Upper Peninsula Health Plan

UPPER PENINSULA HEALTH PLAN

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AUTHORIZATION REQUIREMENTS

MEDICAL

  Clinical Services
           Telephone:    800-835-2556
           Fax:               906-225-7720

The following services require prior authorization from UPHP Clinical Services.
 (Authorization numbers are required in order to receive payment for services.)
  • Out-of-Plan Services
    		•
    1. Elective inpatient admission—prior to admission
    2. Urgent/emergent inpatient admission—within one day of admission
    3. Outpatient referral/service—within at least two business days prior to service
    4. Durable medical equipment and supplies—prior to service
  • In-Plan and Out-of-Plan Inpatient Readmission Within 15 Days:
    		•
    1. Elective admissions—prior to second admission
    2. Urgent/emergent admissions—within one business day of admission
  • Medically Necessary Weight-Reduction Services—prior to service
    		•
  • Medically Necessary Reconstructive Surgery—prior to service
    		•
  • Durable Medical Equipment Not Meeting MDCH Guidelines
       (available at www.michigan.gov/mdch)—prior to service
           Use the DME/Medical Supply Request Form and Cover Sheet.
    		•
  • Skilled-Nursing Facility/Swing Bed—prior to admission
    		•

     

    The following services require prior notification to UPHP Clinical Services.
    (Prior notification is required in order to receive payment for services.)
  • Transplant Services—prior to service
    		•
  • Chiropractic Visits After 18 per Year for Medicaid Members and 24 per
         Year for MIChild Members—    prior to continued service
    		•
  • Maternal Infant Health Program (MIHP) Infant Visits Beyond Initial
         Assessment and Nine Visits—    prior to continued service
    		•

     
  • Clinical Services Prior-Authorization Request Form
         Print Only (Revised July 2007.)
    		•
  • Clinical Services Prior-Authorization Request Form
       (Download or save the document first, then complete and print.)
    		•

     

    PHARMACY
  • UPHP Restricted Drug Classes List
    		•
  • 4D Request for Prior Authorization Form
    		•

    Authorizations must be obtained before services are provided. Retrospective requests will not be reviewed.
     

    Authorization does not guarantee payment. Benefit determinations are subject to diagnosis eligibility, member eligibility, and plan benefits at the time when a service is provided.

    Provider Relations
    Upper Peninsula Health Plan

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    Upper Peninsula Health Plan - 228 W. Washington Street - Marquette, MI 49855

    1-800-835-2556 or  906-225-7500

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