Microsoft Word - E Medical Assistance5.25.07.doc

UPMC for You (Medical Assistance) – Chapter E

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UPMC for You

(Medical Assistance)

E.1 Table of Contents

E.2 At a Glance

E.3 Medical Assistance Managed Care in Pennsylvania

E.5 Covered Benefits

E.36 Other Services

E.39 Services Already Approved by Another PH-MCO or Fee-for-Service

E.40 Services Not Covered

E.41 Program Exception Process

E.45 The EPSDT Program

E.55 Special Needs Unit

E.55 School-based and School-linked Services

E.56 MA Provider Compliance Hotline

E.57 Member Rights and Responsibilities

E.59 Member Complaint and Grievance Procedures

E.79 Appendix E.1 - Other Resources and Forms

E.82 Appendix E.2 - Copayment Schedule

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At a Glance

UPMC for You, affiliate of UPMC Health Plan, offers high-quality care to eligible Medical

Assistance recipients in all 67 counties in the Commonwealth of Pennsylvania. This care is

achieved by combining the benefits of a managed care organization with all the services

covered by Medical Assistance. All UPMC for You providers must abide by the rules and

regulations set forth under the General Provision of 55 Pa. Code, Chapter 1101.

Alert—Department of Human Services Regulations

This manual may not reflect the most recent changes to the Department of

Human Services (DHS) regulations. The Provider Manual is updated at least

annually, or more often, as needed to reflect any program or policy

change(s) made by the DHS via Medical Assistance bulletins when such

change(s) affect(s) information that is required to be included in the Provider

Manual. These updates will be made within six months of the effective date

of the change(s), or within six months of the issuance of the Medical

Assistance bulletin, whichever is later.

If providers have questions regarding UPMC for You coverage, policies, or procedures that

are not addressed in this manual, they may contact Provider Services at 1-866-918-1595

(TTY: 711) from 8 a.m. to 5 p.m., Monday through Friday, or upmchealthplan.com.

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Medical Assistance Managed Care

in Pennsylvania

Pennsylvania’s Department of Human Services (DHS) contracts with managed care

organizations across Pennsylvania to offer managed care to recipients of Medical

Assistance under a program called HealthChoices.

HealthChoices

HealthChoices is Pennsylvania’s innovative mandatory managed care program for

Medical Assistance recipients. Recipients choose among physical health managed care

organizations (PH-MCOs) contracted with DHS to provide at least the same level of

services as offered by ACCESS, the traditional fee-for-service program. Behavioral

health services are provided by behavioral health managed care organizations (BH-MCO)

that contract with DHS.

➢ See: UPMC for You (Medical Assistance) Contacts, Behavioral Health

Services, Table A.5, Welcome and Key Contacts, Chapter A.

UPMC for You is one of the PH-MCOs offered to recipients in the following zones:

• Lehigh/Capital Zone

Adams, Berks, Cumberland, Dauphin, Franklin, Fulton, Huntingdon, Lancaster,

Lebanon, Lehigh, Northampton, Perry, and York counties

• Northeast Zone

Bradford, Carbon, Centre, Clinton, Columbia, Juniata, Lackawanna,

Luzerne, Lycoming, Mifflin, Monroe, Montour, Northumberland, Pike, Schuylkill,

Snyder, Sullivan, Susquehanna, Tioga, Union, Wayne, and Wyoming counties

• Northwest Zone

Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Forest, Jefferson, McKean,

Mercer, Potter, Venango, and Warren counties

• Southeast Zone

Bucks, Chester, Delaware, Montgomery, and Philadelphia counties

• Southwest Zone

Allegheny, Armstrong, Beaver, Bedford, Blair, Butler,

Cambria, Fayette, Greene, Indiana, Lawrence, Somerset, Washington, and

Westmoreland counties

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In these counties, Medical Assistance recipients enroll in a PH-MCO, or change plans, with

the assistance of independent enrollment assistance representatives. Recipients may call the

Pennsylvania Enrollment Service Consumer Support Center at 1-800-440-3989, from 8 a.m.

to 6 p.m., Monday through Friday, or visit enrollnow.net. TTY users should call toll-free

1-800-618-4225.

Figure E.1 - UPMC for You Member Service Area Map

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Covered Benefits

At a Glance

UPMC for You network providers supply a variety of medical benefits and services, some of

which are listed below or itemized on the following pages. For specific information not covered

in this manual, call Provider Services at 1-866-918-1595 (TTY: 711) from 8 a.m. to 5 p.m.,

Monday through Friday.

Key Points

UPMC for You covers:

• Allergy tests and injections.

• Cancer treatments.

• Counseling to stop smoking or using other tobacco products.

• Dental services (benefits vary by age and prior authorization may be required).

➢ See: Dental Care, UPMC for You (Medical Assistance), Chapter E.

➢ See: Table E.1, Dental Limits for Members 21 Years Old and Older,

UPMC for You (Medical Assistance), Chapter E.

• Diagnostic tests.

• Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) for Members younger

than 21 years old (including immunizations/vaccines).

• Electrocardiograms.

• Emergency services.

• Gender-affirming services.

• General medical exams, office visits for obtaining a driver’s license, or for participating

in sports and/or camps.

• Hearing aids for Members younger than 21 years old.

• Home accessibility durable medical equipment.

• Home health aide – Personal care services for Members younger than 21 years old

(requires prior authorization).

• Home health care – Intermittent skilled nursing visits to perform services such as wound

care and dressing changes.

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• Hospice.

• Inpatient (acute or rehab) services.

• Kidney dialysis.

• Laboratory services.

• Medical equipment and supplies.

• Medical services.

• Medically necessary services for Members younger than 21 years old.

• Nutritional counseling.

• Occupational therapy.

• Outpatient hospital services, ambulatory surgical center, or short procedure unit

(copayments may apply).

• PCP visits (for illness or injury).

• PCP annual visit (routine physical exam, wellness/preventive visit), one per calendar

year

• Pediatric Extended Care Center that provides daytime skilled nursing services for

Members younger than 21 years old as an alternative to private duty nursing

(requires prior authorization).

• Physical therapy (may require prior authorization).

• Prenatal care.

• Private duty nursing-skilled nursing services for Members younger than 21 years old

(requires prior authorization).

• Radiation therapy.

• Speech therapy.

• Specialist visits with a verbal referral and coordinated by a PCP

(copayments may apply to chiropractor and podiatrist visits).

• X-rays.

➢ See: Appendix E.2, Copayment Schedule, UPMC for You (Medical Assistance),

Chapter E.

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Coordinated Care

The Member’s PCP must coordinate care. If the PCP refers a Member to an in-network

specialist and also indicates a need for diagnostic testing, the Member should be directed to an

in-network facility for that testing. A separate referral by the specialist is not required. Upon

notification by the Member, family member, Member’s legal designee, or a hospital

emergency department, the Member’s PCP must coordinate any care related to an emergency.

Members may self-direct their care for behavioral health services, chiropractic care, dental

care, routine gynecological examinations, family planning, maternity care or prenatal visits,

and vision care. To verify the coverage of any service, contact Provider Services at

1-866-918-1595 (TTY: 711) or upmchealthplan.com.

All payments made to providers by UPMC for You constitute full reimbursement to the

provider for covered services rendered.

➢ See: the provider’s contract for specific fee schedules.

Copayments

If UPMC for You imposes copayments for certain covered services and a Member cannot

afford to pay the copayment at the time of the service, providers must render covered services

to the Member despite nonpayment of the copayment by the Member. This shall not preclude

providers from seeking payment for the copayments from Members after rendering covered

services.

A provider may bill a UPMC for You Member for a non-covered service or item only if, before

performing the service, the provider informs the Member:

• of the nature of the service;

• that the service is not covered by UPMC for You and UPMC for You will not pay for the

service; and

• the estimated cost to the Member for the service.

The provider must document in the medical record that the Member was advised of and agreed

to accept financial responsibility for the service.

➢ See: Appendix E.2, Copayment Schedule, UPMC for You (Medical Assistance),

Chapter E.

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Closer Look at a Primary Insurance Copayments

If the Member has a primary insurance and there is a copayment,

coinsurance or a deductible due from the Member, that amount is

included in the coordination of benefits calculation.

• If the primary insurance’s payment is greater than the UPMC for You

fee schedule payment, the provider must accept the primary insurance

payment as payment in full. The Member would not be responsible for

the amounts applied to a copayment, coinsurance, or deductible by the

primary insurance.

• If the primary carrier’s payment is less than the fee schedule,

UPMC for You will coordinate benefits and pay up to the fee schedule

amount, i.e., the primary carrier payment and the UPMC for You payment

combined would not equal more than the UPMC for You fee schedule. The

Member would not be liable for any copayment, coinsurance, or deductible applied

by the primary insurance. The provider is required to accept the payment as payment

in full and cannot balance bill the Member except for Medical Assistance-permitted

copayments.

➢ See: Appendix E.2, Copayment Schedule, UPMC for You (Medical Assistance),

Chapter E.

➢ See: Coordination of Benefits, Claims, Chapter H.

➢ See: Determining Primary Insurance Coverage, Member Administration,

Chapter I.

Standards for Member Access to Services

(Wait Time for Appointments)

The Department of Human Services (DHS) standards require that Members be given access to

covered services in a timely manner, depending on the urgency of the need for services, as

follows:

• A Member’s average office waiting time for an appointment for routine care is no

more than 30 minutes or at any time no more than up to one hour when the physician

encounters an unanticipated urgent medical condition visit or is treating a Member with

a difficult medical need.

• If a Member has an emergency, the provider must see the Member immediately or refer

the Member to the emergency department.

➢ See: Table E.2, Appointment Standards, UPMC for You

(Medical Assistance), Chapter E.

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Transportation

Emergency Transportation – Ambulance

Members do not need prior authorization for emergency transportation related to emergency

medical conditions.

➢ Note: Emergency and nonemergency air ambulance transportation requires

authorization. Certain air ambulance services are not covered by

UPMC for You and are only covered when an authorization is

requested through the Program Exception process. Prior authorization

or Program Exception authorization must be requested through Provider

OnLine by accessing upmchealthplan.com/providers.

Nonemergency Transportation – Medically Necessary

All requests for medically necessary nonemergency transportation must be coordinated through

UPMC Medical Transportation at 1-877-521-RIDE (7433) for the following:

• Air ambulance (requires program exception approval)

• Ground ambulance

• Wheelchair van transportation

➢ Note: UPMC for You (Medical Assistance) providers located in

the Lehigh/Capital zone do not need to call UPMC Medical

Transportation.

Nonemergency Transportation – Routine

Members should contact DHS’ Medical Assistance Transportation Program (MATP)

county offices to arrange for most routine nonemergency transportation. MATP requires

24- to 72-hour notice and provides nonemergency transportation to and from Medical

Assistance billable (compensable) nonemergency medical services, i.e., from home

to the doctor’s office for a routine visit.

Nonmedical public transportation – Fixed Route

Fixed route nonmedical public transportation is available at no cost for Members who

reside within the Lehigh/Capital, Northeast or Southeast zone service areas. Fixed Route

transportation is a predetermined and scheduled public transportation route utilizing a standard

mode such as buses. Arrangements may be made for mobile or paper ticketing for single trips or

monthly passes. This service provides nonmedical transportation and does not replace MATP

which provides transportation to compensable medical appointments.

➢ See: Figure E.1, HealthChoices Member Service Area map to determine the

Members’ zone service area. UPMC for You (Medical Assistance), Chapter E.

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If the Member has an unusual nonemergency transportation need due to a medical condition,

the UPMC Health Plan Special Needs Department can be contacted for assistance. The Special

Needs Department can be reached Monday through Friday 7 a.m. to 8 p.m., and Saturday from

8 a.m. to 3 p.m. by calling 1-866-463-1462 (TTY: 711).

➢ See: matp.pa.gov/CountyContact.aspx for a list of MATP providers by county.

Ancillary Services

Ancillary services, such as the following examples radiology, pathology, laboratory, and

anesthesiology, are covered when coordinated by an in-network provider and rendered by an

in-network provider for medically necessary services covered by the Medical Assistance fee

schedule. Some services may have copayments and require prior authorization review.

➢ See: Procedures Requiring Prior Authorization, Utilization Management

and Medical Management, Chapter G.

➢ See: Appendix E.2: Copayments Schedule, UPMC for You (Medical

Assistance), Chapter E.

Chiropractic Care

UPMC for You Members may self-direct to chiropractic care. Chiropractic services are covered

when delivered by an in-network provider. UPMC for You covers medically necessary

evaluations and manual spinal manipulations.

Chiropractic services for children younger than 13 years old require prior authorization.

The provider must contact Utilization Management for a prior authorization review of

medical necessity. Providers may request prior authorization through Provider OnLine by

accessing upmchealthplan.com/providers and entering the authorization request including

supporting clinical documentation and a Certificate of Medical Necessity (CMN).

UPMC for You will not cover x-rays when performed by a chiropractor; however,

chiropractors may refer Members to an in-network provider for x-rays.

Copayments may apply for some Members 18 years old and older.

➢ See: Appendix E.2, Copayment Schedule, UPMC for You

(Medical Assistance), Chapter E.

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Dental Care

All UPMC for You Members receive routine dental care. Additional benefits vary by age and

prior authorization may be required. Members may self-direct their dental care to an in-network

provider.

SKYGEN USA administers routine dental benefits including prior authorization medical

necessity review for UPMC for You Members.

• Providers may contact the SKYGEN USA Provider Call Center at 1-855-806-5193

or [email protected].

• Members may call the UPMC for You Health Care Concierge team at 1-800-286-4242

(TTY: 711).

➢ See: SKYGEN USA Dental Provider Manual at skygenusa.com or

upmchealthplan.com/providers/dental/skygen/default.aspx for full

details of services and for the dental prior authorization process.

Dental services for Members 21 years old and older

UPMC for You Members who are 21 years old and older and do not live in a nursing

home or intermediate care facility (ICF) are eligible for the following services:

• One dental exam (oral evaluation) and cleaning (prophylaxis), every 180 days.

o Additional oral evaluations and prophylaxis will require a benefit limit exception

(BLE).

• One partial upper denture or one full upper denture; and one partial lower denture or

one full lower denture.

o Service is covered once per lifetime.

o Additional dentures will require a BLE.

➢ Note: If UPMC for You paid for a partial or full upper denture since

April 27, 2015, the Member can only receive another partial or

full upper denture if they qualify for a BLE.

➢ Note: If UPMC for You paid for a partial or full lower denture since

April 27, 2015, the Member can only receive another partial or

full lower denture if they qualify for a BLE.

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The following services are not covered unless the Member qualifies for a BLE:

• Crowns and adjunctive services

• Root canals and other endodontic services

• Periodontal services

A provider may not bill a Member for services that exceed the limits unless the following

conditions are met:

• The provider has requested an exception to the limit and the request was denied.

• The provider advised the Member, before the service was provided, that he or she

will be responsible for payment if the exception is not granted.

• The provider advised the Member, before the service was provided, that the Member has

exceeded the limits.

• The provider advised the Member, before the service was provided, and documented the

discussion in the medical record. The provider may have the Member sign an advance

notification form.

An exception to the dental service limits may be granted if the Member meets certain

criteria.

➢ See: Benefit Limit Exceptions, UPMC for You (Medical Assistance),

Chapter E.

The following dental benefits and limits apply to Members 21 years old and older,

including Members 21 years old and older who reside in personal care homes and

assisted living facilities.

• The dental limits do not apply to Members younger than 21 years old or to adults who

reside in a nursing facility or an intermediate care facility (ICF).

• Services beyond a Member’s benefit limits are not covered, unless the Member or the

provider requests and receives approval for a Benefit Limit Exception (BLE). The

provider cannot bill the Member for the non-covered services unless the Member was

advised in advance that the service may not be covered, a BLE was submitted and

denied.

