UPMC Health Plan is dedicated to improving the health and well-being of all our members. We understand the importance of providing access to useful information about your coverage so that you are able to make informed decisions. This is an overview of our claims payment and other helpful policies. After reviewing this information, if you have questions or need assistance, please contact Member Services at 1-844-220-4785.
Out-of-Network Liability and Balance Billing
“Balance Billing” is when a non-participating (out-of-network) provider bills you for the difference between what he or she received as payment from the insurance company versus what the provider charged for their services. “Balance billing” does not include cost-sharing charges like copayments, coinsurance, or deductible balances. Not all plan types provide coverage for services received from non-participating providers. Even if your plan includes benefits for services received from a non-participating provider, you may still be "balance billed" by non-participating providers.
- If you are a Preferred Provider Organization (PPO) plan member, you have two levels of benefits. If you use participating providers you will receive the highest level of benefit coverage. If you obtain services from a non-participating provider, you will receive a lower level of benefit coverage and may be billed for the difference between the provider’s charges and the amount that UPMC Health Plan pays for the services. In other words, non-participating providers may bill you for any amount over and above what UPMC Health Plan covers. If you require Emergency Services and cannot reasonably be attended to by a Participating Provider, UPMC Health Plan will pay for emergency services rendered by an out-of-network provider so that you are not responsible for a greater out-of-pocket expense than if you had been attended to by a Participating Provider.
- If you are an Exclusive Provider Organization (EPO) plan member, you must receive services from a participating or in-network provider in order for services to be covered. UPMC Health Plan will not cover services obtained from a non-participating or out-of-network (OON) provider unless you receive authorization from UPMC Health Plan to see that provider. As an EPO member, all requests to utilize non-participating or out-of-network providers require prior authorization in order to be eligible for coverage. The provider must complete and submit an OON Medical Necessity Form. If you require Emergency Services and cannot reasonably be attended to by a Participating Provider, UPMC Health Plan will pay for emergency services rendered by an out-of-network provider so that you are not responsible for a greater out-of-pocket expense than if you had been attended to by a Participating Provider.
- If you are a Health Maintenance Organization (HMO) plan member, you must receive services from a participating or in-network provider in order for services to be covered. UPMC Health Plan will not cover services obtained from a non-participating or OON provider unless you receive authorization from UPMC Health Plan to see that provider. As an HMO member, all requests to utilize non-participating or out-of-network providers require prior authorization in order to be eligible for coverage. The provider must complete and submit an OON Medical Necessity Form. A referral is also required to access benefits from certain in-network providers. That means that if you need to go to a specialist, you must first obtain a referral from your Primary Care Provider. If you require Emergency Services and cannot reasonably be attended to by a Participating Provider, UPMC Health Plan will pay for emergency services rendered by an out-of-network provider so that you are not responsible for a greater out-of-pocket expense than if you had been attended to by a Participating Provider.
Enrollee Claims Submission
If you receive care from a participating provider, you will not have to submit a claim to UPMC Health Plan. The participating provider will submit the claim to UPMC Health Plan, and UPMC Health Plan will pay the provider directly. However, if you obtain covered services from a non-participating provider and that provider does not submit the claim to UPMC Health Plan, you may have to file a claim yourself. All claims must be filed within one year of the date of service. To submit a claim, please get an itemized bill from the provider, complete the claim form, which is available by accessing the link below, and mail the claim form/itemized bill to the address below or fax it to 412-454-8519.
UPMC Health Plan/UPMC Health Benefits
PO Box 2999
Pittsburgh, PA 15230
Out-of-Network Claims Form
If you have questions about filing a claim yourself, please contact Member Services at 1-844-220-4785.
