2023 Announcements

Recent Announcements

Review our commercial product billing guide

Pennsylvania Act 1 of 2023, signed into law this May, requires insurance policies to cover all costs associated with one supplemental breast screening every year for women with increased risk of breast cancer via MRI or ultrasound.

To assist providers in navigating this new law, we are offering recommendations as a guide to aid with compliance.

We encourage you to review our commercial product billing guide for recommendations around complying with Pennsylvania Act 1 of 2023.

If you have any questions or concerns, please contact your physician account executive or call Provider Services at 1-866-918-1595.
Dec. 2023Important Notices

Coming soon: LGBTQIA+ Affirming Provider Designation toolkits

In the coming weeks, we will send the LGBTQIA+ Affirming Provider Designation toolkits to providers who have earned the designation to date. These kits include a provider welcome letter, postcard, badge reel, lapel pin, table tent, and talking points for office staff. Please note that this shipment requires a signature for delivery.

Interested in earning the designation?
We encourage all providers to earn the LGBTQIA+ Affirming Provider Designation. To get started, complete these three modules:
Dec. 2023Important Notices

Flu, RSV, and COVID-19 vaccine recommendations: Fall and winter 2023–2024

Flu, RSV, and COVID-19 vaccines are recommended by the Centers for Disease Control and Prevention (CDC) to reduce the risk of serious illness, hospitalizations, long-term health impacts, and death.

The CDC recommends an annual influenza vaccination for everyone 6 months old and older in the United States.

The agency also recommends an updated COVID-19 vaccine for the 2023–2024 respiratory viral season. Updated vaccines include Pfizer-BioNTech, Moderna, and Novavax COVID-19 vaccines. Everyone 5 years old and older should get one dose of an updated COVID-19 vaccine to be up to date and protected against serious illness from COVID-19. Children 6 months to 4 years old need multiple doses of a COVID-19 vaccine to be up to date, including at least one dose of the updated vaccine. People who are moderately or severely immunocompromised may get additional doses of an updated COVID-19 vaccine.

Single-dose RSV vaccines—Abrysvo and Arexvy—are available for adults 60 years old and older using shared clinical decision making. Additionally, Abrysvo is recommended for individuals who are 32 to 36 weeks pregnant, using seasonal administration, to prevent RSV lower respiratory tract infection in infants.

Specific to pediatrics, children younger than 8 months old who were born during or are entering their first RSV season are recommended to receive one dose of Beyfortus (nirsevimab) (50 mg for infants <5 kg and 100 mg for infants ≥5 kg). Children 8 months to 19 months old who are at increased risk of severe RSV disease and are entering their second season are recommended to receive one 200 mg dose of Beyfortus (nirsevimab).

Visit the CDC website for more information about the flu, RSV, and COVID-19 vaccines:
UPMC Health Plan updates the benefit status of vaccines as information is published by clinical and regulatory groups, such as ACIP, CDC, CMS, USPSTF, and AAP, and will follow all published requirements in a timely manner. Member cost share may be applied in certain circumstances, such as use of an out-of-network provider or use that does not follow ACIP recommendations. Patients should refer to the UPMC Health Plan member website for a full list of participating pharmacies and/or contact Member Services for assistance in determining coverage for various vaccines.

The provider of care is ultimately responsible for providing accurate and compliant information on all submission of claims and/or billing information.
Dec. 2023Important Notices

Mandatory training for Medicare SNP providers

The Centers for Medicare and Medicaid Services (CMS) require all Medicare Special Needs Plan (SNP) providers to complete the Model of Care (MOC) Training every year. The MOC describes the structure and process by which health care services are delivered to SNP members.

For your convenience, UPMC Health Plan has developed a brief online training module on the MOC for our SNP product, UPMC for Life Complete Care (HMO-SNP) (formerly known as UPMC for Life Dual).

To complete the training, go to upmchp.us/snpmoc You will need your tax identification number to sign in and need to attest to completing the training.

Please note that this training must be completed by Feb. 29, 2024.

If you have any questions or concerns, feel free to contact your physician account executive or call Provider Services at 1-866-918-1595.

Thank you for your continued support and the care you provide for our members!
Dec. 2023Important Notices

CME webinar: ADHD Practice Guidelines

Please join us for a live, CME-accredited webinar on Wednesday, April 17, from noon to 1 p.m. The webinar will provide an overview of ADHD practice guidelines and is being offered as part of the UPMC Health Plan Pediatric Collaborative Call series.

During this presentation, experts will discuss:
  • Familiarizing the prescriber with a variety of common problems and solutions in the diagnosis and treatment of ADHD in children and adolescents.
  • Information about the ADHD HEDIS® Quality Metrics.
  • Essential ADHD pharmacy related insights and the UPMC Health Plan resources to health care professionals engaged in prescribing ADHD medications.

Presenters:
  • Craig Coleman, MD, Assistant Professor of Psychiatry, University of Pittsburgh School of Medicine; Attending Psychiatrist, UPMC Western Wellness​, UPMC Behavioral Health of the Alleghenies, CCP Children’s TIPS
  • Debra Zeh, RN, BSN, Senior Director Quality Improvement, Provider Performance​, UPMC Health Plan​
  • Erin McConnell, PharmD, Senior Program Manager,​ Clinical Pharmacy,​ UPMC Health Plan

Register for the ADHD Practice Guidelines Webinar now. This webinar will be recorded.

You may earn continuing medical education (CME) credits for attending this webinar. This activity is approved for AMA PRA Category 1 Credit™, ANCC, ASWB, and ACPE. Other health care professionals will receive a certificate of attendance confirming the number of contact hours commensurate with the extent of participation in this activity.