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Table E.1: Dental Limits for Members 21 Years Old and Older

Description

Full Benefits

Age 21 and older

(NOT Residing in a Nursing Facility or ICF)

Age 21 and older

(Residing in a Nursing Facility or ICF)

Anesthesia

Covered

May require prior authorization or

subject to retrospective review

Covered

May require prior authorization or

subject to retrospective review

Checkups - (Routine exam)

(including x-rays)

Covered – 1 per 180 days

Additional exams require a BLE

Covered

Cleanings –

(Prophylaxis)

Covered – 1 per 180 days

Additional cleanings require a BLE

Covered

Crowns and adjunctive services

Not covered

Unless a BLE is approved

Covered

Requires prior authorization

Dentures - (One partial upper

denture or one full upper denture and

one partial lower denture or one full

lower denture)

Covered – Once per lifetime

Requires prior authorization

Additional dentures require a BLE

Covered – Once per lifetime

Requires prior authorization

Additional dentures require a BLE

Dental surgical procedures

Covered

Requires prior authorization

Covered

Requires prior authorization

Dental emergencies -

(Emergency care)

Covered

Extractions –

(Impacted tooth removal)

Covered

Requires prior authorization

Covered

Requires prior authorization

Extractions - (Simple tooth removals)

Covered

Fillings - (Restorations)

Covered

Orthodontics (Braces)*

Not covered*

Covered*

Requires prior authorization

Palliative care

(Emergency treatment of dental pain)

Covered

Periodontal & endodontic

services**

Not covered**

Unless a BLE is approved

Covered**

Requires prior authorization

Root canals

Not covered

Unless a BLE is approved

Covered

Requires prior authorization

X-rays

Covered

Inpatient hospital, Short Procedure

Unit (SPU), or Ambulatory Surgical

Center (ASC) dental care***

Covered***

Requires prior authorization

Covered***

Requires prior authorization

➢ Note:

*If braces were put on before age 21, services will be covered until they are completed or until age 23,

whichever comes first, as long as the Member remains eligible for Medical Assistance.

** Exceptions to the periodontal limits with be granted for individuals who have specials needs or a disability,

pregnant women, individuals with coronary artery disease, or individuals with diabetes.

*** Medically necessary dental care such as:

• Oral surgery and impacted teeth removal if the nature of the procedure or the Member’s compromising

condition would cause undue risk if performed on an outpatient basis.

• Teeth extraction and dental restorative services for a Member who is unmanageable and requires

general anesthesia by an anesthesiologist, due to a severe mental and/or physical condition.

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Dental service for Members younger than 21 years old

The following dental services are covered for Members younger than 21 years old when

medically necessary:

• Anesthesia – may be reviewed retrospectively for medically necessity

• Cleanings

• Crowns – requires prior authorization

• Dental emergencies

• Dental exams (routine oral evaluations)

• Dental surgical procedures – requires prior authorization

• Dentures – requires prior authorization

• Extractions (simple tooth removals)

• Extractions (impacted tooth removals) – requires prior authorization

• Fillings

• Fluoride and varnish treatments

• Orthodontics (braces)* – requires prior authorization

• Periodontal services – requires prior authorization

• Root canals – requires prior authorization

• Sealants

• X-rays

Closer Look at Braces*

If braces were put on before age 21, services will be covered until they are completed

or until age 23, whichever comes first, as long as the Member remains eligible for

Medical Assistance.

Members younger than 21 years old are eligible to receive all medically necessary dental

services. The American Dental Association and the American Academy of Pediatric Dentistry

state that the first dental visit should occur after the child’s first tooth eruption but no later than

their first birthday. The Member should be referred to a dental home as part of their EPSDT

well-child screenings. Providers should notify the Special Needs Department of the referral

utilizing the Dental Referral Fax form. The form is located in the EPSDT Clinical & Operational

Guidelines section of the UPMC Health Plan website at

upmchealthplan.com/providers/medical/resources/guidelines/epsdt-guidelines.aspx.

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The form should be faxed to the UPMC Health Plan Clinical Operations Department

(Attention: SNU) at 412-454-7552. Call 1-800-899-7553 (TTY: 711) with any questions. Forms

may also be emailed directly to UPMCforYou[email protected]. This email box is staffed by

the UPMC for You Public Health Dental Hygiene Practitioner (PHDHP) team.

Staff will then contact the Member or the Member’s parent/guardian to assist in locating a

dental home for their child(ren).

➢ See: The EPSDT Program, UPMC for You (Medical Assistance), Chapter E.

➢ See: Appendix E.1, Other Resources and Forms, UPMC for You (Medical

Assistance), Chapter E.

Oral Health Intervention Program

UPMC for You has an oral health intervention program that uses Public Health Dental Hygiene

Practitioners (PHDHPs) to provide oral health education, and dental home connections as well as

Member outreach. UPMC for You encourages the provider community to refer Members and/or

caregivers to the PHDHP team as part of the oral health discussion at the time of well visit for

oral health education. The UPMC for You PHDHP team has both telephonic and regional team

members—the telephonic team supports Members across all counties; the regional team supports

Members residing within a specific county. The PHDHP team can be reached Monday through

Friday from 8 a.m. to 4:30 p.m. at the following numbers:

Oral Health Intervention Program

General program inquires

[email protected]

Telephonic

1-833-776-4525

1-833-776-4526

1-833-854-7384

TTY:711

The Department of Human Services’ pediatric dental periodicity schedule provides

recommendations for preventive dental care and screening recommendations for children,

infancy through 20 years old, for the following:

• Clinical oral evaluation

o Includes anticipatory guidance, i.e., information/counseling given to children

and families to promote oral health.

• Prophylaxis/topical fluoride treatment

o Topical fluoride varnish can be applied by providers in a PCP setting with

certification. Providers can contact their provider network physician account

executive or UPMCforYou[email protected] for additional information.

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• Radiographic assessment

• Assessment for pit and fissure sealants

• Treatment of dental disease/caries risk assessment

➢ See: Appendix E.1, Other Resources and Forms, UPMC for You

(Medical Assistance), Chapter E.

Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program

All medically necessary EPSDT screens are covered for Members younger than 21 years old

and are based on the EPSDT Periodicity Schedule.

➢ See: The EPSDT Program, UPMC for You (Medical Assistance), Chapter E.

➢ See: Appendix E.1, Other Resources and Forms, EPSDT Periodicity Schedule,

UPMC for You (Medical Assistance), Chapter E.

Diagnostic Services

These services include laboratory services, x-rays, and special diagnostic tests. They are

covered when ordered by an in-network provider and performed by an in-network ancillary

provider. Copayments may apply for diagnostic services (medical or radiology diagnostic

testing, nuclear medicine, and radiation therapy).

➢ See: Appendix E.2, Copayment Schedule, UPMC for You (Medical Assistance),

Chapter E.

Refer to the Member’s behavioral health managed care organization for coverage of diagnostic

services related to behavioral health and substance use disorder.

➢ See: Behavioral Health and Substance Use Disorder Services, UPMC for You

(Medical Assistance), Chapter E.

➢ See: Table A.5, UPMC for You (Medical Assistance) Contacts, Behavioral Health

Services, Welcome and Key Contacts, Chapter A.

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Closer Look at Laboratory Services

The Department of Human Services requires that a current Clinical Laboratory

Improvement Amendments (CLIA) certification be on file with the Office of Medical

Assistance Programs (OMAP) for any provider who renders laboratory services to

Medical Assistance Recipients. All laboratory testing sites, including physician’s offices,

are required to have a CLIA certificate. The CLIA certificate and accompanying

identification number identify those procedures that the laboratory is qualified to

perform.

There are several different types of CLIA certifications:

• Certificate of Accreditation

• Certificate of Compliance

• Certificate of Provider Performed Microscopy Procedures (PPMP)

• Certificate of Registration

• Certificate of Waiver (CLIA Waived)

Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) are

required to submit their CLIA certificates even though they are paid an all-inclusive

per encounter payment rate that includes laboratory tests provided at the time of a

face-to-face visit. Hospital laboratories must be Medicare certified or certified by the

Pennsylvania Department of Health (DOH) as meeting the standards comparable to those

of Medicare. Out-of-state hospitals do not need to be licensed by DOH but must be

currently Medicare certified.

➢ See: Medical Assistance bulletin #01-12-67, 08-12-62, 09-12-63,

28-12-01, 31-13-65, 33-13-61, effective Jan. 1, 2013.

Emergency Care

UPMC for You will cover care for emergency medical conditions with acute symptoms of

sufficient severity (including severe pain) such that a prudent layperson, who possesses an

average knowledge of health and medicine, could reasonably expect the absence of immediate

medical attention to result in:

• Placing the health of the Member (or for pregnant women, the health of the woman or

her unborn child) in serious jeopardy;

• Serious impairment to bodily function; or

• Serious dysfunction of any bodily organ or part.

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Closer Look at Emergency Care

The hospital or facility must contact the Utilization Management Department

by accessing Provider OnLine at upmchealthplan.com/providers within

48 hours or on the next business day following an emergency admission that

results in an inpatient hospital admission.

Members with an emergency medical condition or those acting on the Member’s behalf have

the right to summon emergency help by calling 911 or any other emergency telephone number,

or a licensed ambulance service, without getting prior approval from the Member’s PCP or

from UPMC for You.

Redirected Emergency Department Visit

If a Member is instructed by their PCP to come into the office, but instead goes directly to

the emergency department and does not have an emergency medical condition, the visit may

be considered a redirected emergency department visit. Such visits are subject to review on

a case-by-case basis to determine the appropriate level of reimbursement.

Alert—Redirected Emergency Department Visit

Within 24 hours of redirecting an emergency department visit, the PCP

must contact the Member with any alternative care arrangements, such

as an office visit or treatment instructions.

Family Planning

Members may self-direct care to in-network or out-of-network providers and clinics for family

planning and birth control services. These services enable individuals to voluntarily determine

family size and should be available without regard to marital status, age, sex, or parenthood.

UPMC for You Members may access the education and counseling necessary to make an

informed choice about contraceptive methods, pregnancy testing and counseling, breast cancer

screening services, basic contraceptive supplies such as oral birth control pills, long-acting

reversible contraceptives (LARC) such as intrauterine devices (IUDs) and subdermal

contraceptive implants, diaphragms, foams, creams, jellies, condoms (male and female),

injectables, and other family planning procedures.

Hearing Exams/Aids

Hearing exams require a PCP referral. Hearing aids are covered for UPMC for You Members

younger than 21 years old when provided by an in-network provider.

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Home Health Care and Shift Care Services

Home health care services:

Home health care services are covered when coordinated through an in-network provider.

Shift care services:

Shift care services require initial and ongoing prior authorization.

• Home Health Aides (for Members younger than 21 years old)

• Pediatric Extended Care Center services (for Members younger 21 years old)

• Private Duty Nursing in the home (for Members younger than 21 years old)

The provider requesting prior authorization for Home Health Aide Services, Pediatric Extended

Care Center services, or Private Duty Nursing for Members younger than 21 years old must

submit a completed UPMC Health Plan medical necessity form, a Letter of Medical Necessity

and all relevant clinical and social information including Member/family’s school and work

schedules to the Utilization Management department via Provider OnLine at

upmchealthplan.com/providers. Medical necessity forms and instructions for submitting

authorization requests can be found at upmchealthplan.com/providers/forms.

The following services may require prior authorization after a standard number of visits have

been exhausted:

• Home infusion therapy

• Medical social services

• Occupational therapy

• Physical therapy

• Registered dietitian services

• Skilled/Intermittent nursing

• Speech therapy

The provider must contact Utilization Management to request prior authorization by

submitting the request through Provider OnLine at upmchealthplan.com/providers.

Failure to obtain authorization will result in denial of the claim. If written information is

required, it may be sent to:

UPMC Health Plan

Utilization Management Department

U.S. Steel Tower, 11th Floor

600 Grant Street

Pittsburgh, PA 15219

➢ Note: Certain Physical Therapy codes are not on the Medical Assistance fee schedule.

These procedures may only be requested as a Program Exception under the

Program Exception process.

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Home Accessibility Durable Medical Equipment

UPMC for You will pay for the installation of medically necessary covered home

accessibility durable medical equipment installed by qualified personnel and medically

necessary repairs to the equipment, but not home modifications.

For the Member to be eligible for these services their physician or therapist must verify

certain information in accordance with UPMC for You policy.

Covered Services for medically necessary services include but are not limited to:

• Ceiling Lifts

• Metal Accessibility Ramps

• Mobility products that are medically necessary to enter/exit the Member’s home or to

support mobility activities of daily living and meets the definition of 42 CFR Section

440.70 (b)(3)(i-ii)

• Stair Glides

• Wheelchair Lifts

Installation may include the following:

• External supports, such as bracing a wall.

• Installing an electrical outlet or connection to an existing electrical source.

• Labor to attach or mount the item to a surface per the manufacturer’s installation guide.

• Parts or supplies provided or recommended by the manufacturer for attaching or

mounting the item to the surface at the home or residence.

• Pouring a concrete foundation (slab) according to the manufacturer’s instructions (which

may include leveling the ground under the concrete foundation).

• Required permits.

• Removing a portion of an existing railing or banister, only as needed to accommodate the

equipment.

Home modifications are not covered. Home modifications include:

• Modification to the home or place of residence.

• Repairs of the home, including repairs caused by the installation, use or removal of the

medical equipment or appliance.

• Changes to the internal or external infrastructure of the home or residence, including:

o Adding internal supports such that the support requires access to the area behind a

wall or ceiling or underneath the floor.

o Constructing retaining walls or footers for a retaining wall.

o Installation of or modification of a deck.

o Installation of a driveway or sidewalk.

o Upgrading the electrical system.

o Plumbing.

o Ventilation or HVAC work.

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o Widening a doorway.

o Drywall.

o Painting.

o Installation of flooring.

o Tile work.

o Demolition of existing property or structure.

➢ See: Medical Assistance Bulletin: 09-21-04,10-21-01, 14-21-01, 24-21-04, 25-21-01,

31-21-05, 33-21-04, Effective April 1, 2020.

Home Medical Equipment (HME)

Home medical equipment (e.g., hospital beds, manual wheelchairs, walkers, or respiratory

equipment [including oxygen therapy]) is covered when coordinated through an in-network

provider and used for medically necessary services that are on the Medical Assistance fee

schedule. Some HME items are subject to a capped rental.

Specialized Home Medical Equipment (SHME)

Specialized home medical equipment, including but not limited to: power mobility devices,

(e.g., power wheelchairs and scooters); pressure reducing support surfaces; lymphedema pumps,

and bone growth stimulators require a prior authorization review.

SHME is covered when coordinated through an in-network provider and used for medically

necessary services that are on the Medical Assistance fee schedule. The provider must contact

Utilization Management for a prior authorization review of medical necessity to receive

coverage of certain SHME as indicated in the online Policies and Procedures Manual found at

upmchealthplan.com/providers. Providers must submit a prior authorization request through

Provider OnLine by accessing upmchealthplan.com/providers. Failure to obtain authorization

will result in denial of the claim.

Home Physician Visits

Home physician visits are covered when provided by an in-network provider. Specialist visits

require a referral from the Member’s PCP.

Hospice Care – Palliative Care

Hospice care is available for a terminal diagnosis with a prognosis of six months or less. This

care must be coordinated through an in-network provider.

Palliative care is available for qualifying Members when coordinated through an in-network

provider. Palliative care services may require prior authorization. The provider must contact

Utilization Management for a prior authorization review of medical necessity. Providers may

request prior authorization through Provider OnLine by accessing

upmchealthplan.com/providers and entering the authorization request.

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Hospital Admissions

Admissions to hospitals are covered if medically necessary and the provider and hospital

facility obtain prior authorization from UPMC for You. If a specialist admits the Member,

the specialist should coordinate care with the Member’s PCP. If the admission is an

emergency admission, the hospital or facility must contact the Utilization Management

Department through Provider OnLine by accessing upmchealthplan.com/providers

and entering the authorization request within 48 hours or on the next business day

following an emergency that resulted in the inpatient hospital admission.

