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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 April 1, 2021
A.1Chapter A Table of Contents
A.3Provider OnLine
A.4UPMC Health Plan Website
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.15Table A3 UPMC for Kids (CHIP)
A.17Table A4 UPMC for Life (Medicare)
A.19Table A5 UPMC for You (Medical Assistance)
A.24Table A6 UPMC Health Plan (Commercial)
A.26Table A7 UPMC Medicare Special Needs Plans (SNP) Contacts
A.28Table A8 Other Program & Government Contacts
Previous version of Chapter A (effective Jan. 1, 2021)
Provider Standards and Procedures – Effective July 2, 2021
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.53Medical Assistance Revalidation Requirements
B.55Disclosure of Ownership and Control
B.57Provider Sanctioning
B.59Provider Termination
B.60Integrated Denial Notice
Previous version of Chapter B (effective Jan. 1, 2021)
UPMC Health Plan (Commercial) – Effective May 30, 2020
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.17Covered 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
Previous version of Chapter C (effective July 26, 2014)
UPMC for Kids (CHIP) – Effective April 1, 2021
D.1Chapter D Table of Contents
D.2At a Glance (UPMC for Kids)
D.4Covered Benefits (UPMC for Kids)
D.18Benefit Exclusions (UPMC for Kids)
D.19Member Complaint & Grievance Procedures
D.26Member Rights & Responsibilities
Previous version of Chapter D (effective May 31, 2020)
UPMC for You (Medical Assistance) – Effective July 2, 2021
E.1Chapter E Table of Contents
E.2At a Glance (UPMC for You)
E.3Medical Assistance Managed Care in Pennsylvania
E.4Covered Benefits (UPMC for You)
E.33Other Services (UPMC for You)
E.35Services Already Approved by Another MCO or Fee-for-Service (UPMC for You)
E.36Services Not Covered (UPMC for You)
E.37Program Exception Process (UPMC for You)
E.41The EPSDT Program
E.51The Special Needs Unit
E.51School-based and School-linked Services
E.52MA Provider Compliance Hotline
E.53Member Complaint and Grievance Procedures
E.73Appendix E.1 – Other Resources and Forms (UPMC for You)
E.76Appendix E.2 – Copayment Schedule (UPMC for You)
Previous version of Chapter E (effective April 1, 2021)
UPMC for Life (Medicare) – Effective October 4, 2020
F.1 Chapter F Table of Contents
F.2 At a Glance (UPMC for Life)
F.3 UPMC for Life HMO
F.5 UPMC for Life PPO
F.7 UPMC Health Plan Medicare Select and Medicare Supplement
F.8 Benefits & Services for HMO and PPO Members
F.18 Services Not Covered (UPMC for Life)
F.19 Services Requiring Prior Authorization
F.20 Appeals & Grievances
Previous version of Chapter F (effective May 31, 2020)
Utilization Management and Medical Management – Effective Jan. 1, 2021
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 Oct. 3, 2020)
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 Jan. 20, 2021
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 Jan. 1, 2021)
Pharmacy Services – Effective July 2, 2021
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.18 UPMC for Life (Medicare) and UPMC for Life Special Needs Plans Pharmacy Program
J.22 Where to Obtain Prescriptions
Previous version of Provider Manual Chapter J (effective Jan. 20, 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 Jan. 1, 2020
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.24 Clinical Practice Guidelines for Common Behavioral Health Disorders
L.25 UPMC Health Plan Pharmacy Formulary Information
L.26 Member Rights and Responsibilities
L.28 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.48 Provider Satisfaction
L.49 Provider Disputes
L.49 Provider Education
L.49 Provider Advisory Committee
L.49 New Technology
L.50 Case Management Programs
L.52 Quality Improvement Overview
L.54 Fraud and Abuse Reporting
L.56 UPMC Health Plan Claims Procedures
Previous version of Chapter L (effective Oct. 4, 2020)
UPMC Medicare Special Needs Plans – Effective April. 1, 2021
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.21 UPMC Special Needs Plans Model of Care
M.26 UPMC Special Needs Plans – Model of Care — Case Management
M.30 Appendix A: Integrated Denial Notice
M.32 Appendix B: Other Resources
Previous version of Chapter M (effective Oct. 4, 2020)
UPMC Community HealthChoices (Medical Assistance) –
Effective April 1, 2021
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 Description
N.31 Linguistic and Disability Competency
N.33 Alzheimer's Disease and Other Dementias (UPMC Community HealthChoices)
N.34 Other Services
N.36 Services Already Approved by Another MCO or Fee-for-Service
N.37 Services Not Covered
N.38 Program Exception Process
N.41 Service Coordination
N.47 Provider Critical Incident Reporting Requirements
N.51 Additional Provider Requirements
N.52 Medical Assistance Provider Compliance Hotline
N.53 Participant Complaint and Grievance Procedures
N.55 Provider Monitoring
N.56 Electronic Visit Verification
N.57 Other Resources and Forms
N.58 Copayment Schedule
Previous version of Chapter N (effective March 6, 2021)