ACA Risk Adjustment Claims Submission Announcement

Feb. 2025Important Notices
Notice: Submit your claims for ACA members UPMC Health Plan would like to remind all network providers to submit all outstanding CY 2024 claims for ACA members (Platinum, Gold, Silver, and Bronze plans), no later than April 1, 2025. The U.S. Department of Health & Human Services requires all issuers to submit their calendar year claims to the EDGE server by April 30 every year in order to provide more complete and an accurate picture of each patient’s health status. Any claims adjudicated after the deadline are not included for EDGE data submission. You can submit claims through Provider OnLine at upmchealthplan.com/providers/medical. If you have any questions, please reach out to Provider Services or your physician account executive.

Recent Announcements

The importance of PRD forms for complex patients and staying updated on changes

Personal representative designation (PRD) forms are critical to the care process for patients and providers alike. Not only do PRDs support accurate, efficient, and compliant patient care—they also streamline administrative processes.
Aug. 2025Important Notices

Important announcement: UPMC Health Plan retires MP.PA.147

This communication is in regards to UPMC Health Plan Policy MP.PA.147 – Diagnostic and Surveillance Colonoscopy, 18 Years Old and Older. UPMC Health Plan previously communicated that the prior authorization requirement under this policy would be paused until Sept. 1, 2025. However, policy MP.PA.147 has been retired, and this policy will no longer be implemented or active.
Aug. 2025Important Notices

CMS expands Medicare Advantage RADV audits to all eligible plans

On May 21, 2025, the Centers for Medicare & Medicaid Services (CMS) announced a substantial expansion of its Risk Adjustment Data Validation (RADV) audit program for Medicare Advantage plans.
Aug. 2025What's New