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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.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 October 4, 2020
B.1Chapter B Table of Contents
B.2Provider Rights, Responsibilities, and Roles
B.16Provider Standards and Requirements
B.26Accessibility Standards
B.31Referrals and Coordination of Care
B.37Hospital Guidelines
B.41Provider Disputes
B.47Provider Credentialing
B.53Medical Assistance Revalidation Requirements
B.55Provider Sanctioning
B.57Provider Termination
B.58Integrated Denial Notice
Previous version of Chapter B (effective September 14, 2020)
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 October 4, 2020
F.1 Chapter F Table of Contents
F.2 At a Glance (UPMC for Life)
F.3 UPMC for Life HMO
F.5 UPMC for Life PPO
F.7 UPMC Health Plan Medicare Select and Medicare Supplement
F.8 Benefits & Services for HMO and PPO Members
F.18 Services Not Covered (UPMC for Life)
F.19 Services Requiring Prior Authorization
F.20 Appeals & Grievances
Previous version of Chapter F (effective May 31, 2020)
Utilization Management and Medical Management – Effective October 3, 2020
G.1 Chapter G Table of Contents
G.2 At a Glance
G.3 Procedures Requiring Prior Authorization
G.5 How to Contact or Notify Utilization Management
G.6 When to Notify Utilization Management
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 June 7, 2020)
Claims Procedures – Effective September 15, 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 July 4, 2020)
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 – Effective October 4, 2020
L.1 Chapter L Table of Contents
L.2 At a Glance (Behavioral Health Services)
L.3 Providing Behavioral Health Services to UPMC Health Plan members
L.17 Provider Availability Standards
L.20 Coordination of Care, Referrals, and Transition of Care to Other Providers
L.22 Referral Assistance Given to Members in Selecting Behavioral Health Providers
L.23 Statement of UPMC Health Plan’s Policy on Incentives
L.24 Clinical Practice Guidelines for Common Behavioral Health Disorders
L.25 UPMC Health Plan Pharmacy Formulary Information
L.26 Member Rights and Responsibilities
L.28 About Being a UPMC Health Plan Behavioral Health Services Network Provider
L.35 Facility/Organization Assessment, Contracting, and Reassessment
L.40 Termination of Provider from the UPMC Health Plan Behavioral Health Services’ Network
L.42 Record Keeping Standards
L.46 Provider Cultural Competency
L.47 Provider Performance Tracking
L.48 Provider Satisfaction
L.49 Provider Disputes
L.49 Provider Education
L.49 Provider Advisory Committee
L.49 New Technology
L.50 Case Management Programs
L.52 Quality Improvement Overview
L.54 Fraud and Abuse Reporting
L.56 UPMC Health Plan Claims Procedures
Previous version of Chapter L
UPMC Medicare Special Needs Plans – Effective October 4, 2020
M.1 Chapter M Table of Contents
M.2 At a Glance (UPMC Medicare Special Needs Plans)
M.6 Covered Benefits and Services
M.15 Services Not Covered (UPMC Medicare Special Needs Plans)
M.18 Member Appeals and Grievances
M.21 UPMC Special Needs Plans Model of Care
M.26 UPMC Special Needs Plans – Model of Care — Case Management
M.30 Appendix A: Integrated Denial Notice
M.32 Appendix B: Other Resources
Previous version of Chapter M (effective May 9, 2020)
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)