As a participating provider, you can access valuable information online by entering your user ID and password in the login box on this page. First-time users can create an account by contacting their office Provider OnLine Account Administrator or by calling 1-800-937-0438.
With UPMC Health Plan's Provider OnLine, you can:
- View up-to-date eligibility, PCP information, and covered benefits.
- View real-time patient and claims data.
- View members' historical coverage information.
- Chat with a UPMC Health Plan provider service representative in real time.
- Receive 24-hour access to claims and coverage information.
- Interact with the Health Plan on claims issues via a messaging system.
- Determine a patient's primary insurance coverage.
- Get an immediate response if mistakes are made submitting a claim (using HIPAA 837 forms).
A provider office should appoint a staff member to serve as Security Officer. This person will:
- Serve as the provider practice’s primary contact with UPMC Health Plan regarding Provider OnLine security issues.
- Grant access to Provider OnLine to certain staff members on the provider's behalf.
- Make Provider OnLine security requests to UPMC Health Plan on behalf of other staff members.
- Provider OnLine Account Administrator Application
If you have not accessed your Provider OnLine account in the past six months, your account may be disabled. You can request that your account be reactivated by contacting 1-800-937-0438.
UPMC Health Plan's claims processing system allows providers to take advantage of enhanced access to information, including the ability to immediately correct claims that have missing information, incorrect procedure codes, or other errors.
Electronically filed claims may be submitted in the following ways:
Individual claim entry
Individual claim entry, known as Prelog, is available to providers with established Health Plan online accounts. This feature allows direct submission of both professional (HCFA/CMS-1500) and institutional (UB-92) claims via a user-friendly interface, using the Internet's highest level of security to make the process safe and easy. The provider's office can enter claims and verify if they have been accepted and are ready for adjudication. If you choose this option for claims submission and you do not have a Provider OnLine account, complete this form to sign up. If you have questions while you are completing the form, contact our Web Support Services at 1-800-937-0438.
Batch file submissions
UPMC Health Plan accepts electronic claims in data file transmissions.
Providers who have existing relationships with clearinghouses such as WebMD (UPMC Health Plan Payer ID: 23281), NDC, and HDS can continue to transmit claims in the format produced by their billing software. These clearinghouses are then responsible for reformatting these claims to meet HIPAA standards and passing the claims on to the Health Plan.
Providers are able to submit claims directly without incurring clearinghouse expenses. Claim files are transmitted using a secure FTP process that does not require data encryption prior to transmission. Providers may use the standard PGP encryption process in addition to the secure FTP, if additional data security is desired. These claims are loaded into batches and immediately posted in preparation for adjudication. Via the Provider OnLine EDI tools, these batches can be viewed in several standard report formats.
In order to submit EDI files directly to the Health Plan, providers must:
- Use billing software that allows the generation of a HIPAA-compliant 837 professional or institutional file.
- Have a sample 837 file exported from their billing system containing only UPMC Health Plan claims.
- Have a computer with Internet access.
- Have the ability to download and install a free Active-X secure FTP add-on.
- Complete testing and become certified with UPMC Health Plan.
UPMC Health Plan currently accepts dual provider identifiers. Please submit the National Provider Identifier (NPI), along with the tax ID and the provider ID as assigned by UPMC Health Plan. When care is coordinated, submit the referring provider NPI if available, as well as the name and UPIN. For member identification, submit the member's 11-digit ID number or the government-assigned identifiers for Medicare or Medical Assistance members.
If you are interested in HIPAA-compliant EDI file submission, please refer to the additional set-up documents on this website. You can follow up with additional questions to the HealthPlanEDI@upmc.edu distribution group.
About the Electronic Remittance Advice
This portion of the UPMC Health Plan's website is strictly related to HIPAA-mandated EDI transactions. Per HIPAA, the only permissible format for an electronic remittance advice (ERA), in a data file, is the ANSI ASC X12.835, Health Care Claim Payment/ Advice, commonly referred to as an 835. It requires the recipient's Practice or Billing System have the ability to automate loading of a file in the mandated format.
While UPMC does offer the option to generate 835 formatted ERA files (and make them available for direct download via this website) many automated billing systems interface with payers via a clearinghouse. To request a direct interface of an 835 formatted ERA file, from this website or via PGP encrypted file transfer, please complete the 835 Request Form and send via email to HealthPlanEDI@upmc.edu. Someone will contact you.
If your billing system transmits claims to UPMC via a clearinghouse please contact your vendor, or clearinghouse, for instructions on how to automate the processing of ERA's in an 835 format.