HEDIS® The Healthcare Effectiveness Data and Information Set (HEDIS®) is a registered​ trademark of NCQA.
Dec. 2023Education/Webinars

Musculoskeletal procedures update

Effective Feb. 1, 2024, UPMC Health Plan will begin requiring prior authorizations for certain musculoskeletal procedures, which will be evaluated using corresponding Interqual Connect criteria.
Dec. 2023Important Notices

Prescription for Wellness order set updates

Effective Nov. 29, 2023, the Prescription for Wellness order set will be updated to include the following enhancements:
  • Addition of a “Diabetes & Metabolic Health” category that includes following topics:
    • Certified Diabetes Care & Education Specialist – Nurses will engage with members to establish condition-based knowledge and educate on symptom management, medication, and self-care.
    • Diabetes Health Coaching – Health coaches provide longitudinal coaching support to address lifestyle skills and behaviors associated with prevention and management of diabetes and other chronic conditions.
    • Diabetes Prevention Program – Designed to support individuals who are at a higher risk for developing T2DM in the future based on certain risk factors such as weight and hypertension.
  • Addition of “Employment” as a topic in the Patient/Family Support Services category

For more information on Prescription for Wellness, contact director Jamie Delu at RxforWellness@upmc.edu.
Nov. 2023Important Notices

Voluntary nationwide recall: Eye drops (Rugby)

The Harvard Drug Group LLC has recalled certain lots of Rugby brand eye drops because of bacteria found in certain samples of product. The bacteria could cause eye infections that result in partial vision loss or blindness. As of the date of The Harvard Drug Group LLC’s recall announcement, Oct. 31, 2023, there had been three adverse events reported that were related to these listed products. Read the full text of the Rugby brand eye drops recall.
Nov. 2023Pharmacy Updates

Voluntary nationwide recall: Eye drops (Leader)

Cardinal Heath Inc. has recalled certain lots of Leader brand eye drops. These over-the-counter products are used for temporary relief of burning, irritation, and redness of the eye. The drops are being recalled because of bacteria found in certain samples of the product. The bacteria could cause eye infections that result in partial vision loss or blindness. Read the full text of the Leader brand eye drops recall.
Nov. 2023Pharmacy Updates

The 988 Suicide & Crisis Lifeline adds nationwide ASL services for Deaf and Hard of Hearing callers

Pennsylvania implemented the 988 Suicide & Crisis Lifeline last July. Like 911, it is simple to remember. This measure helped make it easier for people to access support during a mental health crisis nationwide.

Support has now expanded to include nationwide American Sign Language (ASL) services for people who are Deaf and Hard of Hearing. Callers who are Deaf, DeafBlind, DeafDisabled, Hard of Hearing, and Late-Deafened can connect directly to a trained 988 Lifeline counselor in ASL using these steps:
  1. Visit 988lifeline.org.
  2. Click the “ASL Now” button.
  3. Follow the prompts.

Direct dialing to 988 from a videophone will be available soon. In the meantime, ASL callers can call 1-800-273-TALK (8255) from their videophone to reach ASL services.
Nov. 2023Important Notices

Provider OnLine improvements coming in early 2024

Provider OnLine is a comprehensive resource that allows participating providers to access valuable information online. Starting in early 2024, the site will begin featuring updates to improve your experience. The first of these are updates to member plan (eligibility) information, and improvement to user set up (security management).

Updates to the features include:
  • Improved search speeds.
  • Improved navigation.
  • Expanded participating network information.
  • Policy-level eligibility views.
  • Simplified screen designs.
  • Usability of information presented.

Log in to explore resources
If you have any questions, please contact your physician account executive or call Provider Services at 1-866-918-1595.

Don’t have a Provider OnLine account?
First-time users can create an account by completing an account administrator application.
Nov. 2023Important Notices

Earn CME credits and support your patients' mental health

Caring for your patients’ physical and mental health needs is essential to their overall well-being. These free continuing medical education (CME) courses centered around mental health aim to help you increase the depth and quality of care you provide:*

Suicide and Depression in the Primary Care Office
  • Get information on the prevalence of depression, suicide, and suicidal thoughts. Learn about the importance of screening for depression and suicide within primary care (including an overview of screening tools), best practices for the treatment of depression (including prescribing practices for antidepressants), preferred pathways for primary care to treat and/or refer patients to best address their behavioral health needs, and behavioral health resources and tools provided by UPMC Health Plan.

This activity is approved for AMA PRA Category 1 Credit™ and ANCC. Other health care professionals will receive a certificate of attendance confirming the number of contact hours commensurate with the extent of participation in this activity.

Suicide Prevention and the 988 National Lifeline
  • Educate yourself on the 988 National Suicide Prevention Lifeline’s 24/7 mental health crisis support and prevention resources so you can increase awareness of the lifeline among patients, families, and communities.

This activity is approved for AMA PRA Category 1 Credit™ and ANCC. Other health care professionals will receive a certificate of attendance confirming the number of contact hours commensurate with the extent of participation in this activity.

*Provider is responsible for verifying CME eligibility.
Nov. 2023Education/Webinars

Provider diagnosis documentation: Updates to Medicare Risk Adjustment/HCC

Please join UPMC Health Plan’s Risk Adjustment/HCC Coding Education Program Director Marlana Tice for a live, CME-accredited webinar on Wednesday, Jan. 24, from noon to 1 p.m., that will provide an overview on provider diagnosis code documentation. During this presentation, viewers will learn:

  • An understanding of diagnosis documentation and ICD-10-CM coding importance for Medicare Advantage patients.
  • Examples of best practice documentation for diagnoses as it relates to notable CMS changes and updates to many ICD-10-CM codes/HCC in the new Medicare Advantage risk adjustment model.
  • Ways to improve diagnosing, documenting, and reporting codes with better specificity based on ICD-10-CM classification.