Some UPMC for You Members 18 years old or older may have a copayment for inpatient

stays.

➢ See: Appendix E.2, Copayment Schedule, UPMC for You (Medical Assistance),

Chapter E.

➢ See: Prior Authorization, Utilization Management and Medical Management,

Chapter G.

Immunizations

PCPs and specialists serving UPMC for You Members who are 18 years old or younger need

to be enrolled in Vaccines for Children (VFC), a federally funded program that provides

vaccines free of charge. To enroll in the PA VFC Program, call 1-888-646-6864 or access

cdc.gov/vaccines/hcp/admin/vfc.html.

PCPs may provide other immunizations not covered under VFC but covered by UPMC for You.

UPMC for You also covers certain adult immunization. To verify the coverage or to obtain

additional information call Provider Services at 1-866-918-1595 (TTY: 711).

Medical Social Services

UPMC for You and the provider must jointly address any identified social or personal needs

that affect a Member’s medical condition (e.g., lack of heat or water).

UPMC Health Plan offers Special Needs Services (case management) for UPMC for You

(Medical Assistance) Members who may have complex physical health needs, multiple physical

or behavioral health needs, or special communication needs. Members may require community

services, or they may just need extra guidance in obtaining health care services. Care managers

will assist with Members who may benefit from care coordination.

Care Management staff is available at 1-866-463-1462 (TTY: 711), Monday through Friday

from 7 a.m. to 8 p.m., and Saturday from 8 a.m. to 3 p.m.

➢ See: Special Needs Services, Utilization Management and Medical Management

Chapter G.

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Mental Health and Substance Use Disorder Benefits

UPMC for You does not manage the Member’s behavioral health benefits. These services are

managed by a behavioral health managed care organization (BH-MCO) in the Member’s county

of residence.

Closer Look at Behavioral Health Managed Care Organizations

Providers are required to refer and coordinate a Member’s care with behavioral

health providers.

➢ See: Table A.5, UPMC for You (Medical Assistance) Contacts, Behavioral

Health Services, Welcome and Key Contacts, Chapter A for a list of

BH-MCOs.

Office Visits

PCP visits are covered. Specialist visits are covered with a PCP referral and coordination.

Copayments may apply to chiropractor and podiatrist visits for some Members.

➢ Note: An annual wellness/preventive visit is covered once per calendar year.

➢ See: Appendix E.1, Other Resources and Forms, UPMC for You

(Medical Assistance), Chapter E for the frequency of EPSDT visits.

o EPSDT Periodicity Schedule

➢ See: Appendix E.2, Copayment Schedule, UPMC for You (Medical Assistance),

Chapter E.

Closer Look at Referrals

UPMC for You does not require the submission of paper referral forms.

PCPs may refer a Member to an in-network specialist following standard medical

referral practices such as calling the specialist or by providing the Member a

“script” or “letter” for the specialist’s records.

The PCP and specialist should coordinate care. The PCP and specialist must

contact Utilization Management for prior authorization approval of an out-of-

network referral by submitting a request through Provider OnLine at

upmchealthplan.com/providers.

➢ Note: Out-of-network Indian Tribe, Tribal Organization, or Urban Indian

Organization Health Care Providers (I/T/U HCPs) can refer Indian

Members (as defined by 42 CFR § 438.14(a)) to in-network

providers.

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Organ Transplants

Certain organ transplants are covered but require prior authorization from UPMC for You.

Members must receive a referral from their PCP for specialist and diagnostic workups.

Out-of-Area or Out-of-Network Care

Routine care performed by out-of-network providers is not covered for UPMC for You

Members. Care for an emergency medical condition, provided by an out-of-network

provider, is covered. Members are encouraged to notify their PCPs after they receive

such care.

Medically necessary nonemergency services may be covered if:

• It is unreasonable to expect the Member to return to the UPMC for You service area for

treatment and prior authorization is obtained.

• Urgent conditions that require immediate attention and for which a delay in care would

result in a significant decline in the Member’s health may justify out-of-area care (by an

out-of-network provider).

• Medically necessary services are not available in the UPMC for You provider network

and a prior authorization is obtained.

UPMC for You Members are not permitted to self-direct to out-of-network providers except

for emergency services or for family planning services; however, in-network providers can

request out-of-network care. The in-network provider must contact Utilization

Management for authorization by submitting a prior authorization request through Provider

OnLine at upmchealthplan.com/providers.

A medical director will review the prior authorization request for medical necessity. The

provider will be notified of the determination by phone. If the request is denied, the provider

and Member will receive written notification. The provider can appeal a denial by following

the instructions outlined in the denial letter.

Alert—Out-of-Network Care Referrals

To send Members to out-of-network specialists or facilities, the in-network

provider must obtain prior authorization by contacting Utilization Management

and submitting an out-of-network prior authorization request through Provider

OnLine at upmchealthplan.com/providers. Failure to obtain authorization

will result in denial of the claim. The referring provider must give the medical

necessity reason for the out-of-network referral.

If written information is required, it may be sent to:

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UPMC Health Plan

Utilization Management Department

U.S. Steel Tower, 11th Floor

600 Grant Street

Pittsburgh, PA 15219

Alert—Out-of-Area Services

Emergency and routine care provided outside the United States is

not covered. The Affordable Care Act of 2010 prohibits payments

of Medicaid funds to institutions or entities located outside of the United

States. United States is defined to include the District of Columbia, Puerto

Rico, Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa.

Outpatient Surgery

Medically necessary outpatient surgeries listed on the Medical Assistance fee schedule are

covered if performed by an in-network provider, hospital, or surgical facility. The provider

must coordinate care with the Member’s PCP and contact Utilization Management to obtain

authorization for procedures as appropriate. Providers may request prior authorization by

logging onto upmchealthplan.com/providers and entering the authorization request through

Provider OnLine.

Podiatric Care

Medically necessary podiatric care is covered with a referral from the Member’s PCP.

Copayments may apply for some Members.

➢ See: Appendix E.2, Copayment Schedule, UPMC for You (Medical Assistance),

Chapter E.

Prescription Drug Coverage

The UPMC for You prescription plan features a two-tier formulary—one tier for generic

medications and another for preferred brand-name medications. UPMC for You must also

use the Pennsylvania Medical Assistance Statewide Preferred Drug List (PDL) as required

by the Department of Human Services (DHS), for certain medication classes. The statewide

PDL is a list of drugs and drug classes developed by DHS. Quantity limits, once-daily dosing,

benefit exclusions, copayments, and prior authorization programs may apply.

The plan offers limited over-the-counter products, when written on a prescription, including

smoking cessation aids and birth control. Members must use the UPMC for You pharmacy

network. Based on the Member’s Medical Assistance category, copayments may apply.

➢ See: UPMC for You Pharmacy Program, Pharmacy Services, Chapter J.

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Closer Look at Prescription Drug Coverage

Providers who have questions about prescriptions should contact Pharmacy

Services at 1-800-979-UPMC (8762) (TTY: 711) from 8 a.m. to 5 p.m.,

Monday through Friday.

UPMC for You Members can receive a 90-day supply of some maintenance

medication prescriptions for the cost of one copayment through the 90-day

retail pharmacy program.

➢ See: Where to Obtain Prescriptions, Pharmacy Services, Chapter J.

Prosthetics and Orthotics

Prosthetic and orthotic services must be coordinated through an in-network provider.

Prosthetic and orthotic items on the Medical Assistance fee schedule are covered when

medically necessary. Some items may require prior authorization.

Prosthetic and orthotic repairs and replacements require prior authorization for coverage.

Rehabilitative Therapy

Inpatient

Inpatient rehabilitative therapy (occupational, physical, respiratory, and speech) is covered when

coordinated through the Member’s PCP and delivered by an in-network provider. The therapy

must be medically necessary and prior authorization must be obtained. The prognosis must

indicate the potential for improvement. Copayments for some Members age 18 and older may

apply.

Outpatient

Medically necessary outpatient rehabilitative therapy (occupational, physical, respiratory, and

speech) is covered when coordinated through the Member’s PCP and delivered by an in-network

provider. All outpatient rehabilitation visits require a referral from the PCP and copayments may

apply.

➢ Note: Physical Therapy may require prior authorization after a standard number

of visits have been exhausted.

➢ See: Appendix E.2, Copayment Schedule, UPMC for You (Medical Assistance),

Chapter E.

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Reproductive Procedures

Abortion

An abortion may be covered when the mother’s life is in danger or pregnancy is the result of

rape or incest. An abortion is covered when a physician certifies that due to a condition, illness,

or injury, an abortion is necessary to prevent the death of the woman, which is a medical

judgment to be made by the certifying physician. A licensed physician may make the

certification regardless of whether the physician has a pecuniary or proprietary interest in the

abortion.

An abortion is covered for women who are victims of rape or of incest if:

• The rape victim makes a report to a law enforcement agency or public health service

agency within 72 hours of the rape.

• The incest victim makes a report to a law enforcement agency or public health service

agency within 72 hours of the time her physician informs her that she is pregnant.

The notification must occur before the abortion is performed. The physician must complete

a Physician Certification for an Abortion Form (MA-3 or MA-3s). This form must be

maintained in the Member’s medical record and a copy submitted with the claim.

Cases of Rape and Incest

In cases of rape or incest, the Member must complete and sign a Recipient Statement Form

(MA-368) before the abortion (the statement does not have to be notarized). The provider must

submit a copy of the statement along with the claim. The statement must note that the Member:

• Was a victim of rape or incest.

• Reported the incident, including the identity of the offender, if known, to the appropriate

law enforcement agency or county child protective service agency (in incest cases where

the Member is a minor). The statement must include the name of the agency as well as

the date the report was made.

• Is aware that any false statements and/or false reports to law enforcement authorities are

punishable by law.

The reporting requirement is waived if the Member was the victim of rape or incest but, in the

physician’s medical judgment, was physically or psychologically incapable of reporting the

crime. The physician must give the reasons for the waiver on the Physician Certification for

Abortion Form and must obtain a signed statement from the woman indicating she was a victim

of rape or incest and that she did not report the crime. A Recipient Statement Form is not

needed for abortions necessitated by life-threatening conditions, illnesses, or injuries.

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Hysterectomy

A hysterectomy is covered when coordinated through a PCP or ob-gyn provider and performed

by an in-network provider. The hysterectomy must be medically necessary and performed for a

valid reason other than sterilization. A second opinion is not required, but the Member may

request one through her PCP or ob-gyn provider. The provider and Member must complete a

Patient Acknowledgement for Hysterectomy form (MA-30). The consent form must be

maintained in the Member’s medical record and a copy of the form must be submitted with the

claim.

Tubal Ligation

A tubal ligation is covered when coordinated through a PCP or ob-gyn provider and performed

by an in-network provider. The Member must voluntarily give informed consent to the

procedure. The Member also must be at least 21 years old at the time she gives informed

consent and must sign a Sterilization Consent form (MA-31 or MA-31s) at least 30 days,

but no more than 180 days, before the procedure to receive coverage. The consent form must

be maintained in the Member’s medical record and a copy of the form must be submitted with

the claim.

Vasectomy

A vasectomy is covered when coordinated through a PCP and performed by an in-network

provider. The Member must voluntarily give informed consent to the procedure. The Member

also must be at least 21 years old at the time he gives informed consent and sign a Sterilization

Consent form (MA-31) at least 30 days, but no more than 180 days, before the procedure to

receive coverage. The consent form must be maintained in the Member’s medical record and a

copy of the form must be submitted with the claim.

Closer Look at Abortion, Hysterectomy, Tubal Ligation,

and Vasectomy

Prior authorization is not required when an abortion, hysterectomy, tubal

ligation, or vasectomy are performed in-network. But if the Member requires

an inpatient admission, following the procedure, Providers must request prior

authorization for the admission through Provider OnLine by logging onto

upmchealthplan.com/providers.

➢ Note: Providers may order consent forms from the Office of Medical Assistance

Programs (OMAP) at expressforms.pa.gov/apps/pa/DHS/MA-

Provider. Questions about forms should be referred to

[email protected].

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Skilled Nursing Facility Care

Skilled nursing facility care is covered if the treating provider obtains prior authorization, and

the care is medically necessary and provided in a licensed facility.

Closer Look at Skilled Nursing Facility Care

UPMC for You’s responsibility to provide benefits for Members who enter a

licensed skilled nursing facility continues up to the date prior to the Community

HealthChoices (CHC) start date.

UPMC for You provides skilled nursing facility care benefits for Members who

enter a licensed skilled nursing facility for the first 30 days of the Member’s stay.

UPMC for You will continue to pay past day 31 and onward until the day the

Member is determined to be eligible for Community HealthChoices (CHC),

assuming the Member remains in the nursing facility.

➢ For example:

The Member is admitted to a nursing facility on April 1.

UPMC for You will pay the first 30 days (April 1 to April 30).

The Member remains in the nursing facility beyond 30 days and

is determined eligible for CHC on June 15; UPMC for You will

be responsible for payment from May 1 to June 14. CHC will begin

paying the nursing facility on June 15.

If the Member is not determined eligible for CHC while they are still in the

nursing facility, UPMC for You will be responsible for payment from day 1 to 30

and from day 31 onward until the Member leaves the facility, even if the Member

is not determined eligible for CHC.

Providers must notify Utilization Management at 1-800-425-7800 (TTY: 711)

if the Member has remained in the skilled nursing facility beyond 30 days.

Specialist Care

Coverage is provided for specialty care when performed by an in-network provider with a

referral from the PCP. Coverage is only for those services coordinated by the PCP.

To ensure coverage, specialists must refer the Member to in-network providers for laboratory

testing and x-rays. Any additional services must be referred and coordinated through the PCP.

Out-of-network services and/or any care ordered by an out-of-network provider are not covered

unless specifically approved by UPMC for You. The out-of-network provider must obtain prior

authorization by contacting Utilization Management at 1-800-425-7800 (TTY: 711).

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Therapy

Outpatient therapy (chemotherapy, dialysis, and radiation) is covered with a prescription when

performed at an in-network facility. Copayments may apply for some Members.

➢ See: Appendix E.2, Copayment Schedule, UPMC for You (Medical Assistance),

Chapter E.

Urgent Care

Urgent care is defined as any illness, injury, or severe condition that, under reasonable

standards of medical practice, would be diagnosed and treated within a 24-hour period

and, if left untreated, could rapidly become an emergency medical condition. Urgent

care is covered when the Member is temporarily absent from the approved service area.

Additionally, such services may be provided under unusual and extraordinary circumstances

within the approved service area when an in-network provider is temporarily unavailable and

when such services are medically necessary and require immediate attention.

Closer Look at Urgent Care

If the Member is unable to call the PCP before going to the emergency department and

the Member does not have an emergency medical condition, the emergency department

should attempt to contact the PCP for approval before providing services. If the PCP

does not respond within 30 minutes or cannot be reached, the emergency department

or Member should attempt to contact Provider Services at 1-866-918-1595. If the

emergency department cannot reach UPMC for You, it should provide the service and

attempt to contact the PCP or UPMC for You afterward.

Routine Vision Benefits

Routine Vision benefits are administered by Envolve Vision. Benefit coverage varies by age.

Providers and Members may contact Envolve Vision directly for additional information.

Envolve Vision’s Provider and Customer Services contacts for:

UPMC Community HealthChoices (Medical Assistance)

1-866-838-7612

UPMC for Kids (CHIP)

1-866-921-7965

UPMC for Life Medicare -

University of Pitt employees-retirees only (GU5, HC7, HC8, TO5)

1-866-921-7963

UPMC for You (Medical Assistance)

1-866-458-2138

TTY

711

Hours: 8 a.m. to 8 p.m., Monday through Friday

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Members 21 years old and older receive:

• Routine vision exams twice a year.

