Enhanced claim editing effective July 1

At UPMC Health Plan, we value our relationships with our network providers and appreciate the excellent care you give to our members. As part of a world-class health care delivery system, we strive to improve our processes where applicable and promote and reflect efficient and current health care practices.

Beginning July 1, 2024, UPMC Health Plan will be implementing additional enhancements to expand claim editing programs that promote correct coding and billing practices. The claim edits will continue to reflect guidelines set forth by industry authorities. Our goal is to process claims consistently and in accordance with best practice standards.

These enhancements take into consideration UPMC Health Plan’s historical claims experience as well as industry-standard guidelines, including:

• AMA CPT coding guidelines.
• National and regional Medicare policies.
State Medicaid guidelines.

After the implementation, you may receive claim denials based on these enhanced comprehensive claim editing concepts on your Explanations of Payment or electronic remittances. Additional resources and supporting documentation will be provided over the next several months at upmchp.us/claimsediting for your reference.

As always, thank you for taking care of our members. If you have any questions, please reach out to your physician account executive or call Provider Services at 1-866-918-1595.