Presenter:
Marlana R. Tice, BA, CCS-P, CPC, CCS, AHIMA-Approved ICD-10-CM/PCS Trainer, Program Director, Risk Adjustment-HCC Coding Education, UPMC Health Plan

Register now. This webinar will be recorded.

Certified coders may earn 1.0 CEU from the American Academy of Professional Coders (AAPC).

You may earn continuing medical education (CME) credits for attending this webinar. This activity is approved for AMA PRA Category 1 Credit™ and ANCC. Other health care professionals will receive a certificate of attendance confirming the number of contact hours commensurate with the extent of participation in this activity.

Provider is responsible for verifying CME eligibility.
Nov. 2023Important Notices

Voluntary nationwide recall: Exela Pharma (October)

"Exela Pharma Sciences, LLC (Exela) is recalling several lots of 8.4% Sodium Bicarbonate Injection, USP. This drug is used for the treatment of metabolic acidosis (a buildup of acid in the body). This drug (NDC: 51754-5001-04) is being recalled because routine inspection of samples found particles of silicone. Administration of an injectable product that contains particulate matter may result in local irritation or swelling in response to the foreign material. If the particulate matter reaches the blood vessels it can travel to various organs and block blood vessels in the heart, lungs, or brain. The blockage can cause stroke and even lead to death. Read the full text of the Excela Pharma recall."
Nov. 2023Pharmacy Updates

Nursing facility ineligible reassessment and certification forms (MA570)

Community HealthChoices patients are required to renew their Community HealthChoices Medicaid eligibility for home- and community-based services in order to continue receiving services and supports in their home rather than needing to receive assistance in an institutional setting such as a nursing facility, ICF/ORC, or other institutional setting. The Pennsylvania Physician Certification Form, also called the MA570, is a required part of the eligibility determination for Community HealthChoices programs.

You may be receiving outreach calls or correspondence from service coordinators, physician account executives, or clinical improvement specialists reminding you that completion of these forms is necessary to prevent delays with your patient’s application. The renewal application requires that the MA570 form be completed in its entirety and signed by an MD or DO. On the form, please remember to indicate your patient’s level of care using the definitions provided on the MA570 form itself. For patients meeting ICF/ORC, page 2 of this form must also be completed. Below is a summary of each available level of care option. It is important to remember that you are only recommending the appropriate level of care for your patient, not determining which setting is most appropriate for them to receive their services.

Nursing Facility Clinically Eligible (NFCE) – The individual has an illness, injury, disability, or medical condition diagnosed by a physician; and as a result of that diagnosed illness, injury, disability, or medical condition, the individual requires care and services above the level of room and board. A physician certifies that the individual is NFCE; and the care and services are either a) skilled nursing or rehabilitation services as specified by the Medicare Program in 42 CFR §§ 409.31(a), 409.31(b)(1) and (3), and 409.32 through 409.35; or b) health-related care and services that may not be as inherently complex as skilled nursing or rehabilitation services, but which are needed and provided on a regular basis in the context of a planned program of health care and management and were previously available only through institutional facilities.

Nursing Facility Ineligible (NFI) – Individuals who do not meet the definition of Nursing Facility Clinically Eligible are considered NFI.

Intermediate Care Facility for Persons with Other Related Conditions (ICF/ORC) – The individual has a diagnosis of Other Related Condition (ORC), a severe, chronic disability (other than a mental illness or an intellectual disability)that manifested before age 22, is likely to continue indefinitely, results in an impairment of either general intellectual functioning or adaptive behavior, and results in substantial functional limitations in at least three of these areas: self-care, understanding and use of language, learning, mobility, self-direction, and capacity of independent living, and requires active treatment—a continuous program that aggressively and consistently gives specialized and generic training, treatment, health services and related services; that focuses on the client acquiring behaviors necessary to function with as much self-determination and independence as possible; and that aims to prevent or slow regression or loss of current optimal functional status.

To prevent delays with your patient’s application, please complete, sign, and return the form to chcscentral@upmc.edu from a secure email or by fax to 1-844-890-7458 as soon as possible, but within 14 days of receipt to avoid any disruption in services or Medicaid eligibility.
Nov. 2023Important Notices

Voluntary nationwide recall: Betaxolol

KVK-Tech Inc. is recalling one lot of Betaxolol tablets, USP 10 mg. This drug is used for the treatment of hypertension (high blood pressure).

KVK-Tech Inc. is recalling one lot of this drug (batch number 17853A) as a precautionary measure because a single Oxycodone HCl tablet 5 mg tablet ws found in one batch of the packaging. Betaxolol tablets have a debossed “K” above bisect “13” on one side and plain on the other side, which looks similar to Oxycodone HCL 5 mg tablets. Inadvertent exposure to a controlled substance, such as oxycodone, in specific patient populations is likely to result in significant slowing in breathing, known as respiratory depression, which is a serious health risk.

As of Sept. 29, 2023, there have been no reports of adverse events related to this recall.

Please see the table below to determine if your product has been recalled:

Product name: Betaxolol tablets USP 10 MG (NDC 10702-0013-01)
Lot number: 17853A
Expiry date:06/2027

If you have Betaxolol 10 mg tablets from this lot, you should stop using/return to place of purchase/discard.