Grace Periods and Claims Pending Policies During the Grace Period
For Marketplace members receiving an Advance Premium Tax Credit (APTC):
The Affordable Care Act (ACA) requires UPMC Health Plan to provide a 3 month grace period if your premium is not paid by the premium due date indicated on your invoice. During the first month of your grace period, UPMC Health Plan will pay all appropriate claims for services according to the terms of your plan. During the second and third months of your grace period your policy will remain in force, but UPMC Health Plan is permitted to pend all payments for your care. This means that UPMC Health Plan does not have to pay your claims for care as it normally would; instead, UPMC Health Plan may place your claims into a temporary hold status until you pay the owed premiums necessary to bring your account into good standing.
If you do not pay your past due premiums before the end of the grace period, your coverage will be terminated retroactively to the end of the first month of the grace period. If this happens, any pended claims will become your responsibility, and any claims that UPMC Health Plan paid during months two and three of the grace period will have their payment reversed. This means that you will be responsible to pay health care providers directly for the drugs, services, equipment, or devices that you received during this time.
For Marketplace members who do not receive an APTC:
You have a grace period of one month from the premium due date. During your grace period, UPMC Health Plan will pay all appropriate claims for services according to the terms of your plan. If you do not pay your past due premiums before the end of the grace period, your coverage will be terminated retroactively to the end of the grace period
Important payment information:
Partial premium payments will not extend the duration of your grace period. You must pay all past due amounts in order to bring your account into good standing.
Beginning with plan year 2018, if your coverage has been terminated and an outstanding premium balance remains on your account, you will be required to pay all current and past due premiums before you can enroll yourself and your dependents in future UPMC Advantage coverage.
A retroactive denial is the reversal of a claim that was previously paid. UPMC Health Plan makes all claims payment determinations based on the information available at the time the claim is processed. If UPMC Health Plan determines that a claim was paid in error (e.g., due to changes in member eligibility status, provider participation, or coordination of benefits with other coverage), the claim may be retroactively denied. If you have a retroactive denial, payment for the reversed claim will become your responsibility.
Tips to Help Avoid Retroactive Denials:
- Make premium payments on time to avoid a possible retroactive denial due to member ineligibility.
- Before visiting a new provider for the first time or going back to a familiar provider after your plan has changed, confirm that they are a participating provider in the specific UPMC Health Plan network (e.g., Partner, Select, Premium) that applies to your benefit plan.
- Tell UPMC Health Plan about other coverage that you may have. This can include coverage for a child from two different parents or benefits under government programs like Pennsylvania Medical Assistance.
Enrollee Recoupment of Overpayments
UPMC Health Plan has established a process to help you get reimbursed for premium overpayments in a timely manner. If your insurance policy has been cancelled or terminated and you have made payments for a coverage period beyond your cancellation or termination date, you will be refunded after the next premium billing cycle. Requests for recoupment of other types of overpayments, such as duplicate monthly premium payments, will be processed in a timely manner. You can request recoupment of an overpayment by calling Member Services at 1-844-220-4785.
Medical Necessity and Prior Authorization Timeframes and Enrollee Responsibilities
Certain non-emergency medical procedures and services must be evaluated by UPMC Health Plan in advance to determine if the care requested by the provider is medically necessary. This process is known as “prior authorization.” When a provider requests prior authorization on your behalf, UPMC Health Plan notifies the provider regarding its decision within two business days. For urgent, pre-service requests, the provider is notified within 24 hours. Medical policies that require prior authorization from UPMC Health Plan are available for providers to review at www.upmchealthplan.com/providers/medical/resources/manuals/policies-procedures.aspx
It is your responsibility to confirm that prior authorization has been granted before you have any medical procedure, test, or service that requires it. The fact that your provider has prescribed, recommended, or referred you for a particular service does not mean that the service is medically necessary or covered under the terms of your benefit plan. If you fail to obtain Prior Authorization for certain services, you may not be eligible for reimbursement under your plan.
To learn about what services require prior authorization, refer to the Covered Services section of your benefit plan’s Policy or Certificate of Coverage. Please note that the list of services that require prior authorization is subject to change throughout the year. You are responsible for verifying that you have the most current information as of your date of service. You may do so by contacting Member Services.
