 Participant Complaint and Grievance Procedures
N.50 Provider Monitoring
N.51 Electronic Visit Verification
N.52 Other Resources and Forms (UPMC Community HealthChoices)
N.53 Copayment Schedule (UPMC Community HealthChoices)
Previous version of Chapter N (effective December 14, 2019)