To learn more about this recall, you can take one or more of the steps below.
  • Talk to your doctor or pharmacist.
  • Call KVK-Tech Inc. at 215-579-1842 Ext: 6002. TTY users should call 711. Help is available Monday through Friday from 8 a.m. to 6 p.m. EST.
  • Visit the FDA website at upmchp.us/betaxolol-drugrecall.
    Oct. 2023Pharmacy Updates

Voluntary nationwide recall: Brexafemme

Scynexis, Inc. is recalling two lots of Brexafemme (ibrexafungerp tablets) due to potential cross-contamination with a nonantibacterial ß-lactam drug substance in the ibrexafungerp citrate used to manufacture the Brexafemme tablets. This drug is used as an antifungal for the treatment of vulvovaginal candidiasis (VVC) and the reduction of the incidence of recurrent vulvovaginal candidiasis (RVVC). Read the full text of the voluntary Brexafemme recall.
Oct. 2023Pharmacy Updates

UPMC begins sharing biometric screening results for its new employees with consent

New employees complete a biometric screening as part of UPMC’s hiring process. During the biometric screening they have clinically appropriate titers and total cholesterol, triglyceride, and glucose levels drawn.

Effective September 2023, new UPMC employees may consent to share all preplacement-related lab work with their PCP. PCPs will receive results from Quest Quanum based on their preferred method on file with Quest. Providers without a method on file will receive results via fax.

Employees may consult with their PCP office regarding these test results. Additionally, UPMC Employee Health will offer any recommended vaccinations, health coaching, and other wellness-related services.
Oct. 2023Important Notices

Voluntary nationwide recall: Sucralfate

VistaPharm LLC has recalled one lot of Sucralfate Oral Suspension, 1 g/10 mL due to Bacillus cereus contamination in the product. This drug is used as an anti-ulcer therapeutic. Read the full text of the Sucralfate recall.
Oct. 2023Pharmacy Updates

Voluntary nationwide recall: Cyclosporine

Novartis is recalling one lot of Sandimmune Oral solution (cyclosporine oral solution, USP), 100 mg/mL, due to crystal formation observed in some bottles. This drug is used to prevent organ rejection in kidney, liver, and heart transplants. Read the full text of the Cyclosporine recall.
Oct. 2023Pharmacy Updates

CME webinar: Intimate Partner Violence: Driving Forward Toward Solutions (recorded)

Marlex Pharmaceuticals Inc. is recalling two lots of this drug because of a label mix-up. Bottles of Digoxin Tablets USP 0.125 mg are incorrectly labeled and contain Digoxin Tablets USP 0.25 mg. Bottles of Digoxin Tablets USP 0.25 mg are incorrectly labeled and contain Digoxin Tablets USP 0.125 mg. This drug is used for the treatment of mild to moderate heart failure. Read the full text of the voluntary Digoxin recall.
Sep. 2023Important Notices

Drug recall: Voluntary nationwide recall: Digoxin

"Please make time to listen to this on-demand, CME-accredited webinar on intimate partner violence (IPV)—a global health issue that affects physical and mental health and well-being. Judy C. Chang, MD, MPH, who has dedicated much of her career to sharing strategies and tactics around IPV prevention and interventions, discusses a range of topics around this issue during the webinar.
What the webinar will cover
  • Overview of intimate partner violence (IPV)
  • Impact of IPV on women’s health
  • Lessons learned from the COVID-19 pandemic
  • How we can help women experiencing IPV
Presenter:
Judy C. Chang, MD, MPH
Associate Professor
Departments of Obstetrics, Gynecology and Reproductive Sciences and General Internal Medicine
Assistant Dean of Medical Student ResearchUniversity of Pittsburgh School of Medicine

Watch now

You may earn continuing medical education (CME) credits for attending this webinar. This activity is approved for AMA PRA Category 1 Credit™ and ANCC. Other health care professionals will receive a certificate of attendance confirming the number of contact hours commensurate with the extent of participation in this activity.Provider is responsible for verifying CME eligibility."
Sep. 2023Pharmacy Updates

Drug recall: Voluntary Nationwide Recall: Tydemy (Lupin July)

Lupin Pharmaceuticals Inc. has recalled two lots of Tydemy™ (Drospirenone, Ethinyl Estradiol and Levomefolate Calcium Tablets 3 mg/0.03 mg/0.451 mg and Levomefolate Calcium Tablets 0.451 mg) because they did not pass stability testing, which could impact the effectiveness of the product. Taking an ineffective product could potentially result in unexpected pregnancy. Read the full text of the voluntary Tydemy recall.
Sep. 2023Important Notices

September is National Recovery Month & earn CME credits on a timely webinar series

September is National Recovery Month, and you are invited to watch a timely, CME-accredited webinar series on the topic. Michael Lynch, MD, FACMT, UPMC Health Plan Quality and Substance Use Disorder Services Medical Director and University of Pittsburgh School of Medicine Associate Professor of Emergency Medicine and Medical Toxicology, leads this four-part series. Watch these recorded webinars to build your knowledge base:
You may earn continuing medical education credits (CMEs) for completing each course.*

*Provider is responsible for verifying CME eligibility.
Sep. 2023Important Notices

Make sure your data is current in the National Plan & Provider Enumeration System

Please review your National Provider Identifier (NPI) data in the National Plan & Provider Enumeration System (NPPES) as soon as possible to monitor that accurate provider data is displayed. Providers are legally required to keep their NPPES data current.

If you have any questions about NPPES, refer to https://nppes.cms.hhs.gov/webhelp/nppeshelp/HOME%20PAGE-SIGN%20IN%20PAGE.html.
Aug. 2023Important Notices

New policy: MP.PA.104

Effective Sept. 15, 2023, UPMC Health Plan will implement a new medical policy: Elective Percutaneous Coronary Intervention (PCI) – MP.PA.104. This is a change from the previously communicated effective date of Sept. 1, 2023, as posted in the August issue of Provider Partner Update. This policy will require prior authorization of PCI services to be considered for reimbursement. View more information on MP.PA.104.
Aug. 2023Important Notices

UPMC Health Plan achieves high ratings in provider satisfaction

In 2022, 95 percent of physician practice survey respondents indicated they would recommend UPMC Health Plan to other physician practices. In addition, respondents ranked UPMC Health Plan in the 95th percentile when comparing UPMC Health Plan to other Health Plans with whom they participate.

