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Provider Manual

This manual is for physicians, hospitals and other health care practitioners in the UPMC Health Plan network. Refer to it for quick guidance on the Health Plan's operational and medical management practices.

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Key Points

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Table of Contents

Welcome and Key Contacts – Effective June 6, 2020
A.2Welcome
A.3Provider OnLine
A.4UPMC Health Plan Website
A.6How to Use This Manual
A.7Key Contacts
A.8Table A1 UPMC Health Plan Behavioral Health Services (BHS) Contacts
A.10Table A2 UPMC Community HealthChoices Contacts
A.15Table A3 UPMC for Kids (CHIP)
A.17Table A4 UPMC for Life (Medicare)
A.19Table A5 UPMC for You (Medical Assistance)
A.24Table A6 UPMC Health Plan (Commercial)
A.26Table A7 UPMC Medicare Special Needs Plans (SNP) Contacts
A.28Table A8 Other Program & Government Contacts
Previous version of Chapter A (effective December 10, 2019)
Provider Standards and Procedures – Effective June 8, 2020
B.2Provider Rights, Responsibilities, and Roles
B.15Provider Standards and Requirements
B.25Accessibility Standards
B.30Referrals and Coordination of Care
B.36Hospital Guidelines
B.40Provider Disputes
B.46Provider Credentialing
B.52Medical Assistance Revalidation Requirements
B.54Provider Sanctioning
B.56Provider Termination
B.57Integrated Denial Notice
Previous version of Chapter B (effective December 9, 2018)
UPMC Health Plan (Commercial) – Effective May 30, 2020
C.2Employer Group Products at a Glance
C.4Health Maintenance Organization (HMO)
C.6Enhanced Access: Point-of-Service (POS)
C.8Preferred Provider Organization (PPO)
C.10Exclusive Provider Organization (EPO)
C.12UPMC Consumer Advantage (Consumer Directed Health Care Plans)
C.14UPMC HealthyU
C.15UPMC Inside Advantage
C.17Covered Benefits
C.29Benefit Exclusions
C.30Services That May Be Covered With Certain Restrictions
C.31Complaints & Grievances
C.32Complaint Procedures
C.34Grievance Procedures
C.41UPMC Individual Products
C.45Covered Benefits for Individuals and Their Families
C.48Benefit Exclusions for Individuals and Their Families
C.49Complaints and Grievances for Individuals and Their Families
C.50Complaint Procedures for Individuals and Their Families
C.52Grievance Procedures for Individuals and Their Families
C.58Other Resources and Links
C.59Preventive Guidelines
Previous version of Chapter C (effective July 26, 2014)
UPMC for Kids (CHIP) – Effective May 31, 2020
D.2At a Glance (UPMC for Kids)
D.4Covered Benefits (UPMC for Kids)
D.18Benefit Exclusions (UPMC for Kids)
D.19Member Complaint & Grievance Procedures
D.26Member Rights & Responsibilities
Previous version of Chapter D (effective February 3, 2019)
UPMC for You (Medical Assistance) – Effective June 6, 2020
E.2At a Glance (UPMC for You)
E.3Medical Assistance Managed Care in Pennsylvania
E.4Covered Benefits (UPMC for You)
E.29Other Services (UPMC for You)
E.31Services Already Approved by Another MCO or Fee-for-Service (UPMC for You)
E.32Services Not Covered (UPMC for You)
E.33Program Exception Process (UPMC for You)
E.37The EPSDT Program
E.45Member Complaint and Grievance Procedures
E.65Other Resources and Forms (UPMC for You)
E.66Copayment Schedule (UPMC for You)
Previous version of Chapter E (effective May 24, 2019)
UPMC for Life (Medicare) – Effective May 31, 2020
F.2At a Glance (UPMC for Life)
F.3UPMC for Life HMO
F.5UPMC for Life PPO
F.7UPMC Health Plan Medicare Select and Medicare Supplement
F.8Benefits & Services for HMO and PPO Members
F.16Services Not Covered (UPMC for Life)
F.17Services Requiring Prior Authorization
F.18Appeals & Grievances
Previous version of Chapter F (effective April 10, 2014)
