*Medical policies require prior authorization from our Medical Management Department. Submit prior authorizations via Provider OnLine.
If you are a provider and have any questions, contact Medical Management at 1-800-425-7800.
You can view upcoming changes to medical policies at upmchp.us/ProviderRLDocs.
You can view upcoming negative changes to pharmacy policies at upmchp.us/PHChanges.
For details about the InterQual® criteria sets listed in CRM.003, please contact Member Services or Provider Services.
UPMC for Life and UPMC for Life Complete care current and prospective members can click on the link below to access criteria used to make medical necessity determinations. Please create a new account if you currently do not have one under "Create One Healthcare ID."
UPMC Health Plan Self-Registration Transparency for UPMC for Life Medicare Advantage credentialed providers
Peer-to-peer discussions: Providers may request a peer-to-peer discussion with a UPMC medical director by telephone regarding adverse benefit determinations based on medical necessity. Providers should contact Clinical Operations/Utilization Management at 412-454-2765, Monday through Friday from 8 a.m. to 5 p.m.
♦ Disclaimer: Policies and procedures designated with a ♦ are pending approval by the Department of Human Services (DHS) and are not currently approved for use for the Medical Assistance product. Please refer to the UPMC Health Plan website frequently for updates on approval.
Reimbursement Policies