• A $100 allowance toward eyeglasses (one frame and two lenses) or toward one pair of

contact lenses and fitting per year (from prior service date). If the Member chooses

standard eyeglasses or contact lenses that are within the allowance, there is no cost to the

Member. If the cost exceeds the allowance, the Member will be responsible for any cost

over the $100.

• Glasses or contact lenses to treat cataracts or aphakia (medical condition).

• Specialist eye exam with referral from PCP.

Members younger than 21 years old receive:

• Routine vision exams twice a year, or more often if medically necessary.

• A $100 allowance towards eyeglasses or toward one pair of contact lenses and fitting. If

the Member chooses standard eyeglasses or contact lenses that are within the allowance,

there is no cost to the Member. If the cost exceeds the allowance, the Member will be

responsible for any cost over the $100.

• Two frames and four lenses per year (from prior service date).

➢ Note: The second pair of glasses is available if medically necessary.

Example: The Member’s prescription changes.

Exception to limits can be made if medically necessary and

written documentation is provided.

• Replacement of eyeglasses or contact lenses if they are broken or lost, or if there is a

prescription change, provided written documentation of the necessity of the service is

submitted by the provider.

• Eyeglasses and all other vision services deemed medically necessary provided written

documentation of the necessity of the service is submitted by the provider.

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Women’s Health

Routine Ob-gyn Services

Members may self-direct care to an in-network ob-gyn provider for routine annual gynecological

exams and obstetrical care.

Nonroutine Ob-gyn Services

Members with women’s health problems may self-direct care to an in-network ob-gyn.

Family Planning

Members may self-direct care to any in-network or out-of-network provider and clinics for

family planning and birth control services. These services enable individuals to voluntarily

determine family size and should be available without regard to marital status, age, sex, or

parenthood.

➢ See: Covered Services - Family Planning, UPMC for You (Medical Assistance),

Chapter E.

Pregnancy Care

Members can self-direct care to an in-network ob-gyn provider for maternity care and prenatal

visits. The ob-gyn provider must notify the Member’s PCP in writing that the Member is

receiving maternity care. UPMC for You offers pregnant women the UPMC Health Plan Baby

Steps Maternity care management program, which provides patient-centered support and

education throughout the prenatal and postpartum period. Maternity Health coaches provide

education, coordination of care, and referrals to a variety of resources to address identified

Member needs. Interactions are available by telephone, face-to-face and/or virtual/telehealth

encounters.

➢ See: UPMC AnywhereCare, UPMC for You Medical Assistance, Chapter E.

Face to Face in-home visits by Mobile Maternity Health Coaches are available in certain

geographic regions. The focus of the program is to help Members achieve and maintain a healthy

pregnancy and safe delivery with an emphasis on the psychosocial and socioeconomic issues that

could affect a pregnancy. The Maternity Health Coaches are available to answer Members’

questions, provide education and remove barriers to care.

Closer Look at Health Coaches

A health coach is a health care professional who specializes in the delivery

of a wide spectrum of lifestyle programs for improving nutrition, increasing

physical activity, quitting smoking or other tobacco use, managing weight,

and more. They also deliver programs designed to help individuals better

manage chronic health conditions such as diabetes, coronary artery disease,

hypertension, asthma, and depression.

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Women should be encouraged to call UPMC for You and enroll in the UPMC Health Plan Baby

Steps Maternity Program. Women who participate in the program and regularly attend prenatal

visits are eligible for a baby gift incentive. This program rewards participation in ongoing care

and addresses safe travel for the baby. Enrollees who meet the following criteria may be eligible

to receive an infant care seat, stroller, or a portable play yard:

• Prenatal care prior to 13 weeks

• Enrollment in the UPMC Health Plan Maternity Program

• Compliance with lab testing as recommended by provider

• Compliance with all prenatal care visits

• Participation in all scheduled contacts by maternity program staff

Providers will need to complete the provider section of the “Baby Gift Checklist” to verify the

Member’s compliance with attendance at all appointments and lab testing recommendations.

Members or providers may call the UPMC Health Plan Maternity Program at

1-866-778-6073 (TTY: 711), Monday through Friday from 7 a.m. to 8 p.m. and Saturday

from 8 a.m. to 3 p.m.

Postpartum Care

The postpartum period (12 months after delivery) is an extremely important time for the well-

being of both mother and baby. UPMC for You supports the proactive scheduling of the

postpartum office visit within 7 and 84 days after the baby’s birth. Additionally, UPMC for You

pays for postpartum home health visit for all UPMC for You Members.

Obstetrical Needs Assessment Form

Ob-gyns and PCPs performing routine obstetric services should complete an Obstetrical Needs

Assessment Form (OBNA Form of ONAF), which is a comprehensive assessment of the

physical, psychological, and obstetrical history of the Member. This information will be used to

identify Members at risk for complications in pregnancy and who would benefit from enrollment

in the UPMC Health Plan Baby Steps maternity program. Providers must include either their four-

digit site ID number or their PROMISe (MMIS) ID number on the form. To obtain additional information

about the provider’s site ID number, contact Provider Services at 1-866-918-1595 from 8 a.m. to 5 p.m.,

Monday through Friday.

➢ See: Provider Services, Welcome and Key Contacts, Chapter A.

➢ Note: Providers must be enrolled in the Medical Assistance program and

possess an active PROMISe ID (also known as the MMIS ID) for

each location at which they provide services.

➢ See: Medical Assistance Revalidation Requirement, Provider Standards and

Procedures, Chapter B.

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Closer Look at Obstetrical Needs Assessment Form

Providers should complete the OBNA form and must submit it electronically to

UPMC Health Plan in Optum OB Care. For questions about submitting the form

electronically, providers may call Provider Services at 1-866-918-1595 or the

UPMC Health Plan Baby Steps Maternity Program at 1-866-778-6073

(TTY:711).

All OB providers will utilize the Optum OB Care web tool. For questions about

the form or to obtain information about using the Optum OB Care web tool,

providers may also contact the UPMC Health Plan Baby Steps Maternity

Program at 1-866-778-6073 (TTY: 711).

The OBNA should be submitted within 30 days of the following visit dates:

• The initial visit between 28 and 32 weeks, and

• Following the postpartum visit (7-84 days after delivery).

In addition, the OBNA should be updated as applicable for any change in the

Member’s OB status, [i.e., new diagnosis pregnancy induced hypertension (PIH)

or preterm labor (PTL)].

It is important that the dates of all the prenatal visits are included and risk factors

are documented. This information is used to help identify Members for the UPMC

Health Plan Baby Steps maternity program.

For questions about the form contact the UPMC Health Plan Baby Steps

Maternity Program at 1-866-778-6073 (TTY: 711).

A blank form, instructions, tip sheet, and DHS validated depression screening

tools, can be found on Provider OnLine under documents/form, Maternity,

Obstetrical Needs Assessment form at upmchealthplan.com/providers. The

form is also located in the Physician Forms section at

upmchealthplan.com/providers/medical/resources/forms/medical-pa.aspx.

➢ See: Maternity Program, Utilization Management and Medical Management,

Chapter G.

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Depression Screening Tools

Providers are required to screen pregnant Members for depression both prenatally and during the

postpartum period (12 months after delivery) using a validated depression screening tool that is

applicable for the provider’s practice.

➢ Note: DHS does not endorse a specific screening tool to assess depression.

Forms, example screening tools, and instructions are also available online in the Medical

Provider Resources section at:

upmchealthplan.com/providers/medical/resources/guidelines/epsdt-guidelines.aspx.

➢ See: The Maternity Program, Utilization Management and Medical Management,

Chapter G.

➢ See: Appendix E.1, Other Resources and Forms, UPMC for You (Medical Assistance),

Chapter E.

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Other Services

Other services available to UPMC for You Members include:

Health Management Programs

UPMC for You offers several health management programs, including asthma, cardiovascular

disease (coronary artery disease and congestive heart failure), chronic obstructive pulmonary

disease, and diabetes at no cost to the Member. Health coaches are available to answer

Members’ questions and offer support and advice between their visits. Information about the

programs is available at 1-866-778-6073 (TTY: 711) Monday through Friday from 7 a.m. to

8 p.m. and Saturday from 8 a.m. to 3 p.m.

Health management programs are an important component of UPMC for You’s efforts to

improve Members’ health by providing intensive care management for Members with specific

chronic illnesses.

The goals are to improve clinical outcomes and quality of life. The program is structured to

identify and outreach to Members with chronic conditions. Nurse Care Managers will assess

Members’ needs, develop a coordinated care plan that is created with Members’ input, and

monitor Members’ progress with that plan. An assessment of Members’ medical and behavioral

health, compliance status, use of self-monitoring tools, and their understanding of the condition

are completed to determine areas for focused education or care coordination. All interventions

are aimed at increasing Members’ knowledge of their condition and improving their ability to

manage their disease.

A specialized team of health coaches (nurses, social workers, dietitians, exercise physiologists,

counselors, and health educators), in collaboration with the Members’ providers, work to

accomplish these goals through Member education, coordination of care, and timely treatment.

UPMC for You offers the following types of health education classes:

• Breastfeeding

• Diabetes management

• Maternity

• Nutritional counseling

• Tobacco cessation

Contact the Health Management Department at 1-866-778-6073 (TTY: 711) for

information on education classes.

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In addition, these programs provide help for Members to manage their chronic illnesses through

preventive practices and adherence to their treatment plans. Health management programs also

help form connections with community support groups and agencies. There are also programs to

assist with lifestyle risk goals such as smoking/tobacco cessation, weight management, nutrition,

stress management, and physical exercise. Members enrolled in these programs receive

educational materials and have frequent clinical sessions with their health coach.

Providers who serve Members who would benefit from these health management programs

should contact Health Management at 1-866-778-6073 (TTY: 711) for information and

enrollment. Health Management staff is available Monday through Friday from 7 a.m. to 8 p.m.

and Saturday from 8 a.m. to 3 p.m.

Additional information on health management programs can be found online at:

upmchealthplan.com/providers/medical/resources/other/patient-health.aspx in

the Provider section under Patient Health.

UPMC MyHealth 24/7 Nurse Line

A 24/7 advice line for Members seeking general health advice or information regarding a

specific medical issue. Experienced registered nurses are available 24 hours a day, 7 days a

week, 365 days a year to provide Members with prompt and efficient services. The UPMC

MyHealth 24/7 Nurse Line is available for medical questions concerning both adults and

children. The Member may call 1-866-918-1591 (TTY: 711) or log in to MyHealth OnLine.

➢ See: upmchealthplan.com/members/learn/benefis-and-services/nurse-line.aspx

for additional information.

UPMC AnywhereCare

AnywhereCare Virtual Urgent Care—UPMC Health Plan’s telemedicine tool—offers

Members access to high-quality care from the comfort of their own home day or night.

It works well for issues such as rashes, sore throats, colds, and other nonemergency issues.

Members can have a Virtual Urgent Care visit with a provider from their smartphone, tablet, or

computer. The Member downloads UPMC Anywhere Care app from the App Store or Google

Play

TM

by searching for “UPMC AnywhereCare,” or they can register at

upmcanywherecare.com from their computer.

UPMC AnywhereCare has expanded to offer care to children of all ages. With UPMC Children’s

AnywhereCare children ages 0-17 can have virtual urgent Care visits 24/7 with UPMC

Children’s Hospital of Pittsburgh providers over live video. Members age 18 and older will

continue to use UPMC AnywhereCare.

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In order for a child (ages 0-17) to have a UPMC Children’s AnywhereCare visit, the child’s

parent or legal guardian must be with the child during the video portion of the visit.

Members must be in Pennsylvania at the time of the visit for it to be covered by UPMC for You.

If outside of Pennsylvania, Members will be required to pay out-of-pocket for the cost of the

visit.

Providers interested in participating as an AnywhereCare provider should contact Provider Services

at 1-844-860-9303 from 8 a.m. to 5 p.m., Monday through Friday, or call their physician account

executive.

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Services Already Approved by Another

PH-MCO or Fee-for-Service

If a Member, upon enrolling in UPMC for You, is receiving services authorized by another

Physical Health Managed Care Organization (PH-MCO) or by the Medical Assistance fee-for-

service (FFS) program (ACCESS), those services will continue for the length of time, quantity of

services, and scope of services specified by the approved prior authorization. The length of time

that the service will continue will vary depending on if the Member is younger or older than 21

years old and/or the Member is pregnant. However, the provider still must notify UPMC for

You with information regarding those services. Contact Utilization Management at 1-800-425-

7800.

Members younger than 21 years old:

The Member will continue to receive any prior authorized service until the end of the time period

previously authorized.

Members 21 years old and older:

The Member will continue to receive any prior authorized service up to 60 days after enrollment

with UPMC for You. Utilization Management will conduct a concurrent clinical review of all

pertinent information to determine if the services are medically necessary beyond the initial

authorization period.

For Members who are pregnant:

If a pregnant Member is already receiving care from an out-of-network ob-gyn provider at the

time of enrollment with UPMC for You, the Member may choose to continue to receive an

ongoing clinically appropriate course of treatment from that specialist throughout the pregnancy

and postpartum care related to the delivery.

Closer Look at Services Already Approved by Another PH-MCO

or Fee-for-Service

Before authorization from the previous PH-MCO or fee-for-service program

expires, the provider needs to review prior authorization and referral requirements

for service and make necessary prior authorization requests.

➢ See: Services Requiring Prior Authorization, Utilization Management and

Medical Management, Chapter G.

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Services Not Covered

Not all services are covered under the UPMC for You program unless requested as a

Program Exception and prior authorization is obtained from Utilization Management.

Providers must contact the Utilization Management Department by submitting a

request through Provider OnLine at upmchealthplan.com/providers to determine if a

service is eligible to be considered for a prior authorization.

➢ Note: Members younger than age 21 are eligible for Medically

necessary services required to treat conditions detected during

a visit.

The following list contains examples of noncovered services but is not an all-inclusive list.

• Acupuncture

• Behavioral health services covered by a Member’s Behavioral Health Managed Care

Organization (BH-MCO)

• Experimental or investigative treatments

• Infertility services

• Medical services or surgical procedures and diagnostic tests performed on an inpatient

basis that could have been performed in the provider’s office, the clinic, the emergency

department, or a short procedure unit without endangering the life or health of the Member

• Nonmedically necessary treatments or surgery (e.g., cosmetic surgery)

• Out-of-country care (services provided outside the U.S.)

➢ See: Out-of-Area or Out-of-Network Care, UPMC for You (Medical Assistance),

Chapter E.

• Out-of-network care (except for emergency services and family planning)

• Procedures or services not on the Medical Assistance fee schedule

• Self-directed care, except as noted in the Coordinated Care section

➢ See: Coordinated Care, UPMC for You (Medical Assistance), Chapter E.

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Program Exception Process

The program exception process occurs when a provider requests a Utilization Management

review of a service which is included in the Member’s benefit package but is not currently

listed on the MA Program fee schedule to determine if an exception should be made based

on medical necessity. The process also applies to benefit limit exception requests for

additional treatment for a Member who has exhausted the benefit limit (i.e., duration or

quantity) of a particular service.

The Utilization Management Department will consider requests by providers for program

exceptions and benefit limit exceptions for UPMC for You Members.

Providers may submit program exception or benefit limit exception requests to Utilization

Management by submitting a request through Provider OnLine at:

upmchealthplan.com/providers and entering the authorization request, or by sending

a letter to:

UPMC Health Plan

Attn: Utilization Management

U.S. Steel Tower, 11th Floor

600 Grant Street

Pittsburgh, PA 15219

A provider or the provider on behalf of the Member must submit the following

information to request an exception:

• Member’s name

• Member’s address and telephone number

• Member’s UPMC for You Member ID

• A description of the service for which the provider or the Member is requesting an

exception

• The reason the exception is necessary

• Supporting clinical documentation demonstrating the medical necessity of the

service/item

• The provider’s name and telephone number

The provider may request a program or benefit limit exception before or after the service has

been delivered. A Member may only request a benefit limit exception before the service is

delivered.