UPMC Health Plan contracts with Press Ganey, formerly SPH, to measure provider satisfaction levels and to meet one or more NCQA Health Plan Accreditation Standards. Press Ganey incorporates a percentile ranking to allow health plans to compare performance to a cohort of similar health plans who initiate a provider satisfaction survey.

You may be a randomly selected provider invited to participate in the 2023 survey that will begin this month! The survey will ask for feedback on your experience with UPMC Health Plan. Watch for an invitation in the mail or via email later this month.
Aug. 2023Important Notices

Complete reinstated PROMISe ID enrollment requirements to avoid claim denials for Medical Assistance, CHC, and CHIP

All service locations must comply with the reinstated PROMISe™ ID enrollment requirements to avoid claim denials for patients with UPMC for You (Medical Assistance), UPMC for Kids (Children’s Health Insurance Program/CHIP), and UPMC Community HealthChoices coverage for service dates starting Sept. 1, 2023. Providers who offer, order, refer, or prescribe services for patients with these coverage types must take the following steps to comply with the requirements:
  • Enroll every service location where they see members with the Department of Human Services (DHS).
  • Obtain a PROMISe ID (also known as a Medicaid ID or MPI) and revalidate these locations as required every five years.
  • Log in to PROMISe to check the revalidation dates of each service location and submit revalidation applications at least 60 days prior to the revalidation dates.
  • Enroll any service locations that are not listed in PROMISe.

      • Review Medical Assistance Bulletin 99-21-01 and Medical Assistance Bulletin 99-22-11 to learn more about the reinstatement of provider enrollment requirements.

      Contact DHS with questions on provider enrollment, revalidation, enrollment fees, site visits, and criminal background checks. You can reach DHS at 1-800-537-8862 (option 2, option 4, option 2).
      Jul. 2023Important Notices

Recall: Albuterol Sulfate

Cipla US is recalling six batches of Albuterol Sulfate Inhalation Aerosol, 90 mcg (200 Metered Inhalation), manufactured in November 2021. They initiated the recall because of a complaint where leakage was observed through the inhaler’s inhaler valve. This drug is used to treat asthma and to prevent exercise-induced asthma. Read the full text of the Albuterol Sulfate recall.
Jul. 2023Pharmacy Updates

New implementation date for Skilled Nursing and Personal Care Shift Services & MA & MP.PA.050.1

We previously communicated in the July Provider Partner Update that effective Aug. 1, 2023, per Pennsylvania DHS, HCPCS T1019 will be discontinued and replaced with the following HCPCS codes and modifiers:
  • G0156 with modifier U7 for pediatric aide services by a non-legally responsible relative
  • G0156 with modifiers U7/SC for pediatric aide services by a legally responsible relative
  • G0156 U7 TT – Services of home health/hospice aide in home health or hospice settings, each 15 minutes (services by a non-legally responsible relative) – extra patient
  • G0156 U7 SC TT – Services of home health/hospice aide in home health or hospice settings, each 15 minutes (services by a legally responsible relative) – extra patient

Please be aware that due to an additional and more recent communication from PA DHS, the implementation date was changed to Oct. 1, 2023 (previously communicated in the July PPU as Aug. 1, 2023).
Jul. 2023Important Notices

UPMC Health Plan achieves high ratings in provider satisfaction

In 2022, 95 percent of physician practice survey respondents indicated they would recommend UPMC Health Plan to other physician practices. In addition, respondents ranked UPMC Health Plan in the 95th percentile when comparing UPMC Health Plan to other Health Plans with whom they participate.

UPMC Health Plan contracts with Press Ganey, formerly SPH, to measure provider satisfaction levels and to meet one or more NCQA Health Plan Accreditation Standards. Press Ganey incorporates a percentile ranking to allow health plans to compare performance to a cohort of similar health plans who initiate a provider satisfaction survey.

You may be invited to participate in the 2023 survey that will begin next month. The survey is provided to a random sampling of primary care network providers and will ask for feedback on your experience with UPMC Health Plan. Watch for an invitation in the mail or via email next month!
Jul. 2023Important Notices

CME webinar: 2023 UPMC for Life Medicare Product Training

Please join us for a live, CME-accredited webinar Tuesday, July 11, from 7 a.m. to 8 a.m., that will provide an overview on Medicare.

During this presentation, our expert will discuss:
  • The difference between Medicare Fee for Service and Medicare Advantage, why Medicare Advantage exists, and where it’s going in the future.
  • The importance of value-based care.
  • UPMC Health Plan’s Medicare Advantage Plan, UPMC for Life.
  • Care managers and what they do, optimizing information flow.
  • Health outcomes, accountability for costs, and why this is a better patient experience.

Presenter:
  • Barbara Kevish MD, AVP, Medicare Medical Services, UPMC Health Plan

Register now. This webinar will be recorded.

You may earn continuing medical education (CME) credits for attending this webinar. This activity is approved for AMA PRA Category 1 Credit™ and ANCC. Other health care professionals will receive a certificate of attendance confirming the number of contact hours commensurate with the extent of participation in this activity.

Provider is responsible for verifying CME eligibility.
Jun. 2023Education/Webinars

CME webinar: Fluoride Varnish and the Pediatric Patient – Making It Work for Your Office

Please join us for a live, CME-accredited webinar Wednesday, Aug. 9, from noon to 1 p.m. that will provide an overview of topical fluoride varnish. This webinar is being offered as part of the Pediatric Collaborative Call series.

During this presentation, experts will discuss:
  • How to understand the oral health benefits of fluoride.
  • How applying fluoride varnish can impact the medical office.
  • The future implications of applying fluoride varnish.

