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.

Look out for the notes and symbols below. You will see them with important information.

Key Points

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

Purple search icon Closer Look
Closer Looks provide additional information about a topic, such as an important phone number, address, or useful fact.
Purple alert icon Alert
Alerts draw attention to critical information.

Navigate to specific sections of the manual below.

Table of Contents

Welcome and Key Contacts – Effective January 1, 2018
A.2Welcome
A.3Provider OnLine
A.4UPMC Health Plan Website
A.5How to Use This Manual
A.7Key Contacts
A.8Table A1 UPMC Health Plan (Commercial)
A.10Table A2 UPMC for Kids (CHIP)
A.12Table A3 UPMC for You (Medical Assistance)
A.22Table A4 UPMC for Life (Medicare)
A.24Table A5 UPMC Medicare Special Needs Plans (SNP) Contacts
A.26Table A6 Other Program & Government Contacts
A.27Table A7 UPMC Health Plan Behavioral Health Services (BHS) Contacts
A.30Table A8 UPMC Community HealthChoices Contacts
Printable PDF
Provider Standards and Procedures – Effective January 1, 2018
B.2Provider Rights, Responsibilities, & Roles
B.13Provider Standards & Requirements
B.22Accessibility Standards
B.27Referrals & Coordination of Care
B.33Hospital Guidelines
B.37Provider Disputes
B.41Provider Credentialing
B.47Provider Sanctioning
B.49Provider Termination
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 December 13, 2013
D.2At a Glance
D.4Covered Benefits
D.13Benefit Exclusions
D.14Member Complaint & Grievance Procedures
D.19Member Rights & Responsibilities
D.21UPMC for Kids Quick Reference Guide
Printable PDF
UPMC for You (Medical Assistance) – Effective July 1, 2018
E.2At a Glance
E.3Medical Assistance Managed Care in Pennsylvania
E.4Covered Benefits
E.30Other Services
E.32Services Already Approved by Another MCO or Fee-for-Service
E.33Services Not Covered
E.34Program Exception Process
E.38The EPSDT Program
E.46Member Complaint and Grievance Procedures
E.67Other Resources and Forms
E.68Copayment Schedule
Printable PDF
UPMC for Life (Medicare) – Effective April 10, 2014
F.2At a Glance
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
F.17Services Requiring Prior Authorization
F.18Appeals & Grievances
F.21Quick Reference Guide
Printable PDF
Medical Management – Effective January 1, 2018
G.2 At a Glance
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
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 January 1, 2018
J.2 At a Glance
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.17 UPMC for Life (Medicare) and UPMC for Life Special Needs Plans Pharmacy Program
J.21 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
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 January 4, 2014
M.2 At a Glance
M.8 Covered Benefits and Services
M.15 Services Not Covered
M.17 Member Appeals and Grievances
M.20 Model of Care
M.25 Model of Care — Case Management
M.30 Quick Reference Guide
Printable PDF
UPMC Community HealthChoices (Medical Assistance) – Effective January 1, 2018
N.2 At a Glance
N.3 Medical Assistance Managed Care in Pennsylvania
N.4 Population Served
N.5 Covered Benefits
N.34 Linguistic and Disability Competency
N.36 Other Services
N.37 Services Already Approved by Another MCO or Fee-for-Service
N.38 Services Not Covered
N.38 Program Exception Process
N.41 Service Coordination
N.46 Provider Critical Incident Reporting Requirements
N.48 MA Provider Compliance Hotline
N.49 Participant Complaint and Grievance Procedures
N.63 Other Resources and Forms
N.64 Copayment Schedule
Printable PDF
Apple Store Google Play