Enhanced claim editing effective July 1

Apr. 2024Important Notices

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.


Recent Announcements

HPV Vaccination Resources

To help protect against cancers later in life, it is important to increase HPV vaccination rates in adolescents starting at age 9. According to the Centers for Disease Control and Prevention, HPV vaccination is routinely recommended at age 11 or 12, but the vaccine can be given starting at age 9.1 The Pennsylvania Cancer Coalition cites the following potential benefits of initiating the HPV vaccine series at age 9:2
Mar. 2025Important Notices

Special notice: Important policy changes

Effective May 1, 2025, the following policies will be retired and replaced with prior authorization policies. For more information, please visit upmchp.us/policiesandprocedures.
Mar. 2025Important Notices

CME Webinar: Essential Best Practices for Newborn Care: Ensuring Healthy Beginnings Through Comprehensive Care

Please join us for a live, CME-accredited webinar on Wednesday, May 7, from noon to 1 p.m. that will provide an overview of newborn care.
Feb. 2025Education/Webinars