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For an exception request made before the service has been delivered, UPMC for You will

respond within 21 days upon receipt of the request. If the provider indicates an urgent need

for a quick response, UPMC for You will respond within 48 hours upon receipt of the request.

If a service that is not on the fee schedule or normally requires prior authorization is delivered

in an emergency UPMC for You will respond within 30 days upon receipt of the request. An

exception request made after the service has been delivered must be submitted by the provider

through the provider appeal process no later than 30 days from the date UPMC for You rejects

the claim. Exception requests made after 30 days from the claim rejection date will be denied.

Both the Member and the provider will receive written notice of the approval or denial of the

exception request. For exception requests made before the service has been delivered, if the

provider or recipient is not notified of the decision within 21 days of the date the request is

received, the exception will be automatically granted.

A provider may not hold the Member liable for payment and bill the Member for services that

exceed the limits unless the following conditions are met:

• The provider advised the Member, before the service was provided, that the Member has

exceeded the limits.

• The provider advised the Member, before the service was provided, that he or she will be

responsible for payment if the exception is not granted.

• The provider has requested an exception to the limit and the request was denied.

Closer Look at Benefit Limit Exceptions

Benefit Limit Exception:

An exception to service limits may be granted if the UPMC for You Member:

• Has a serious chronic illness or other serious health condition, and without the

additional service, the Member’s life would be in danger; or

• Has a serious chronic illness or other serious health condition, and without the

additional service, the Member’s health will get much worse; or

• Has to go into a nursing home or institution if the exception is not granted; or

• Needs a more costly service if the exception is not granted.

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Closer Look at Dental Benefit Limit Exceptions

An exception to the dental benefit limits may be granted if:

• It is determined that the Member has a serious chronic systemic illness or

other serious health condition and denial of the exception will jeopardize the

life of the Member; or

• It is determined that the Member has a serious chronic systemic illness or

other serious health condition and denial of the exception will result in the

rapid, serious deterioration of the health of the Member; or

• It is determined that granting a specific exception is a cost-effective

alternative for UPMC for You; or

• It is determined that granting an exception is necessary in order to comply

with federal law.

If the dental BLE request identifies that the beneficiary has one of the conditions set

forth below, as part of the dental BLE review process, UPMC for You will review the

Member’s claim history to determine if the condition was previously identified on a

claim:

• Cancer of the Face, Neck, and throat (does not include stage 0 or

stage 1 non-invasive basal or sarcoma cell cancers of the skin).

• Coronary Artery Disease or risk factors for the disease.

• Diabetes.

• Intellectual Disability.

• Current Pregnancy only through the end of the postpartum period

(12 months after delivery)

If the condition was previously identified on a claim, UPMC for You will not require

supporting medical record documentation of the condition. If the condition was not

previously identified on a claim, UPMC for You will notify the dental provider that

supporting medical record documentation is needed to review the BLE request.

The supporting medical record documentation if the condition was not previously

identified on a claim, and any additional information requested, must be submitted to

Utilization Management within 14 days of UPMC for You’s request to the dental

provider. Upon receipt of the medical record documentation or additional

information, Utilization Management will review the request for a dental BLE to

confirm that one of the criteria for the granting of a BLE is met. The dental provider

and Member will be informed of the Utilization Management determination by

written Notice of Decision. If the BLE request is approved, the services can be

provided and paid for as long as the Member maintains MA eligibility and only

until the end of the postpartum period (12 months after delivery) for a pregnant

Member.

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Closer Look at the Difference Between the Turnaround

Times for a Program Exception Request and a Prior

Authorization Request.

Program exception requests should be submitted to Utilization Management by

the provider along with supporting information demonstrating the medical

necessity of the exception. The medical director will review all requests for

program exceptions to determine medical necessity. Members may request their

provider to initiate a program exception on their behalf. Members can contact the

UPMC for You Health Care Concierge team if they need assistance or have any

questions on how to request a program exception.

Urgent pre-service requests are reviewed for medical necessity and a

determination will be made within 24 hours. Providers will receive oral

notification of the decision within 24 hours receipt of the request in addition

to a written notification. The written notification is sent to the provider within

24 hours and a copy is sent to the Member.

Prior to issuing a medical necessity denial letter, for Members younger than 21

years old, the medical director will make a reasonable effort to outreach to the

ordering provider at least three times to attempt to obtain additional information

to support medical necessity. The reasonable effort must be documented in

writing.

Nonurgent pre-service requests are reviewed for medical necessity and a

determination will be made within two business days. Providers will receive

oral notification of decision within two business days of receipt of the request.

In addition, the provider will receive written notification within two business

days of the oral notification.

Prior to issuing a medical necessity denial notice for Members younger than 21

years old, the medical director will make a reasonable effort to outreach to the

ordering provider at least three times to attempt to obtain additional information

to support medical necessity. The reasonable effort must be documented in

writing.

Continuation of Service requests for services that the Member is currently

receiving and the medical director’s medical necessity review results in

termination or reduction of the service, the effective date of the termination

of those services will be 10 days from the date of the denial letter.

The services will continue at the previously approved level if the Member

requests an appeal within the 10 days from the date of the denial notice. The

previously approved level of service will continue until the appeal decision is

rendered.

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The EPSDT Program

At a Glance

The Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program provides

comprehensive preventive, acute, and chronic care services for children younger than 21

years old who are eligible for Medical Assistance.

The program provides comprehensive health services and focuses on early identification of

health conditions with a special emphasis on preventative care through regular well-child visits

with a PCP. Services covered under EPSDT include but not limited to well child visits,

developmental screenings, depression screening, dental and vision screening, etc.

Services covered can be found on the EPSDT and Dental Periodicity Schedules.

➢ See: Appendix E.1, Other Resources and Forms, UPMC for You

(Medical Assistance), Chapter E.

o EPSDT Periodicity Schedule

o Preventive Pediatric Oral Health Care (Dental Schedule)

If the provider is unable to obtain sufficient information to bill the Member’s primary

insurance UPMC for You may act as the primary carrier for EPSDT services. If, however, a

claim is received with another insurance carrier’s explanation of benefits (EOB) or explanation

of payment (EOP), UPMC for You will coordinate benefits.

➢ See: Determining Primary Insurance Coverage, Member Administration,

Chapter I.

➢ See: Coordination of Benefits, Claims, Chapter H.

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Provider Responsibilities in the EPSDT Program

All UPMC for You providers must comply with the following responsibilities:

• Providers must make reasonable efforts to obtain information regarding all insurances

the Member may have. Medical Assistance is generally the payer of last resort. If a

UPMC for You Member has other insurance that would be primary to Medical

Assistance, claims must be submitted to the primary insurance. The remaining balance

can be submitted to UPMC for You for consideration and coordination of benefits. If the

provider is unable to bill the primary insurance due to lack of information, UPMC for

You will act as the primary carrier for EPSDT services and coordinate with the primary

insurer, as appropriate.

➢ Note: This process applies to preventive pediatric care (including EPSDT

services to children), and services to children having medical coverage

under a Title IV-D child support order.

• Provide primary and preventive care to UPMC for You Members.

• Act as a Member advocate by providing, recommending, and arranging for medically

necessary care.

• Maintain the continuity of care for each Member in his or her care.

• Coordinate the Member’s physical and behavioral health care needs.

• Provide referrals for any medical services that cannot be provided by the PCP, including

referrals for in-network specialists and obtaining authorization for out-of-network care.

• Refer the Member to a dental home by age 1 and notify the PHDHP team at

[email protected] of the referral utilizing the appropriate dental form

or faxing the form to the Special Needs Department at 412-454-7552 (TTY: 711). The

form can be found at

upmchealthplan.com/providers/medical/resources/guidelines/epsdt-guidelines.aspx.

• Refer the Member to the Pediatric Care Management Department, as needed, to address

coordination of care and resource needs of the Member. Contact the Pediatric Care

Management Department at [email protected] or by calling

1-855-772-8762 (TTY: 711).

• Locate, coordinate, and monitor all primary care and other medical and rehabilitative

services for Members.

• Perform and report all EPSDT screens in the appropriate format, including all applicable

procedure codes and modifiers in accordance with the UPMC Health Plan EPSDT

Periodicity Schedule located at

upmchealthplan.com/providers/medical/resources/guidelines/epsdt-guidelines.aspx.

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• Contact Members who are not compliant with the EPSDT periodicity and immunization

schedule, as indicated on the UPMC for You EPSDT quarterly roster. PCPs should

contact Members within one month of the noncompliance to schedule an appointment.

PCPs also should document the reason for noncompliance and that efforts have been

made to bring Members into compliance. Members who are noncompliant may be

referred to a care manager by contacting the Pediatric Care Management Department

at [email protected] or by calling 1-855-772-8762 (TTY: 711).

➢ See: Appendix E.1, Other Resources and Forms, UPMC for You

(Medical Assistance), Chapter E.

o EPSDT Periodicity Schedule

o Preventive Pediatric Oral Health Care (Dental Periodicity Schedule)

Closer Look at the Quarterly EPSDT Roster

An EPSDT roster is sent quarterly to any provider who has a UPMC for You

Member younger than 21 years old. This roster contains information on Members

who are due and overdue for an EPSDT screening.

If a provider is not utilizing the rosters to determine needed outreach and has opted

to suppress the receipt of the rosters, an alternative process must be put in place to

contact Members that are due or overdue for their screenings. Contact Provider

Services at 1-866-918-1595 (TTY: 711) for assistance to receive the rosters or set

up an alternative process.

➢ See: Key Contacts, Chapter A.

• Provide childhood lead poisoning prevention services in accordance with DHS’s EPSDT

program requirements and lead screening guidelines established by the Centers for

Disease Control and Prevention (CDC). According to the EPSDT Periodicity schedule a

child should have a blood lead test between 9-11 months, age 1, and again at 24

months. Care for any Member with an elevated blood lead level should be coordinated

with the Pediatric Care Management Department. Providers should contact the Pediatric

Care Management Department at [email protected] or by calling

1-855-772-8762 (TTY: 711).

• Coordinate and monitor the care provided to Members by other health care practitioners.

• Maintain a centralized and current medical record, including documentation of all

services provided as well as referrals to specialists.

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• Screen for developmental, behavioral, and social delays in accordance with the EPSDT

Periodicity Schedule by using a standardized, validated screening tool on or before the

first, second, and third birthdays. Maintain a copy of the completed validated tool

within the Members medical record. Examples of validated tools can be found at

upmchealthplan.com/providers/medical/resources/guidelines/epsdt-guidelines.aspx.

• In cases of suspected developmental delay or elevated blood lead levels, the PCP

Must refer the child for Early Intervention Services, by contacting CONNECT at

1-800-692-7288 (TTY: 711) or by completing the Early Intervention referral form

located on the UPMC Health Plan website at

upmchealthplan.com/providers/medical/resources/guidelines/epsdt-guidelines.aspx.

The referral must be documented in the medical record. Providers may contact the

UPMC Health Plan Special Needs Unit at 1-866-864-1462 to discuss next steps for

children 0-5 years old.

• Arrange care management services for Members with complex medical needs, including

serious multiple disabilities or illnesses. Contact the Pediatric Care Management

Department at 1-855-772-8762 (TTY: 711) or by email at

[email protected].

• When appropriate, provide the Member or the Member’s parent (or guardian) with

information on how to access Behavioral Health services.

• Assess for child abuse or neglect and report any suspected cases of abuse or neglect via

Child Line at 1-800-932-0313 (TTY: 711) and inform the appropriate county Children

and Youth Agency. Additional resources can be found at the DHS website:

dhs.pa.gov/citizens/childwelfareservices.

• Assist Members, who are receiving care in a pediatric care environment, with transition

planning to the adult health care system, as appropriate. Including but not limited to:

o Assistance in coordinating transition from a pediatric specialists to adult

specialists.

o Coordinating care needs for supportive services transition.

o Move from pediatric practice to adult practice.

o Support skill building for accessing adult health care.

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EPSDT Appointment Scheduling and Outreach

UPMC for You conducts outreach to Members eligible for EPSDT screenings. Outreach

includes:

• Contact new Members or their parent or guardian to provide education on preventive

health and wellness including well child visits and immunizations.

• Assist the Member with scheduling an appointment with the PCP or other appropriate

provider if due or overdue for care.

• Assist Members/caregivers with scheduling dental care appointments.

• Assist in scheduling a new Member exam within 45 days of enrollment with UPMC for

You, according to the periodicity schedule, unless the child is already under the care of a

PCP and is current with screens and immunizations.

➢ See: Appendix E.1, Other Resources and Forms, EPSDT Periodicity Schedule,

UPMC for You (Medical Assistance), Chapter E.

In situations where Members continue to be noncompliant with making or keeping EPSDT

screening appointments, UPMC for You also will attempt other outreach methods.

EPSDT Services

Under Pennsylvania and federal laws, the EPSDT program must provide the following

services according to a periodicity schedule developed by DHS as recommended by the

American Academy of Pediatrics.

• Screening services, including a comprehensive health and developmental history,

developmental assessment, nutritional assessment, and all appropriate immunizations per

CDC guidelines

• An unclothed comprehensive physical examination

• Calculation of body mass index and growth chart percentile

• Health education and guidance: age-appropriate nutritional counseling, anticipatory

guidance/risk factor reduction interventions

• Ordering of appropriate laboratory tests, including hemoglobin and hematocrit,

dyslipidemia, urinalysis, iron levels, TB skin testing, sickle cell anemia screening,

and lead levels

• Newborn metabolic/hemoglobin screening and follow-up consistent with the Pennsylvania

Newborn Screening Panel: newborn bilirubin screening, growth measurements and head

circumference

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• Psychosocial/Behavioral assessments: behavioral health services, including counseling.

Assessment should be family centered and may include an assessment of the child’s

social-emotional health, social determinants of health, and caregiver

anxiety/depression/substance use disorder

• Maternal depression screening: administration of caregiver-focused health risk assessment

instrument (e.g., health hazard appraisal) with scoring and documentation, per

standardized screening tool that is most suitable for the provider’s practice

• Referral to behavioral health or medical providers to correct or ameliorate any problems

discovered upon the screen, including those not covered on the Medical Assistance fee-

for-service program

• Regular depression screening during adolescence

• Teenage pregnancy services or referral for those services

• Tobacco, alcohol, and drug use assessment

• Screening for sexually transmitted infections (STI)

• Testing for HIV and annual reassessment, per the EPSDT Periodicity Schedule, and for

those at increased risk for HIV infection, including those who are sexually active,

participate in injection drug use, or are being tested for other STIs

• Vision services, including diagnosis and treatment for defects in vision, and eye exams

for the provision of glasses. Screening for visual acuity using traditional methods (e.g.,

Snellen chart) or instrument-based screening for visual acuity and other ocular risk factors.

Instrument-based screening may be completed to detect amblyopia, strabismus, and/or

high refractive error in children who are unable or unwilling to cooperate with traditional

screening.

• Hearing services, including diagnosis and treatment for defects in hearing, and testing or

the provision of hearing aids. Newborns should receive a hearing screening prior to their

discharge from the hospital. A hearing screening is to be performed during the newborn

screening and if not, must be completed by age 3 months.

• Ordering of all other medically necessary health care, diagnostic services, and treatment

measures

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• Dental screening, including diagnosis and treatment of dental disease, no later than

age 1. PCPs should conduct an oral exam as part of the comprehensive examination.

Administration of oral health risk assessment and assessment of the need for fluoride

supplementation. Determination of whether the individual has a dental home or if a

referral is needed.