Medical Management – Effective June 7, 2020
G.2 At a Glance (Medical Management)
G.3 Procedures Requiring Prior Authorization
G.5 How to Contact or Notify Medical Management
G.6 When to Notify Medical Management Case Management Services
G.10 Case Management Services
G.13 Special Needs Services
G.15 Health Management Programs
G.17 Clinical and Preventive Health Care Guidelines
G.18 Member and Provider Surveys and Assessments
G.21 Quality Improvement Program
Previous version of Chapter G (effective January 1, 2018)
Claims Procedures – Effective July 4, 2020
H.2 At a Glance (Claims Procedures)
H.5 Submission Guidelines
H.7 Provider OnLine
H.15 Claims Documentation
H.27 Codes & Modifiers
H.34 Reimbursement
H.37 Denials & Appeals
H.38 False Claims
Previous version of Chapter H (effective January 1, 2018)
Member Administration – Effective January 1, 2018
I.2 Member Identification Cards
I.5 Provider and Member Rights and Responsibilities
I.6 Identifying Members and Verifying Eligibility
I.9 Determining Primary Insurance Coverage
I.16 Selecting or Changing a Primary Care Provider
I.21 Removing a Member from a Provider's Practice
Printable PDF
Pharmacy Services – Effective June 6, 2020
J.2 At a Glance (Pharmacy Services)
J.4 Pharmacy Policies
J.6 UPMC Health Plan (Commercial) Pharmacy Program
J.12 UPMC for Kids Pharmacy Program
J.14 UPMC for You (Medical Assistance) Pharmacy Program
J.18 UPMC for Life (Medicare) and UPMC for Life Special Needs Plans Pharmacy Program
J.22 Where to Obtain Prescriptions
Previous version of Provider Manual Chapter J (effective May 27, 2019)
Glossary and Abbreviations – Effective June 7, 2020
K.2 Glossary of Health Care Terms
K.13 Glossary of Behavioral Health Terms
K.18 Abbreviations
Previous version of Chapter K (effective January 1, 2018)
Behavioral Health Services
L.1 At a Glance (Behavioral Health Services)
L.3 Providing Behavioral Health Services to UPMC Health Plan members
L.13 About Being a Network Behavioral Health Provider
L.38 Overview of Quality Improvement
L.41 Fraud and Abuse Reporting
L.42 Information about UPMC Health Plan Claims Procedures
L.43 Glossary of Terms and Abbreviations Prepared for Behavioral Health Providers
Printable PDF
UPMC Medicare Special Needs Plans – Effective May 9, 2020
M.2 At a Glance (UPMC Medicare Special Needs Plans)
M.6 Covered Benefits and Services
M.14 Services Not Covered (UPMC Medicare Special Needs Plans)
M.17 Member Appeals and Grievances
M.20 UPMC Special Needs Plans Model of Care
M.25 UPMC Special Needs Plans – Model of Care — Case Management
M.29 Quick Reference Guide (UPMC Medicare Special Needs Plans)
Previous version of Chapter M (effective June 15, 2019)
UPMC Community HealthChoices (Medical Assistance) –
Effective June 1, 2020
N.2 At a Glance (UPMC Community HealthChoices)
N.3 Community HealthChoices Managed Care in Pennsylvania
N.4 Population Served
N.5 Coordination Between Medicare and UPMC Community HealthChoices
N.6 Covered Benefits
N.28 Linguistic and Disability Competency
N.30 Alzheimer's Disease and Other Dementias
N.31 Other Services (UPMC Community HealthChoices)
N.33 Services Already Approved by Another MCO or Fee-for-Service (UPMC Community HealthChoices)
N.34 Services Not Covered (UPMC Community HealthChoices)
N.35 Program Exception Process (UPMC Community HealthChoices)
N.38 Service Coordination
N.43 Provider Critical Incident Reporting Requirements
N.47 MA Provider Compliance Hotline
N.48 Participant Complaint and Grievance Procedures
N.50 Provider Monitoring
N.51 Electronic Visit Verification
N.52 Other Resources and Forms (UPMC Community HealthChoices)
N.53 Copayment Schedule (UPMC Community HealthChoices)
Previous version of Chapter N (effective February 17, 2020)