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Important Information About Utilization Management

Our utilization management (UM) decisions are based on the appropriateness of care and service needed, as well as the member’s coverage according to his or her health plan. We do not reward physicians or other individuals for issuing denials of coverage, service, or care. In addition, we do not offer financial incentives for UM decision makers to encourage decisions resulting in under-utilization.

The Medical Management Department works with members and providers to answer questions about the utilization process and the authorization of care. Members can find contact information at Providers can call the Medical Management Department at 1-800-425-7800. Normal business hours are Monday through Friday from 8 a.m. to 4:30 p.m. After-hours callers have the option of leaving a voice mail message, and we will respond on the next business day. Providers can also contact the Medical Management Department to discuss a utilization decision that is based on medical necessity with a physician reviewer. All calls must be initiated within two business days from notification of the denial.

The Medical Management Department applies criteria and guidelines on a case-by-case basis, taking into account each individual's unique circumstances. All denials of coverage that are based on medical necessity are made by a Health Plan medical director. A member or provider can obtain the criteria used for a specific review decision by contacting the Medical Management Department at:

Medical Management Department
UPMC Health Plan
U.S. Steel Tower
600 Grant Street
Pittsburgh, PA 15219

UPMC Health Plan uses nationally recognized criteria, as well as Health Plan medical policies, to determine utilization management decisions. All criteria are reviewed and approved by physicians on the Quality Improvement Committee. UPMC Health Plan is currently using the following licensed proprietary criteria:

2014 InterQual

  • Level of Care Criteria — Acute Adult
  • Level of Care Criteria — Acute Pediatric
  • Level of Care Criteria — Acute Rehabilitation
  • Level of Care Criteria — Subacute and SNF
  • Level of Care Criteria — Long-Term Acute Care
  • Level of Care Criteria — Home Care
  • Care Planning Criteria — Procedures
  • Care Planning Criteria — Imaging
  • Care Planning Criteria — Durable Medical Equipment

Behavioral Health

  • Mihalik Group's Medical Necessity Manual for Behavioral Health, version 8.0
  • Pennsylvania Client Placement Criteria 2nd Ed.: Department of Health: Bureau of Drug and Alcohol Programs for all levels of adult substance abuse
  • American Society for Addiction Medicine: Patient Placement Criteria for all levels of adolescent substance abuse treatment

Providers can access can access Health Plan medical policies by checking the Policies and Procedures Manual. These policies provide authorization requirements for specific services.