Presenters:
  • Richard Celko, DMD, MBA, Chief Dental Officer, UPMC; Adjunct Assistant Professor, University of Pittsburgh School of Dental Medicine
  • Tanya Gayley, BSDH, RDH, PHDHP, EFDA, Dental Care Manager
  • Barbara Hammerschmitt, MPH, RDH, PHDHP, Dental Care Manager
  • Nora Lugaila, BSDH, RDH, PHDHP, Dental Care Manager
  • Rebecca Nagle, MS, BSN, RN CPHQ, Director of Medicaid and CHIP Quality Program
  • Deborah Moss, MD, MPH, FAAP, Professor of Pediatrics, Children’s Hospital of Pittsburgh; Pediatric Medical Director, UPMC Health Plan

Register for the Fluoride Varnish and the Pediatric Patient: Making It Work for Your Office webinar now. This webinar will be recorded.

Provider is responsible for verifying continuing medical education (CME) eligibility.

You may earn continuing medical education (CME) credits for attending this webinar. This activity is approved for AMA PRA Category 1 Credit™ and ANCC. Other health care professionals will receive a certificate of attendance confirming the number of contact hours commensurate with the extent of participation in this activity.
Jun. 2023Education/Webinars

Continuous coverage unwinding

The continuous coverage unwinding period began on April 1. Medicaid recipients may have questions about their Medicaid eligibility determination.

We developed this FAQ to help you educate patients who have already submitted their renewal.

The goal of this material is to:

Patients' Medical Assistance and SNAP Benefits Renewal

"Effective May 18, 2023, patients renewal dates for both Medical Assistance and the Supplemental Nutrition Assistance Program (SNAP) benefits will be available in Provider OnLine.

You can access these dates by clicking on the ""Eligibility"" view on the left navigation panel and entering the members information in the search function. Dates will be available for both UPMC for You members and UPMC Community HealthChoices participants.

For UPMC for You-credentialed providers, we have also compiled a comprehensive list of your UPMC for You patients who have an upcoming Medicaid and/or SNAP renewal due date. This list is available to you through Provider OnLine under the Reports tab at the site level within the Clinical folder.

We encourage you to use this information to proactively educate your patients about their upcoming renewals to help them avoid a loss in coverage and benefits.

Below are instructions you can provide to your patients on how to complete their Medical Assistance and SNAP renewals on time.

Renewals: (Medicaid and SNAP)
  • COMPASS is the Department of Human Services’ (DHS) online tool to manage benefit information and apply for services. Recipients can complete their renewal by visiting compass.state.pa.us to renew their benefits online.
  • Call the Consumer Service Center for Health Care Coverage at 1-866-550-4355 to renew benefits by phone.
  • Visit their local County Assistance Office (CAO) to renew benefits in person.Receive a renewal packet in the mail. It will explain how to renew Medicaid benefits. Patients should complete the renewal packet and mail it back to their CAO by the due date listed.

If your patients have questions about their renewal, they can call the Statewide Customer Service Center at 1-877-395-8930 or 215-560-7226 in Philadelphia. They can also call the Customer Service Center to ask questions about their benefits or report changes to their contact information, income, and more. The Customer Service Center cannot renew patients benefits by phone.

Additional important information to share with patients about Continuous Coverage can be found on this flyer or by visiting dhs.pa.gov/PHE/Pages/Stakeholder-Resources.aspx."
May 2023Important Notices

Voluntary nationwide recall: Akorn Operating Company LLC

Akorn Operating Company LLC is initiating a voluntary recall of various within-expiry human and animal products. As a result of a bankruptcy, the firm is removing several products from the market due to the discontinuation of the Quality program, which would result in the company’s inability to assure that products meet the identity, strength, quality, and purity standards. Read the full text of the Akorn voluntary recall.
May 2023Important Notices

Earn CME credits for National Mental Health Month

Caring for your patients’ physical and mental health needs is essential to their overall well-being. These free continuing medical education (CME) courses centered around mental health aim to help you increase the depth and quality of care you provide:*

  • Suicide and Depression in the Primary Care Office
    • Get information on the prevalence of depression, suicide, and suicidal thoughts. Learn about the importance of screening for depression and suicide within primary care (including an overview of screening tools), best practices for the treatment of depression (including prescribing practices for antidepressants), preferred pathways for primary care to treat and/or refer patients to best address their behavioral health needs, and behavioral health resources and tools provided by UPMC Health Plan.
  • Perinatal Psychiatry: Updates for the OB-GYN in a Rapidly Evolving Field
    • Learn about perinatal psychiatry and the impact that COVID-19 has had on maternal mental health, updates in pharmacological management of perinatal depression, and implementing awareness of health care disparities as it relates to perinatal psychiatry.
  • Suicide Prevention and the 988 National Lifeline
    • Educate yourself on the 988 National Suicide Prevention Lifeline’s 24/7 mental health crisis support and prevention resources so you can increase awareness of the lifeline among patients, families, and communities.
  • Pediatric Behavioral Health: Best Practices for Primary Care
    • Enhance your knowledge of pediatric screening for behavioral health issues.