➢ See: Appendix E.1, Other Resources and Forms, UPMC for You

(Medical Assistance), Chapter E.

o Preventive Pediatric Oral Health Care (Dental Periodicity Schedule),

• Autism screening utilizing a standard screening tool

➢ See: Appendix E.1, Other Resources and Forms, UPMC for You

(Medical Assistance), Chapter E.

o Validated Screening Tools for Autism Spectrum Disorder

• Developmental screening, utilizing a standard screening tool

➢ See: Appendix E.1, Other Resources and Forms, UPMC for You

(Medical Assistance), Chapter E.

o Validated Screening Tools for Developmental Delays

Services are provided under the direction of the individual’s PCP. When possible, it is preferable

for the child to receive the examination and treatment from the same provider. If the PCP is

unable to perform an examination or treatment, the provider must arrange for the services to be

performed by another in-network provider. The PCP must coordinate and monitor the care

provided by other practitioners and maintain a centralized medical record.

A complete listing of services, schedule, guidelines, and other information can be found on the

UPMC Health Plan website and within Medical Assistance bulletins.

➢ See: Appendix E.1, Other Resources and Forms, UPMC for You (Medical Assistance),

Chapter E.

Initial EPSDT Visits for Newborns

The first EPSDT visit should be the newborn physical exam in the hospital, providing that it

includes all the screening components.

The first follow-up visit for the newborn should be provided within three to five days after

discharge from the hospital.

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Diagnosis and Treatment in the EPSDT Program

If a screening examination or an encounter with a health professional results in the detection of a

suspected problem, the child must be evaluated as necessary for further diagnosis and treatment.

The EPSDT program covers the provision of all medically necessary health care services

required to treat a condition diagnosed during an encounter with a health care professional.

If a provider suspects developmental delay, the provider must refer the child for Early

Intervention Services by contacting CONNECT at 1-800-692-7288 (TTY: 711) and should

complete the Pediatric Care Management Early Intervention referral form located on the

UPMC Health Plan website at

upmchealthplan.com/providers/medical/resources/guidelines/epsdt-guidelines.aspx.

If a provider detects elevated blood lead levels, the provider must coordinate care with the

Pediatric Care Management Department at 1-855-772-8762 (TTY: 711) or by email at

[email protected]. A referral to CONNECT at 1-800-692-7288 should be made as

appropriate.

Closer Look at Providing Services to SSI or SSI-related

Members

At the first appointment following enrollment of a Supplemental Security

Income (SSI) Member or SSI-related Member (i.e., spouse and dependents),

the PCP should conduct a complete assessment to determine the child’s health

care needs over an appropriate period (not to exceed one year).

The initial appointment should occur within 45 days of enrollment with

UPMC for You, unless the Member already is receiving care with a PCP

or specialist.

The assessment should include the child’s need for specialty care, which will

be discussed with the caregiver, custodial agency and, when age-appropriate,

the child. This assessment becomes part of the child’s medical record.

The PCP, at the time of the initial exam, must make a recommendation regarding

care management services. With the caregiver’s or custodial agency’s consent,

the PCP should contact Pediatric Care Management Department at 1-855-772-

8762 (TTY: 711) with a referral for care management services.

Childhood Lead Poisoning Prevention

Providers should administer childhood lead poisoning prevention services according to

current guidelines from the Centers for Disease Control and Prevention, which sets the

standard for comprehensive childhood lead poisoning prevention services.

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PCPs should conduct blood lead testing or refer the testing to a participating laboratory in

accordance with the EPSDT Periodicity Schedule. Children with elevated lead levels should

be identified on the CMS-1500 claim form utilizing the appropriate diagnosis code and EPSDT

modifiers. PCPs who discover Members younger than 21 years old with blood lead levels

equal to or greater than 5µg /dL should order an Environmental Lead Investigation (ELI)

and contact the Special Needs Department at 1-866-463-1462 (TTY: 711).

UPMC for You pays for environmental lead investigations for children with a blood lead levels

equal to or greater than 5µg /dL (via venous blood lead level). An ELI is an in-home

assessment to determine if the cause of lead is within a Member’s home. To order an ELI a

provider must complete and submit the ELI request form found at:

p.widencdn.net/n22t3b/providers_environmental-lead-investigation-request-form_web to

[email protected].

Environmental lead investigation is completed in accordance with the PA Department of Health

recommendations. Environmental lead investigators possess current certification from the

Pennsylvania Department of Labor and Industry as an environmental risk assessor or a lead

inspector.

Care Management services are available to any Member/family with an elevated blood lead

level. To refer a Member/family to care management services contact the Pediatric Care

Management Department at 1-855-772-8762 (TTY: 711) or outreach to

[email protected].

➢ See: Appendix E.1, Other Resources and Forms, EPSDT Periodicity Schedule,

UPMC for You (Medical Assistance), Chapter E.

➢ See: Medical Assistance bulletin #01-18-10, Environmental Lead Investigation,

effective 8-22-2018.

Closer Look at High Lead Levels

PCPs who discover Members younger than 21 years old with blood lead

levels equal to or greater than 5µg /dL should order an environmental lead

investigation and contact the Pediatric Care Management Department at

1-855-772-8762 (TTY:711) or outreach to [email protected].

Members with elevated blood levels are also appropriate for early intervention

services. To arrange these services providers must contact CONNECT at

1-800-692- 7288 (TTY: 711). The referral to CONNECT must be documented

in the medical records. Children with elevated lead levels should be managed

according to CDC recommendations.

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EPSDT Expanded Services

Expanded services are those services required to treat conditions a provider detects during an

encounter with a Member who is younger than 21 years old that may or may not normally be

covered by the Medical Assistance FFS program (ACCESS) such as certain medical supplies or

durable medical equipment.

All requests for EPSDT expanded services must be authorized by the Utilization Management

Department by submitting a request through Provider OnLine at

upmchealthplan.com/providers. The request must include a letter of medical necessity

describing the rationale for the expanded services and the benefit the service will provide the

Member. Utilization Management will review the prior authorization request for medical

necessity with the medical director. Urgent requests are processed within 24 hours to ensure

that the child’s medical care is not jeopardized.

The Member and provider will be notified of the decision regarding the request for service

within 21 days of the receipt of the request. This notice includes denials, reductions, or changes

in scope or duration of services. If the decision to approve or deny a covered service or item is

not made by the 21st day from the date the request was received, the service or item is

automatically approved.

➢ See: Services Requiring Prior Authorization, Utilization Management and

Medical Management, Chapter G.

EPSDT Claims Submission and Payment

All PCPs must perform EPSDT screens according to the periodicity schedule.

➢ See: Appendix E.1, Other Resources and Forms, EPSDT Periodicity Schedule,

UPMC for You (Medical Assistance), Chapter E.

To receive reimbursement for an EPSDT screening, providers should submit their claims

electronically or complete a CMS-1500 form utilizing the appropriate codes and modifiers,

and send the claim within 90 days of the date of service to:

UPMC for You

PO Box 2995

Pittsburgh, PA 15230-2995

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Special Needs Unit

The UPMC for You Special Needs Unit is available to assist providers in connecting Members

with care management services, assist in troubleshooting care coordination needs as well as

connecting to community-based resources to assist in addressing social barriers to

accessing/managing/maintaining health.

Providers can contact the Special Needs Unit by email at SN[email protected] or by

calling 1-866-463-1462 (TTY: 711), Monday through Friday from 7 a.m. to 8 p.m. and Saturday

from 8 a.m. to 3 p.m.

School-based and School-linked Services

The UPMC for You Special Needs Department coordinates school-based and school-

linked services with providers to:

• Make sure PCPs interact with school-based centers as necessary.

• Arrange for the coordination and integration of school-based health service information

into the PCP’s Member record, as necessary.

• Help coordinate specialized treatment plans for children with special health care needs,

including participation on interagency teams.

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MA Provider Compliance Hotline

If a provider has knowledge of suspected MA provider noncompliance, recipient or provider

fraud, waste or abuse, or of substandard quality of care for services paid for under the

Pennsylvania Medical Assistance Program, contact the MA Provider Compliance Hotline at

1-866-379-8477.

Recipient fraud is defined as someone who receives cash assistance, Supplemental Nutritional

Assistance Program (SNAP) benefits, Heating/Energy Assistance (LIHEAP), child care, medical

assistance, or other public benefits AND that person is not reporting income, not reporting

ownership of resources or property, not reporting who lives in the household, allowing another

person to use his or her ACCESS/MCO card, forging or altering prescriptions, selling

prescriptions/medications, trafficking SNAP benefits or taking advantage of the system in any

way.

Provider fraud is defined as billing for services not rendered, billing separately for services in

lieu of an available combination code; misrepresentation of the service/supplies rendered (billing

brand named for generic drugs; upcoding to more expensive service than was rendered; billing

for more time or units of service than provided, billing incorrect provider or service location);

altering claims, submission of any false data on claims, such as date of service, provider or

prescriber of service, duplicate billing for the same service; billing for services provided by

unlicensed or unqualified persons; billing for used items as new.

Reported problems will be referred to the Office of Administration's Bureau of Program Integrity

for investigation, analysis, and determination of the appropriate course of action.

The hotline number operates Monday through Friday from 8:30 a.m. to 4 p.m. Callers may

remain anonymous and may call after hours and leave a voice mail if they prefer.

➢ See: Provider Role in: Reporting Fraud, Waste, and Abuse to UPMC Health Plan,

Provider Standards and Procedures, Chapter B.

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Member Rights and Responsibilities

Member Rights

UPMC for You Members have the right:

• To be treated with respect, recognizing their dignity and need for privacy, by UPMC for

You staff and in-network providers.

• To get information in a way that they can easily understand and find help when they need

it.

• To get information that they can easily understand about UPMC for You, its services, and

the doctors and other providers that treat them.

• To pick the in-network health care providers that they want to treat them.

• To get emergency services when they need them from any provider without UPMC for

You’s approval.

• To get information that they can easily understand and talk to their providers about their

treatment options, without any interference from UPMC for You.

• To make all decisions about their health care, including the right to refuse treatment. If

they cannot make treatment decisions by their self, they have the right to have someone

else help make decisions or make decisions for them.

• To talk with providers in confidence and to have their health care information and records

kept confidential.

• To see and get a copy of their medical records and to ask for changes or corrections to

their records.

• To ask for a second opinion.

• To file a Grievance if they disagree with UPMC for You’s decision that a service is not

medically necessary.

• To file a Complaint if they are unhappy about the care or treatment they have received.

• To ask for a DHS Fair Hearing.

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• To be free from any form of restraint or seclusion used to force them to do something, to

discipline them, to make it easier for the provider, or to punish them.

• To get information about services that UPMC for You or a provider does not cover

because of moral or religious objections and about how to get those services.

• To exercise their rights without it negatively affecting the way DHS, UPMC for You, and

in-network providers treat them.

• To make recommendations about the rights and responsibilities of UPMC for You’s

Members.

Member Responsibilities

Members need to work with their health care service providers. UPMC for You needs the

Member’s help so that they get the services and supports they need.

UPMC for You Members have the responsibility to:

• Provide, to the extent they can, information needed by their providers.

• Follow instructions and guidelines given by their providers.

• Be involved in decisions about their health care and treatment.

• Work with their providers to create and carry out their treatment plans.

• Tell their providers what they want and need.

• Learn about UPMC for You coverage, including all covered and non-covered benefits and

limits.

• Use only in-network providers unless UPMC for You approves an out-of-network

provider.

• Get a referral from their PCP to see a specialist.

• Respect other patients, provider staff, and provider workers.

• Make a good-faith effort to pay their co-payments.

• Report fraud and abuse to the DHS Fraud and Abuse Reporting Hotline.

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Member Complaint and Grievance

Procedures

UPMC for You Members have a Complaint, Grievance, and Fair Hearing process available to

them if they are unhappy about services provided by UPMC for You or their provider.

The UPMC for You Member Complaint, Grievance and Fair Hearing process is separate and

distinct from the Provider Dispute process outlined in the UPMC Health Plan provider manual,

Chapter B, Provider Standards and Procedures.

The Member may ask the provider to file a Complaint or Grievance on their behalf, but the

Member, the Member’s parent/guardian, or the Member’s designated representative must

officially appoint the provider as their personal representative in writing.

Member’s Written Consent Guidelines

If a Member requests that a provider file a grievance, the Member must complete a consent form

or write a letter. The consent form or letter of consent must include certain information,

statements, and signatures that are required by the Pennsylvania Department of Health.

Required Information

The following general information is required in the letter of consent or on the consent form:

• The name and address of the Member and of the policyholder (if they are different),

the Member’s date of birth, and the Member’s identification number

• If the Member is a minor or is legally incompetent, the name and relationship to the

Member of the person who signs the consent

• The name, address, and UPMC Health Plan’s identification number of the provider to

whom the Member is providing the consent

• UPMC Health Plan’s name and address

• A description of the specific service for which coverage was provided or denied

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Required Statements

The following statements are required in the letter of consent or on a consent form:

• The Member or Member’s representative may not submit a grievance concerning the

services listed in this letter of consent or consent form unless the Member or Member’s

representative rescinds consent in writing. The Member or Member’s representative has

the right to rescind consent at any time during the grievance process.

• The consent of the Member or Member’s representative shall be automatically rescinded

if the provider fails to file a grievance.

• The Member or Member’s representative has read this consent form and has had it

explained to their satisfaction.

Required Signatures

The following signatures are required in the letter of consent or on a consent form:

• The dated signature of the Member or the Member’s representative

• The dated signature of a witness

The following are instructions that have been provided to the Member in their UPMC for You

Member handbook on how they may file a Complaint, Grievance, request a Fair Hearing, or an

External Grievance review, and how to continue to receive services during the process.

➢ Note: The terms “you” or “your” in the following excerpt are referring

to the Member.

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UPMC for You Member Handbook Excerpt

(Section 8 - Complaints, Grievances, and Fair Hearings)

Complaints, Grievances, and Fair Hearings

If a provider or UPMC for You does something that you are unhappy about or do not agree with,

you can tell UPMC for You or the Department of Human Services what you are unhappy about

or that you disagree with what the provider or UPMC for You has done. This section describes

what you can do and what will happen.

Complaints

What is a Complaint?

A Complaint is when you tell UPMC for You that you are unhappy with UPMC for You or your

provider or do not agree with a decision by UPMC for You.

Some things you may complain about:

• You are unhappy with the care you are getting.

• You cannot get the service or item you want because it is not a covered service or item.

• You have not gotten services that UPMC for You has approved.

• You were denied a request to disagree with a decision that you have to pay your provider.

First Level Complaint

What Should I Do if I Have a Complaint?

To file a first level Complaint:

• Call UPMC for You at 1-800-286-4242 (TTY: 711) and tell UPMC for You your

Complaint, or

• Write down your Complaint and send it to UPMC for You by mail or fax, or

• If you received a notice from UPMC for You telling you UPMC for You’s decision and

the notice included a Complaint/Grievance Request Form, fill out the form and send it to

UPMC for You by mail or fax.

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UPMC for You’s address and fax number for Complaints:

UPMC for You

Complaints, Grievances, and Appeals

PO Box 2939

Pittsburgh, PA 15230-2939

Fax: 412-454-7920

Your provider can file a Complaint for you if you give the provider your consent in writing

to do so.

When Should I File a First Level Complaint?

Some Complaints have a time limit on filing. You must file a Complaint within 60 days of

getting a notice telling you that

• UPMC for You has decided that you cannot get a service or item you want because it

is not a covered service or item.

• UPMC for You will not pay a provider for a service or item you got.

• UPMC for You did not tell you its decision about a Complaint or Grievance you told

UPMC for You about within 30 days from when UPMC for You got your Complaint

or Grievance.

• UPMC for You has denied your request to disagree with UPMC for You’s decision that

you have to pay your provider.

You must file a Complaint within 60 days of the date you should have gotten a service or

item if you did not get a service or item. The time by which you should have received a service

or item is listed below:

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Table E.2: Appointment Standards

New Member appointment for

your first examination…

We will make an appointment for you…

Members with HIV/AIDS

with PCP or specialist no later than 7 days after

you become a Member in UPMC for You unless

you are already being treated by a PCP or

specialist.

