Welcome and Key Contacts – Effective Jan. 1, 2024 |
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.13 | Table A3 UPMC for Kids (CHIP) |
A.15 | Table A4 UPMC for Life (Medicare) |
A.18 | Table A5 UPMC for You (Medical Assistance) |
A.23 | Table A6 UPMC Health Plan (Commercial) |
A.25 | Table A7 UPMC Medicare Special Needs Plans (SNP) Contacts |
A.27 | Table A8 Other Program & Government Contacts |
Previous version of Chapter A (effective Oct. 15, 2022) |
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 Dec. 5, 2021 |
H.1 | Chapter 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 |
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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) |