*Provider is responsible for verifying CME eligibility.
May 2023Education/Webinars

Voluntary medical device correction: Freestyle Libre

Abbott has initiated a voluntary medical device correction for readers that are used as part of the FreeStyle Libre, FreeStyle Libre 14 Day, and FreeStyle Libre 2 Flash glucose monitoring systems. These systems continuously measure the blood glucose levels of individuals with diabetes. Read more about the voluntary medical device correction for Freestyle Libre.
Apr. 2023Important Notices

Recall: Dabigatran

Ascend Laboratories LLC has recalled 10 lots of Dabigatran capsules due to the presence of a nitrosamine, N-nitroso-dabigatran, above the established Acceptable Daily Intake (ADI) level. Dabigatran is a drug used as an oral anticoagulant to lower the risk of stroke and blood clots. Read more about the Dabigatran recall.
Apr. 2023Pharmacy Updates

Withdrawal: Makena

On March 7, 2023, Covis Pharma announced that it is withdrawing Makena (hydroxyprogesterone caproate injection; also referred to as 17-OHPC) from the market. This drug is used to reduce the risk of preterm birth in women who are pregnant with one baby and have a history of spontaneous preterm birth. Read more about the Makena withdrawal.
Apr. 2023Pharmacy Updates

Recall: Atovaquone

Camber Pharmaceuticals Inc. is recalling Atovaquone Oral Suspension, USP 750 mg/5 mL, lot #E220182 with an expiration date of 12/2023, due to possible bacterial contamination in the product. This drug is used for the prevention and treatment of a lung infection called Pneumocystis jiroveci pneumonia (PCP) in adults and children 13 years old and older who cannot tolerate other medicines, such as trimethoprim-sulfamethoxazole. Read the full text of the Atovaquone recall.
Apr. 2023Pharmacy Updates

Earn the UPMC LGBTQIA+ Affirming Provider designation

"The LGBTQIA+ Affirming Provider designation makes it easy for members to find providers who have been trained to create a safe, welcoming patient-provider relationship for LGBTQIA+ patients and validate the LGBTQIA+ patient.

Eligibility
Providers must complete the appropriate learning modules and attestation and be listed in either the UPMC Health Plan Find Care provider directory or the UPMC Health Services Find a Doctor provider directory to earn the designation.

Earning
  • Providers: Complete three learning modules and an attestation. Each learning module is approved for a maximum of 1.0 AMA PRA Category 1 Credits™. These credits also qualify for the patient safety or risk management requirement.
  • Non-UPMC-employed providers: Access the learning modules and attestation on UPMC Health Plan’s patient health resources page.
  • UPMC-employed providers: Access the learning modules and attestation through HR Direct Learning by searching for ""Affirmative Communication with LGBTQIA+ Patients & Members.""

Encouraging
Providers who earn this designation will receive the following items to let patients know that the provider has earned this important and supportive designation:
  • LGBTQIA+ Affirming Provider badge reel
  • LGBTQIA+ Affirming Provider pin
"
Apr. 2023Important Notices

CME webinar: Suicide and Depression in the Primary Care Office (recorded)

"What the webinar will cover*
  • Information on the prevalence of depression, suicide, and suicidal thoughts and behaviors from a state and national perspective
  • How to incorporate routine screenings for depression and suicide into daily practice
  • A multipronged approach in the treatment for depression and suicide in primary care
  • How to determine when and how to refer to behavioral health services
  • The spectrum of UPMC Health Plan resources that support behavioral health conditions

Presenters:
Geoff Neimark, MD
Chief Medical Officer
Community Care Behavioral Health Organization

Nicholas DeGregorio, MD, MMM, FACP
AVP, Medicaid Medical Services
UPMC Health Plan

Watch now
Watch the recording of the Suicide and Depression in the Primary Care Office webinar.

Provider is responsible for verifying continuing medical education (CME) eligibility.

*This activity is approved for AMA PRA Category 1.5 Credits™ and ANCC. Other health care professionals will receive a certificate of attendance confirming the number of contact hours commensurate with the extent of participation in this activity."
Mar. 2023Education/Webinars

Recall: Brimonidine

Apotex Corp. is voluntarily recalling six lots of Brimonidine Tartrate Ophthalmic Solution, 0.15%. The drug is used to reduce elevated intraocular pressure (IOP) in patients with open-angle glaucoma or ocular hypertension. This recall is due to cracks that have developed in some of the Brimonidine tartrate ophthalmic solution bottles’ caps. Read the full text of the Brimonidine recall.
Mar. 2023Pharmacy Updates

IMPORTANT NOTICE: End of COVID-19 PHE

IMPORTANT NOTICE: The Biden Administration has announced that the COVID-19 PHE is expected to end on May 11, 2023. Some benefits or flexibilities made available during the PHE will expire on that date. UPMC Health Plan will update this Appendix A with more information about expiring benefits prior to the end of the PHE.
Mar. 2023Important Notices

CME webinar: Vaccination Acceptance & Addressing Today’s Challenges

"Please join us for a live, CME-accredited webinar Wednesday, May 17, from noon to 1 p.m. that will provide an overview of how to address vaccine acceptance. This webinar is being offered as part of the Pediatric Collaborative Call series.

During this presentation, experts will discuss:
  • The history of vaccine development, effectiveness, and attitudes.
  • Current trends in vaccination rates.
  • The challenge of vaccine hesitancy.

Presenters:
  • Andrew Nowalk, MD, PHD, Associate Professor of Pediatrics, University of Pittsburgh; Clinical Director of Infectious Diseases, UPMC Children’s Hospital of Pittsburgh; Co-Director, Pediatrics Residency Program, UPMC Children’s Hospital of Pittsburgh
  • Mary Ann Rigas, MD, FAAP, Medical Director of Pediatrics, UPMC Cole; President, Pennsylvania Chapter of the American Academy of Pediatrics
  • Todd Wolynn, MD, MMM, IBCLC, CEO—Kids Plus Pediatrics; Advisory Board President, Shots Heard Round the World
  • Deborah Moss, MD, MPH, FAAP, Professor of Pediatrics, Children’s Hospital of Pittsburgh; Pediatric Medical Director, UPMC Health Plan
  • Robert Rutkowski, MD, FAAP, Medical Director, Practice Transformation and Provider Relations, UPMC Health Plan; Co-Lead Physician, UPMC CCP Children’s Community Pediatrics, Shenango
    • Alin Severance, MD, Medical Director, Behavioral Health Services, UPMC Health Plan; Associate Medical Director, Community Care Behavioral Health Organization

Register now. This webinar will be recorded.