Members who receive Supplemental

Security Income (SSI)

with PCP or specialist no later than 45 days after

you become a Member in UPMC for You, unless

you are already being treated by a PCP or

specialist.

Members under the age of 21

with PCP for an EPSDT exam no later than 45

days after you become a Member in UPMC for

You, unless you are already being treated by a PCP

or specialist.

All other Members

with PCP no later than 3 weeks after you become

a in UPMC for You

Members who are pregnant:

We will make an appointment for you . . .

Members in their first trimester

with ob-gyn provider within 10 business days of

UPMC for You learning you are pregnant.

Members in their second trimester

with ob-gyn provider within 5 business days of

UPMC for You learning you are pregnant.

Members in their third trimester

with ob-gyn provider within 4 business days of

UPMC for You learning you are pregnant.

Members with high-risk pregnancies

with ob-gyn provider within 24 hours of UPMC for

You learning you are pregnant

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Appointment with…

An appointment must be scheduled . . .

PCP

Urgent medical condition

Within 24 hours

Routine appointment

Within 10 business days

Health assessment/general physical

examination

Within 3 weeks

Specialists (when referred by PCP)

Urgent medical condition

Within 24 hours of referral

Routine appointment with one of the

following specialists:

• Dentist

• Dermatology

• Orthopedic surgery

• Otolaryngology

• Pediatric allergy and immunology

• Pediatric dentistry

• Pediatric endocrinology

• Pediatric gastroenterology

• Pediatric general surgery

• Pediatric hematology

• Pediatric infectious disease

• Pediatric nephrology

• Pediatric neurology

• Pediatric oncology

• Pediatric pulmonology

• Pediatric rehab medicine

• Pediatric rheumatology

• Pediatric urology

Within 15 business days of referral

Routine appointment with all other

specialists

Within 10 business days of referral

➢ Note: You may file all other Complaints at any time.

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What Happens After I File a First Level Complaint?

After you file your Complaint, you will get a letter from UPMC for You telling you that UPMC

for You has received your Complaint, and about the First Level Complaint review process.

You may ask UPMC for You to see any information UPMC for You has about the issue you filed

your Complaint about at no cost to you. You may also send information that you have about

your Complaint to UPMC for You.

You may attend the Complaint review if you want to attend it. UPMC for You will tell you the

location, date, and time of the Complaint review at least 10 days before the day of the Complaint

review. You may appear at the Complaint review in person, by phone, or by videoconference.

If you decide that you do not want to attend the Complaint review, it will not affect the decision.

A committee of 1 or more UPMC for You staff who were not involved in and do not work for

someone who was involved in the issue you filed your Complaint about will meet to make a

decision about your Complaint. If the Complaint is about a clinical issue, a licensed doctor will

be on the committee. UPMC for You will mail you a notice within 30 days from the date you

filed your First Level Complaint to tell you the decision on your First Level Complaint. The

notice will also tell you what you can do if you do

not like the decision.

What to do to continue getting services:

If you have been getting the services or items that are being reduced, changed or denied and

you file a Complaint verbally, or that is faxed, postmarked, or hand-delivered within 10 days

of the date on the notice telling you that the services or items you have been receiving are not

covered services or items for you, the services or items will continue until a decision is made.

What if I Do Not Like UPMC for You’s Decision?

You may ask for an external Complaint review, a Fair Hearing, or an external Complaint review

and a Fair Hearing if the Complaint is about one of the following:

• UPMC for You’s decision that you cannot get a service or item you want because it is

not a covered service or item

• UPMC for You’s decision to not pay a provider for a service or item you got

• UPMC for You’s failure to decide a Complaint or Grievance you told UPMC for You

about within 30 days from when UPMC for You got your Complaint or Grievance

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• You not getting a service or item within the time by which you should have received it

• UPMC for You’s decision to deny your request to disagree with UPMC for You’s

decision that you have to pay your provider

You must ask for an external Complaint review within 15 days of the date you got the First

Level Complaint decision notice.

You must ask for a Fair Hearing within 120 days from the mail date on the notice telling you

the Complaint decision.

For all other Complaints, you may file a Second Level Complaint within 45 days of the date

you got the Complaint decision notice.

Second Level Complaint

What Should I Do if I Want to File a Second Level Complaint?

To file a Second Level Complaint:

• Call UPMC for You at 1-800-286-4242 (TTY: 711) and tell UPMC for You your Second

Level Complaint, or

• Write down your Second Level Complaint and send it to UPMC for You by mail or fax,

or

• Fill out the Complaint Request Form included in your Complaint decision notice and

send it to UPMC for You by mail or fax.

UPMC for You’s address and fax number for Second Level Complaints

UPMC for You

Complaints, Grievances, and Appeals

PO Box 2939

Pittsburgh, PA 15230-2939

Fax: 412-454-7920

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What Happens After I File a Second Level Complaint?

After you file your Second Level Complaint, you will get a letter from UPMC for You telling

you that UPMC for You has received your Complaint, and about the Second Level Complaint

review process.

You may ask UPMC for You to see any information UPMC for You has about the issue you filed

your Complaint about at no cost to you. You may also send information that you have about

your Complaint to UPMC for You.

You may attend the Complaint review if you want to attend it. UPMC for You will tell you the

location, date, and time of the Complaint review at least 15 days before the Complaint review.

You may appear at the Complaint review in person, by phone, or by videoconference. If you

decide that you do not want to attend the Complaint review, it will not affect the decision.

A committee of 3 or more people, including at least 1 person who does not work for UPMC

for You, will meet to decide your Second Level Complaint. The UPMC for You staff on the

committee will not have been involved in and will not have worked for someone who was

involved in the issue you filed your Complaint about. If the Complaint is about a clinical issue,

a licensed doctor will be on the committee.

UPMC for You will mail you a notice within 45 days from the date your Second Level

Complaint was received to tell you the decision on your Second Level Complaint. The letter will

also tell you what you can do if you do not like the decision.

What if I Do Not Like UPMC for You’s Decision on My Second Level

Complaint?

You may ask for an external review by either the Department of Health or the Insurance

Department.

You must ask for an external review within 15 days of the date you got the Second Level

Complaint decision notice.

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External Complaint Review

How Do I Ask for an External Complaint Review?

You must send your request for external review of your Complaint in writing to either:

Pennsylvania Department of Health

or

Pennsylvania Insurance Department

Bureau of Managed Care

Bureau of Consumer Services

Health and Welfare Building, Room 912

Room 1209, Strawberry Square

625 Forster Street

Harrisburg, Pennsylvania 17120

Harrisburg, PA 17120-0701

Telephone Number: 1-888-466-2787

Telephone Number: 1-877-881-6388

If you ask, the Department of Health will help you put your Complaint in writing.

The Department of Health handles Complaints that involve the way a provider gives care or

services. The Insurance Department reviews Complaints that involve UPMC for You’s policies

and procedures. If you send your request for external review to the wrong Department, it will be

sent to the correct Department.

What Happens After I Ask for an External Complaint Review?

The Department of Health or the Insurance Department will get your file from UPMC for You.

You may also send them any other information that may help with the external review of your

Complaint.

You may be represented by an attorney or another person such as your representative during the

external review.

A decision letter will be sent to you after the decision is made. This letter will tell you all the

reason(s) for the decision and what you can do if you do not like the decision.

What to do to continue getting services:

If you have been getting the services or items that are being reduced, changed, or denied and

your request for an external Compliant review is postmarked or hand-delivered within

10 days of the date on the notice telling you UPMC for You’s First Level Complaint decision

that you cannot get service or items you have been receiving because they are not covered

services or items for you, the services or items will continue until a decision is made.

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GRIEVANCES

What is a Grievance?

When UPMC for You denies, decreases, or approves a service or item different than the service

or item you requested because it is not medically necessary, you will get a notice telling you

UPMC for You’s decision.

A Grievance is when you tell UPMC for You that you disagree with UPMC for You’s decision.

What Should I Do if I Have a Grievance?

To file a Grievance:

• Call UPMC for You at 1-800-286-4242 (TTY: 711) and tell UPMC for You

your Grievance, or

• Write down your Grievance and send it to UPMC for You by mail or fax, or

• Fill out the Complaint/Grievance Request Form included in the denial notice you

got from UPMC for You and send it to UPMC for You by mail or fax.

UPMC for You’s address and fax number for Grievances:

UPMC for You

Complaints, Grievances, and Appeals

PO Box 2939

Pittsburgh, PA 15230-2939

Fax: 412-454-7920

Your provider can file a Grievance for you if you give the provider your consent in writing to

do so. If your provider files a Grievance for you, you cannot file a separate Grievance on your

own.

When Should I File a Grievance?

You must file a Grievance within 60 days from the date you get the notice telling you about

the denial, decrease, or approval of a different service or item for you.

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What Happens After I File a Grievance?

After you file your Grievance, you will get a letter from UPMC for You telling you that UPMC

for You has received your Grievance, and about the Grievance review process.

You may ask UPMC for You to see any information that UPMC for You used to make the

decision you filed your Grievance about at no cost to you. You may also send information that

you have about your Grievance to UPMC for You.

You may attend the Grievance review if you want to attend it. UPMC for You will tell you the

location, date, and time of the Grievance review at least 10 days before the day of the Grievance

review. You may appear at the Grievance review in person, by phone, or by videoconference.

If you decide that you do not want to attend the Grievance review, it will not affect the decision.

A committee of 3 or more people, including a licensed doctor, will meet to decide your

Grievance. The UPMC for You staff on the committee will not have been involved in and will

not have worked for someone who was involved in the issue you filed your Grievance about.

UPMC for You will mail you a notice within 30 days from the date your Grievance was received

to tell you the decision on your Grievance. The notice will also tell you what you can do if you

do not like the decision.

What to do to continue getting services:

If you have been getting services or items that are being reduced, changed, or denied and you

file a Grievance verbally, or that is faxed, postmarked, or hand-delivered within 10 days of

the date on the notice telling you that the services or items you have been receiving are being

reduced, changed, or denied, the services or items will continue until a decision is made.

What if I Do Not Like UPMC for You’s Decision?

You may ask for an external Grievance review or a Fair Hearing or you may ask for both an

external Grievance review and a Fair Hearing. An external Grievance review is a review by a

doctor who does not work for UPMC for You.

You must ask for an external Grievance review within 15 days of the date you got the

Grievance decision notice.

You must ask for a Fair Hearing from the Department of Human Services within 120 days

from the date on the notice telling you the Grievance decision.

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External Grievance Review

How Do I Ask for External Grievance Review?

To ask for an external Grievance review:

• Call UPMC for You at 1-800-286-4242 (TTY: 711) and tell UPMC for You

your Grievance, or

• Write down your Grievance and send it to UPMC for You by mail to

UPMC for You

Complaints, Grievances, and Appeals

PO Box 2939

Pittsburgh, PA 15230-2939

UPMC for You will send your request for external Grievance review to the Department

of Health.

Pennsylvania Department of Health

Bureau of Managed Care

Health and Welfare Building, Room 912

625 Forster Street

Harrisburg, PA 17120-0701

Telephone Number: 1-888-466-2787

What Happens After I Ask for an External Grievance Review?

The Department of Health will notify UPMC for You of the external Grievance reviewer’s name,

address and phone number. UPMC for You will send your Grievance file to the reviewer, and

notify you of the external Grievance reviewer’s name, address and phone number. You will also

be given information about the external Grievance review process. You may provide additional

information that may help with the external review of your Grievance to the reviewer within 15

days of filing the request for an external Grievance review. You will receive a decision letter

within 60 days of the date you asked for an external Grievance review. This letter will tell you

all the reason(s) for the decision and what you can do if you do not like the decision.

What to do to continue getting services:

If you have been getting the services or items that are being reduced, changed, or denied and

you ask for an external Grievance review verbally or in a letter that is postmarked or hand-

delivered within 10 days of the date on the notice telling you UPMC for You’s Grievance

decision, the services or items will continue until a decision is made.

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Expedited Complaints and Grievances

What Can I Do if My Health Is at Immediate Risk?

If your doctor or dentist believes that waiting 30 days to get a decision about your First Level

Complaint or Grievance, or 45 days to get a decision about your Second Level Complaint, could

harm your health, you or your doctor or dentist may ask that your Complaint or Grievance be

decided more quickly. For your Complaint or Grievance to be decided more quickly:

• You must ask UPMC for You for an early decision by calling UPMC for You at

1-800-286-4242 (TTY: 711), faxing a letter or the Complaint/Grievance Request

Form to 412-454-7920, or sending an email to: [email protected].

• Your doctor or dentist should fax a signed letter to 412-454-7920 within 72 hours of

your request for an early decision that explains why UPMC for You taking 30 days to

tell you a decision about your First Level Complaint or Grievance, or 45 days to tell

you a decision about your Second Level Complaint, could harm your health.

If UPMC for You does not receive a letter from your doctor or dentist and the information

provided does not show that taking the usual amount of time to decide your Complaint or

Grievance could harm your health, UPMC for You will decide your Complaint or Grievance in

the usual time frame of 30 days from when UPMC for You first got your First Level Complaint

or Grievance, or 45 days from when UPMC for You got your Second Level Complaint.

Expedited Complaint and Expedited External Complaint

Your expedited Complaint will be reviewed by a committee that includes a licensed doctor.

Members of the committee will not have been involved in and will not have worked for

someone who was involved in the issue you filed your Complaint about.

You may attend the expedited Complaint review if you want to attend it. You can attend the

Complaint review in person but may have to appear by phone or by videoconference because

UPMC for You has a short amount of time to decide an expedited Complaint. If you decide that

you do not want to attend the Complaint review, it will not affect the decision.

UPMC for You will tell you the decision about your Complaint within 48 hours of when UPMC

for You gets your doctor’s or dentist’s letter explaining why the usual time frame for deciding

your Complaint will harm your health or within 72 hours from when UPMC for You gets your

request for an early decision, whichever is sooner, unless you ask UPMC for You to take more

time to decide your Complaint. You can ask UPMC for You to take up to 14 more days to

decide your Complaint. You will also get a notice telling you the reason(s) for the decision and

how to ask for expedited external Complaint review, if you do not like the decision.

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If you did not like the expedited Complaint decision, you may ask for an expedited external

Complaint review from the Department of Health within 2 business days from the date you get

the expedited Complaint decision notice. To ask for expedited external review of a Complaint:

• Call UPMC for You at 1-800-286-4242 (TTY: 711) and tell UPMC for You your

Complaint, or

• Send an email to UPMC for You at [email protected], or

• Write down your Complaint and send it to UPMC for You by mail or fax:

UPMC for You

Complaints and Grievances Department

PO Box 2939

Pittsburgh, PA 15230-2939

Fax: 412-454-7920

Expedited Grievance and Expedited External Grievance

A committee of 3 or more people, including a licensed doctor, will meet to decide your

Grievance. The UPMC for You staff on the committee will not have been involved in and will

not have worked for someone who was involved in the issue you filed your Grievance about.

You may attend the expedited Grievance review if you want to attend it. You can attend the

Grievance review in person but may have to appear by phone or by videoconference because

UPMC for You has a short amount of time to decide the expedited Grievance. If you decide that

you do not want to attend the Grievance review, it will not affect our decision.

UPMC for You will tell you the decision about your Grievance within 48 hours of when UPMC

for You gets your doctor’s or dentist’s letter explaining why the usual time frame for deciding

your Grievance will harm your health or within 72 hours from when UPMC for You gets your

request for an early decision, whichever is sooner, unless you ask UPMC for You to take more

time to decide your Grievance. You can ask UPMC for You to take up to 14 more days to

decide your Grievance. You will also get a notice telling you the reason(s) for the decision and

what to do if you do not like the decision.

If you do not like the expedited Grievance decision, you may ask for an expedited external

Grievance review or an expedited Fair Hearing by the Department of Human Services or both

an expedited external Grievance review and an expedited Fair Hearing.