If you have questions about whether a service requires prior authorization, or what provider network your plan includes, please contact Member Services at 1-844-220-4785.
Drug Exceptions Timeframes and Enrollee Responsibilities
If the medication you take is not on the list of covered drugs for your benefit plan (also called a “formulary”), you can ask us to cover it. This is called a “non-formulary exception.” A request for a non-formulary exception will only be approved if there is documented evidence that the formulary alternatives are not effective in treating your condition; the formulary alternatives would cause adverse side effects; or a contraindication exists such that you cannot safely try the formulary drug.
As a first step, you can contact Member Services for a list of similar drugs that are covered by your plan or you can go to our Find a Medication search for this information. When you have the list, show it to your doctor and see whether he or she is able to prescribe one of the drugs on this list.
If you need to request a non-formulary exception, contact Member Services or access the exception request form in the MyHealth Online website. When you make this request, we may contact your prescriber or physician for information to support your request. After UPMC Health Plan receives your request, we will make our decision within 48 hours. You can request a faster (expedited) decision if you or your doctor believe that waiting up to 48 hours for a decision could seriously harm your health. If your request to expedite is granted, we must give you a decision no later than 24 hours from when we received your request.
If we deny your request for a non-formulary exception, you may first request an internal review of that decision by contacting Member Services. If the denial of the non-formulary exception request is upheld through an internal review, you may then request an external review by an Independent Review Organization (IRO). Requests for an external review can also be made by contacting Member Services at 1-844-220-4785.
Information on Explanations of Benefits (EOBs)
An Explanation of Benefits (EOB) is a statement that explains how UPMC Health Plan has processed and either paid or denied a claim for medical services under your plan. An EOB provides important information about your benefits, including the status of claims and confirmation of costs you are responsible for, such as copayments, deductibles, and coinsurance.
UPMC Health Plan will send you an EOB shortly after a claim for medical services you receive has been processed. You will receive your EOB in the mail, or you can log in to MyHealth Online to opt out of receiving paper EOBs and instead request to receive them electronically. If you receive a service that is paid by UPMC Health Plan at 100% and you are not responsible for any cost-sharing, we will not mail you an EOB. Electronic EOBs are available for all claims.
UPMC Health Plan has created a tutorial designed to help you better understand how to read and locate important information on your EOB.
Explanation of Benefits Tutorial
Coordination of Benefits (COBs)
In addition to your UPMC Health Plan insurance, you may have additional health insurance coverage through your spouse, another employer, or a government-sponsored program such as Medicare or Medical Assistance. If you have insurance coverage from more than one source, your insurance carriers must coordinate the benefits from these different sources and determine which insurance company is your primary carrier. We do this to help ensure that your benefits are paid appropriately and to avoid duplicate payments for the same medical services. We follow standard health insurance industry guidelines to determine which of your insurance carriers is responsible for your primary coverage.
If you have questions regarding the terms and conditions of your coverage, please review your benefit plan’s Policy or Certificate of Coverage. We have posted sample Policy and Certificate of Coverage documents outlining the terms of coverage relative to various commercial individual and Small Business Health Options Program (SHOP) products offered by UPMC Health Plan Inc. and its affiliates, including UPMC Health Options, Inc., UPMC Health Coverage, Inc., and UPMC Health Network, Inc. Please note that if you enroll in any product offered by UPMC Health Plan, Inc. or its affiliates, you will receive policy documents outlining the terms of coverage specific to the product in which you enroll.
View Sample Individual and/or Family Coverage
View Sample Small Business Health Options Program (SHOP) Coverage
The information on this page is specific to UPMC Advantage and Small Business Health Options Program (SHOP) insurance products offered by UPMC Health Plan. If you have any additional questions, please contact Member Services 1-844-220-4785.