You may earn continuing medical education (CME) credits for attending this webinar.This activity is approved for AMA PRA Category 1 Credit™ and ANCC. Other health care professionals will receive a certificate of attendance confirming the number of contact hours commensurate with the extent of participation in this activity.

Provider is responsible for verifying CME eligibility."
Mar. 2023Education/Webinars

Stimulant medication shortages

"UPMC Health Plan has become aware of shortages for generic stimulant medications used to treat attention-deficit/hyperactivity disorder. We wanted to provide details on how your patients (our members) may navigate these shortages since we are not sure how long they will last.

Through outreach, we have learned that most pharmacies have or can acquire brand-name versions of these drugs. If a patient’s pharmacy does not have one of the generic medications listed below, a one-time override for the noted generic’s brand counterpart may be requested by you, your patient, or the patient’s pharmacy. This process is applicable to all lines of business.

  • Amphetamine salts immediate-release tablet, dextroamphetamine-amphetamine immediate-release tablet (generics for Adderall tablet)
  • Dextroamphetamine-amphetamine extended-release capsule (generics for Adderall XR capsule)
  • Methylphenidate extended-release tablet (generics for Concerta tablet)
    • Note: Brand Concerta is preferred on the Statewide Preferred Drug List for Medical Assistance and Community HealthChoices, so an override should not be needed for members with primary coverage through UPMC for You or UPMC Community HealthChoices.

In the case of UPMC Health Plan Commercial members, brand claims may pay without an override but with higher out-of-pocket costs. To avoid this financial burden on our members, please reach out for an override. With the override, the cost for brand would be the same as generic for a Commercial member whose plan does not have a deductible or whose deductible has already been met.

To obtain overrides or to ask questions, providers can call Pharmacy Services at 1-800-979-8762. Pharmacies can call the Pharmacy Help Desk at 1-800-396-4139 and follow the prompts to speak with the Health Plan. Members can call the Member Services phone number on their member ID card.

We understand that this process is time consuming, but our shared goal is member and patient satisfaction. We will continue to monitor the situation and provide updates accordingly."
Mar. 2023Pharmacy Updates

Recall: Tirosint

IBSA Pharma Inc. has recalled 27 lots of TIROSINT®-SOL (levothyroxine sodium) Oral Solution because these lots may be subpotent (they have a lower than normal or acceptable potency). Read the full text of the Tirosint recall.
Feb. 2023Pharmacy Updates

Listening to and acting on feedback

Our goal is to provide our members with access to high-quality care. As a partner in care, you are key in helping us achieve this goal. Surveys give us actionable information that can help improve our members’ health care experiences and promote a high level of care.

Gathering feedback
Every year, UPMC Health Plan members provide anonymous feedback on their health care experiences in these ways:
  • The Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey for Commercial, Medicaid, Medicare, and CHIP members
  • The Qualified Health Plan Enrollee Experience survey (QHP) for Marketplace members

Marketing accreditation requirements
These surveys are required to maintain ratings and accreditations:
  • National Committee for Quality Assurance (NCQA) accreditation
  • NCQA ratings
  • Centers for Medicare and Medicaid Service (CMS) star ratings

Reviewing the results1
While we know that you provide excellent care to our members, there are always areas for improvement. The answers to these questions from the 2022 CAHPS surveys identify these opportunities.

Case coordination
  • How often did your doctor have your medical records or other information about your care?
  • How often did you get test results as soon as you needed them?
  • How often did someone from your personal doctor’s office follow up with test results?
  • How often did you and your personal doctor talk about all the prescription medicines you were taking?
  • Did you get the help you need from your personal doctor’s office to manage your care among these different providers and services?
  • How often did your personal doctor seem informed and up to date about care you got from specialists?

Getting care quickly
  • When you needed care right away, how often did you get care as soon as you needed?
  • When you made an appointment for a check-up or routine care at a doctor’s office or clinic, how often did you get an appointment as soon as you needed?

Getting needed care
  • How often was it easy to get the care, tests, or treatment that you needed?
  • How often did you get an appointment to see a specialist as soon as you needed?

Annual flu vaccine
  • Have you had a flu shot since July 1?

Find care options
It is important for our members to get the right care at the right time. You can help by encouraging them to use our new text messaging Care Finder program. Members can text “SERVICES” to 478-762 to learn about UPMC AnywhereCare visits, talk to a nurse through the UPMC MyHealth 24/7 Nurse Line, or work with the Prescription for Wellness team to make healthy lifestyle changes.

To view the CAHPS survey for each line of business1, please visit these websites:

As always, thank you for making outstanding care a priority.

1Please note that the CAHPS survey varies slightly depending on the member’s insurance plan. For example, the survey for individual plan members is different from the survey for Medicaid members.

CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).
Feb. 2023Important Notices

EOP emails starting again

Please note, email notifications of new explanation of payments (EOPs) have resumed as of February 6. As previously indicated, there was no interruption in the posting of EOPs and EOPs will continue to be posted on Provider OnLine as they are finalized.
Feb. 2023Important Notices

Recall: Quinapril

Lupin Pharmaceuticals Inc. has recalled four lots of Quinapril Tablets because they contain of a nitrosamine impurity, N-Nitroso-Quinapril, observed in recent testing above the Acceptable Daily Intake (ADI) level. Such impurities may increase the risk of cancer if people are exposed to them above acceptable levels over long periods of time. Read the full text of the Quinapril recall.
Jan. 2023Pharmacy Updates