You must ask for expedited external Grievance review by the Department of Health within

2 business days from the date you get the expedited Grievance decision notice.

To ask for expedited external review of a Grievance:

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• Call UPMC for You at 1-800-286-4242 (TTY: 711) and tell UPMC for You your

Grievance, or

• Send an email to UPMC for You at [email protected], or

• Write down your Grievance and send it to UPMC for You by mail or fax:

UPMC for You

Complaints and Grievances Department

PO Box 2939

Pittsburgh, PA 15230-2939

Fax: 412-454-7920

UPMC for You will send your request to the Department of Health within 24 hours after

receiving it.

You must ask for a Fair Hearing within 120 days from the date on the notice telling you the

expedited Grievance decision.

What Kind of Help Can I Have with the Complaint and Grievance Processes?

If you need help filing your Complaint or Grievance, a staff member of UPMC for You will help

you. This person can also represent you during the Complaint or Grievance process. You do not

have to pay for the help of a staff member. This staff member will not have been involved in any

decision about your Complaint or Grievance.

You may also have a family member, friend, lawyer, or other person help you file your

Complaint or Grievance. This person can also help you if you decide you want to appear at the

Complaint or Grievance review.

At any time during the Complaint or Grievance process, you can have someone you know

represent you or act for you. If you decide to have someone represent or act for you, tell

UPMC for You, in writing, the name of that person and how UPMC for You can reach him

or her.

You or the person you choose to represent you may ask UPMC for You to see any information

UPMC for You has about the issue you filed your Complaint or Grievance about at no cost to

you.

You may call UPMC for You toll-free telephone number at 1-800-286-4242 (TTY: 711) if

you need help or have questions about Complaints and Grievances, you can contact your local

Pennsylvania Legal Aid Network office at 1-800-322-7572 or call the Pennsylvania Health

Law Project at 1-800-274-3258.

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Persons Whose Primary Language Is Not English

If you ask for language services, UPMC for You will provide the services at no cost to you.

Persons with Disabilities

UPMC for You will provide persons with disabilities with the following help in presenting

Complaints or Grievances at no cost, if needed. This help includes:

• Providing sign language interpreters;

• Providing information submitted by UPMC for You at the Complaint or Grievance review

in an alternative format. The alternative format version will be given to you before the

review; and

• Providing someone to help copy and present information.

DEPARTMENT OF HUMAN SERVICES FAIR HEARINGS

In some cases, you can ask the Department of Human Services to hold a hearing because you are

unhappy about or do not agree with something UPMC for You did or did not do. These hearings

are called “Fair Hearings.” You can ask for a Fair Hearing after UPMC for You decides your

First Level Complaint or decides your Grievance.

What Can I Request a Fair Hearing About and By When Do I Have to Ask

for a Fair Hearing?

Your request for a Fair Hearing must be postmarked within 120 days from the date on the

notice telling you UPMC for You’s decision on your First Level Complaint or Grievance about

the following:

• The denial of a service or item you want because it is not a covered service or item.

• The denial of payment to a provider for a service or item you got and the provider can

bill you for the service or item.

• UPMC for You’s failure to decide a First Level Complaint or Grievance you told UPMC

for You about within 30 days from when UPMC for You got your Complaint or

Grievance.

• The denial of your request to disagree with UPMC for You’s decision that you have to

pay your provider.

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• The denial of a service or item, decrease of a service or item, or approval of a service or

item different from the service or item you requested because it was not medically

necessary.

• You’re not getting a service or item within the time by which you should have received a

service or item.

You can also request a Fair Hearing within 120 days from the date on the notice telling you that

UPMC for You failed to decide a First Level Complaint or Grievance you told UPMC for You

about within 30 days from when UPMC for You got your Complaint or Grievance.

How Do I Ask for a Fair Hearing?

Your request for a Fair Hearing must be in writing. You can either fill out and sign the Fair

Hearing Request Form included in the Complaint or the Grievance decision notice or write and

sign a letter.

If you write a letter, it needs to include the following information:

• Your (the Member’s) name and date of birth;

• A telephone number where you can be reached during the day;

• Whether you want to have the Fair Hearing in person or by telephone;

• The reason(s) you are asking for a Fair Hearing; and

• A copy of any letter you received about the issue you are asking for a Fair Hearing about.

You must send your request for a Fair Hearing to the following address:

Department of Human Services

Office of Medical Assistance Programs – HealthChoices Program

Complaint, Grievance and Fair Hearings

PO Box 2675

Harrisburg, PA 17105-2675

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What Happens After I Ask for a Fair Hearing?

You will get a letter from the Department of Human Services’ Bureau of Hearings and Appeals

telling you where the hearing will be held and the date and time for the hearing. You will receive

this letter at least 10 days before the date of the hearing.

You may come to where the Fair Hearing will be held or be included by phone. A family

member, friend, lawyer, or other person may help you during the Fair Hearing. You MUST

participate in the Fair Hearing.

UPMC for You will also go to your Fair Hearing to explain why UPMC for You made the

decision or explain what happened.

You may ask UPMC for You to give you any records, reports and other information about the

issue you requested your Fair Hearing about at no cost to you.

When Will the Fair Hearing Be Decided?

The Fair Hearing will be decided within 90 days from when you filed your Complaint or

Grievance with UPMC for You, not including the number of days between the date on the

written notice of the UPMC for You’s First Level Complaint decision or Grievance decision and

the date you asked for a Fair Hearing.

If you requested a Fair Hearing because UPMC for You did not tell you its decision about a

Complaint or Grievance you told UPMC for You about within 30 days from when UPMC for

You got your Complaint or Grievance, your Fair Hearing will be decided within 90 days from

when you filed your Complaint or Grievance with UPMC for You, not including the number of

days between the date on the notice telling you that UPMC for You failed to timely decide your

Complaint or Grievance and the date you asked for a Fair Hearing.

The Department of Human Services will send you the decision in writing and tell you what to do

if you do not like the decision. If your Fair Hearing is not decided within 90 days from the date

the Department of Human Services receives your request, you may be able to get your services

until your Fair Hearing is decided. You can call the Department of Human Services at

1-800-798-2339 to ask for your services.

What to do to continue getting services:

If you have been getting the services or items that are being reduced, changed, or denied and

you ask for a Fair Hearing and your request is postmarked or hand-delivered within 10 days

of the date on the notice telling you UPMC for You’s First Level Complaint or Grievance

decision, the services or items will continue until a decision is made.

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Expedited Fair Hearing

What Can I Do if My Health Is at Immediate Risk?

If your doctor or dentist believes that waiting the usual time frame for deciding a Fair Hearing

could harm your health, you may ask that the Fair Hearing take place more quickly. This is

called an expedited Fair Hearing. You can ask for an early decision by calling the Department at

1-800-798-2339 or by faxing a letter or the Fair Hearing Request Form to 717-772-6328.

Your doctor or dentist must fax a signed letter to 717-772-6328 explaining why taking the usual

amount of time to decide your Fair Hearing could harm your health. If your doctor or dentist

does not send a letter, your doctor or dentist must testify at the Fair Hearing to explain why

taking the usual amount of time to decide your Fair Hearing could harm your health.

The Bureau of Hearings and Appeals will schedule a telephone hearing and will tell you its

decision within 3 business days after you asked for a Fair Hearing.

If your doctor does not send a written statement and does not testify at the Fair Hearing, the Fair

Hearing decision will not be expedited. Another hearing will be scheduled and the Fair Hearing

will be decided using the usual time frame for deciding a Fair Hearing.

You may call UPMC for You’s toll-free telephone number at 1-800-322-7572 if you need

help or have question about Fair Hearings, you can contact your local Pennsylvania Legal

Aid Network office at 1-800-274-3258 or call the Pennsylvania Health Law Project at

1-800-274-3258.

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© 2022, updated 8-9-22. All rights reserved.    79 
 
Appendix E.1 
Other Resources and Forms 
 
 
EPSDT Clinical & Operational Guidelines 
upmchealthplan.com/providers/medical/resources/guidelines/epsdt-guidelines.aspx 
 
Important information and forms: 
•  EPSDT Periodicity Schedule 
•  EPSDT Billing Guide 
•  EPSDT Telemedicine Guide 
•  Adolescent Well-care and Telehealth Tip Sheet 
•  Lead Screening: Provider Tip Sheet 
•  Autism Screening Tip Sheet 
•  Developmental Screening: Provider Tip Sheet 
•  Weight Assessment and Counseling Tip Sheet 
•  Environmental Lead Investigative Request Form 
•  Recommendations for Preventive Pediatric Oral Health Care (Dental Periodicity 
Schedule) 
•  Dental Referral Form 
•  Early Intervention Referral Form 
•  EPSDT Quarterly Report 
•  CMS 1500 Form 
•  Immunization Schedules (0-18 years and “catch-up”) 
•  Day Calculator 
•  Screening Tools: 
o  Validated Screening Tools for Developmental Delays and Autism Spectrum 
Disorder 
▪  Developmental Screening Tools 
▪  Autism Screening Tools  
o  Screening Tools for Maternal Depression 
▪  Depression Screening Tools  
o  Tobacco, Alcohol, or Drug Use Assessment 
▪  Assessment Recommended by AAP 
 
 
➢  Note: This is not an exhaustive list of validated screening tools. UPMC Health Plan 
        and UPMC for You do not endorse or require the use of any specific screening 
        tool. 
 
 

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Childhood Nutrition and Weight Management Services:

• Medical Assistance Bulletin: Childhood Nutrition and Weight Management Services for

Recipients Under 21 Years of Age

• Provider Quick Tip: Childhood Nutrition and Weight Management Services Reminder

Telehealth Guidelines

upmchealthplan.com/providers/medical/resources/telehealth-guidelines.aspx

Provider Telehealth Toolkit

• Considering Telehealth

• Getting started

• Preparing your patients for telehealth

• Telehealth FAQ

• Quality measures and telehealth

• Policy/Billing and coding/reimbursement

• Well-child visit via telehealth

• Video visit checklist

• Cultural Sensitivity

• Overcoming barriers

• Becoming a telehealth provider in the UPMC Health Plan Provider Directory

• UPMC AnywhereCare

• UPMC Virtual Care

• Home Health

Clinical Practice Guidelines:

upmchealthplan.com/providers/medical/resources/guidelines/clinical-practice.aspx

• ADHD

• Adult Cholesterol Management

• Adult Diabetes

• Adult Preventative Guidelines

• Anxiety

• Asthma

• Cardiovascular Risk Factors and Coronary Artery Disease

• COPD

• Depression

• Heart Failure Guidelines

• Hypertension Management

• Opioid Use

• Pediatric Preventative Guidelines

• Prenatal Clinical Practice Guidelines

• Substance Abuse

• Additional Resources for UPMC Health Plan Members

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Medical Prior Authorization

upmchealthplan.com/providers/medical/resources/forms/medical-pa.aspx

• Patient Health Guidelines

o Clinical Guidelines

o Medical Record Documentation Guidelines

o Preventive and Immunization Guidelines

o Utilization Management Clinical Criteria

• Physician Forms

o Autism Treatment Plan

o Home Accessibility

o Home Health

o Long Term Services and Supports (LTSS) for CHC

o MCO Shift Care Form

o Nutritional Products

o Obstetrical Needs Assessment

o Out-of-Network Service Requests

o Parenteral Nutrition

o Provider Appeal on Behalf of a Member

o Provider Consent Form to File a Fair Health on Behalf of a Member

o Provider Consent Form to File a Grievance for a Member

o Provider Consent Form to File a Grievance for a UPMC Community

HealthChoices participant

o Provider Dispute/Appeal Cover Sheet

o Private Duty Nursing

▪ Medical Necessity Form for Private Duty Nursing

▪ Tip Sheet for Requesting Authorization of Shift Care Services

▪ Concurrent Authorization Request Form

▪ Agency Request Form to Transfer Shift Care Hours

• Physician Certification Form for a Child with Special Needs

o Certification Form and Instruction

o Letter Addressed to Physician from Department

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Appendix E.2

Copayment Schedule

Copayments Schedule–Adult Medical Assistance Members age 18 and older*

Services

Copayment by County

Northwest

Southwest

Lehigh/Capital

North East

Southeast

Ambulance (per trip)

$0

Dental Care

$0

Inpatient Hospital (Acute or Rehab)

Per Day

$3

$0

Maximum with Limits

$21

$0

Medical Centers

Emergency Department (nonemergent visits)

$3

$0

Ambulatory Surgical Center

$3

$0

Federal Qualified Health Center (FQHC) or

Regional Health Center (RHC)

$0

Independent Medical/Surgical Center

$2

$0

Convenience Care or Urgent Care Centers

$2

$0

Short procedure unit

$3 max

$0

Medical Equipment

Purchase

$0

Rental

$0

Medical Visits

Certified nurse practitioner

$0

Chiropractor

$2 max

$0

Doctor (PCP, ob-gyn)

$0

Optometrist

$0

Podiatrist

$2 max

$0

Therapy (occupational, physical, speech)

$2 max

$0

Outpatient Hospital (includes Hospital-based Clinics

Per visit

$2

$0

Prescriptions

Generic

$1

$0

Brand

$3

$0

Diagnostic Services (not performed in a doctor’s office)

Medical diagnostic testing (per service)

$1

$0

Radiology diagnostic testing (per service)

$1

$0

Nuclear medicine (per service)

$1

$0

Radiation therapy (per service)

$1

$0

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➢ Note: *Copayment is the amount the Member pays for some covered services.

Copayments are not required for Members who reside within the

Lehigh/Capital, Northeast, or the Southeast zone service areas.

➢ See: Figure E.1, HealthChoices Member Service Area map to determine the

Members’ zone service area, UPMC for You, Chapter E.

➢ Note: *The following Members do not have to pay copayments:

• Members eligible for benefits under the Breast and Cervical Cancer

Prevention and Treatment Program

• Members eligible for benefits under Title IV-B Foster Care and Title IV-E

Foster Care and Adoption Assistance

• Members who live in a long-term care facility, including Intermediate

Care Facilities for the Intellectually Disabled and Other Related

Conditions or other medical institution

• Members who live in a personal care home or domiciliary care home

• Members under age 18

• Pregnant women, including the postpartum period (12 months after the

delivery)

➢ Note: *The following services do not require a copayment:

• Emergency services

• Family planning services, including supplies

• Home health services

• Hospice services

• Laboratory services

• Tobacco cessation services

➢ Note: *Pharmacy Copayments:

If the Member is unable to pay the copayment they cannot be denied a

prescription drug. The pharmacist can still try to collect the copayment.

• For adults: – brand-name prescription drugs and brand-name over-the-counter

drugs cost $3 for each new prescription or refill. – Generic prescription drugs

and generic over-the counter drugs cost $1 for each new prescription or refill.

• For children: – Brand-name prescription drugs and brand-name over-the-

counter drugs cost $0 for each new prescription or refill. – Generic prescription

drugs and generic over-the-counter drugs cost $0 for each new prescription or

refill.

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• Many categories of drugs do not have a copayment. These drugs include:

o Anti-convulsants (seizure drugs)

o Anti-depressants (drugs for depression)

o Anti-diabetics (diabetes drugs)

o Anti-glaucoma agents (glaucoma drugs)

o Anti-hypertensives (high blood pressure drugs)

o Anti-neoplastics (cancer drugs)

o Anti-Parkinson’s agents (Parkinson’s disease drugs)

o Anti-psychotics (drugs for psychosis)

o Cardiovascular preparations (heart disease drugs)

o Drugs for opioid overdose (naloxone products)

o Drugs, including immunization (shots), given by a physician

do not have copayments

o HIV/AIDS medications or agents

➢ See: The UPMC for You drug formulary and the Pennsylvania Medical Assistance

Statewide PDL for a complete list of medications and specialty medicines at

upmchealthplan.com/providers/medical/resources/other/pharmacy.aspx.