Authorizations
Upper Peninsula Health Plan (UPHP) does require some services and items to be reviewed prior to you receiving those services or items. This is called prior authorization. This approval from UPHP may be required before you get a service, medical equipment, or fill a prescription in order to be paid for by UPHP. Work with your provider to see if an authorization has been given. UPHP provides information to UPHP network providers on what services require prior authorization. You may also call UPHP Customer Service at 1-800-835-2556 (TTY: 711) to make sure you have the authorization you need. UPHP does not require referrals.
Your health care services are to be directed by your primary care provider (PCP) or specialist. You must use UPHP in-network providers for your care when available. These are health care providers that have a contract with UPHP as a provider of care. Use of out-of-network providers will require prior authorization from UPHP unless stated otherwise. Your UPHP provider can send in a prior authorization request for you to receive out-of-network services and/or for the services listed below.
- Out-of-network services, including:
- Planned hospital admissions and surgeries
- Providers
- Facilities
- Medical Suppliers
- If you need more than 144 units of physical and occupational therapy or 36 visits of speech therapy per calendar year
- Genetic testing
- Gender Affirmation Surgery
- Breast reduction surgery
- Panniculectomy surgery (removal of excess skin after weight loss)
- Bariatric surgery (weight loss surgery)
- If you need more than 18 chiropractic visits per calendar year
- Durable medical equipment (DME)
- Bi-PAP/CPAP
- Continuous glucose monitors
- Hospital beds (semi and total electric)
- Medical Items/supplies not meeting MDHHS Medicaid or CMS guidelines
- Miscellaneous DME and Orthotic and Prosthetic codes
- Negative pressure wound therapy (wound vacs)
- Osteogenic bone stimulators
- Pneumatic compression
- Power wheelchairs and accessories
- Speech Generating Devices
- TENS unit
- Ventilators
- Wearable cardioverter-defibrillators
- Certain Medications- please go to https://www.uphp.com/pharmacy/ for more information
- Emergency medical services
- Family planning services, including out-of-network services/providers
- Maternity care, including out-of-network providers
You can call UPHP Customer Service Monday through Friday from 8 a.m. to 5 p.m. Eastern Time to ask about prior authorization. You can also leave a message if you are not able to call during those hours. The toll-free phone number is 1-800-835-2556 (TTY: 711). Language assistance is available. You can get this information for free in other languages.
UPHP does not issue authorizations for services you have already received.
Upper Peninsula Health Plan
Utilization Management Prior Authorization Metrics
For Dental and Medical Items/Services
(Excluding Drugs)
Background: Upper Peninsula Health Plan must follow a federal rule called the CMS Interoperability and Prior Authorization rule. This rule says we must post certain information on our website every year. We must share a list of all medical services and items (not including medicines) that need prior authorization (approval). We must also share data about the requests we received for those services, such as how many were approved or denied during the past year. Sharing this information helps keep things open and honest and helps members understand how prior authorization works. This also allows doctors and other providers to see how well we are doing. These numbers can also be used to compare health plans and programs. If you have questions about the information below, contact UPHP Utilization Management (UM) Department at 906-225-7774.
Reporting Period: 2025
| These are the medical items and services for which we require prior authorization (excluding drugs): |
| https://www.uphp.com/wp-content/uploads/um/UPHP_Prior_Authorization_and_Notification_Grid.pdf |
Before Jan. 1, 2026, certain health plans must follow deadlines for giving decisions on prior authorization requests. These deadlines are:
- Medicare Advantage (MA) plans and some integrated plans: 72 hours for expedited (urgent) requests and 14 days for standard (non-urgent) requests
- Medicaid managed care plans and Children’s Health Insurance Program (CHIP) managed care groups: 72 hours for expedited (urgent) requests and 14 days for standard (non-urgent) requests
Starting Jan. 1, 2026, a new federal rule requires MA plans, Medicaid programs, and CHIP programs to give prior authorization decisions within:
- 72 hours for expedited (urgent) requests
- 7 days for standard (non-urgent) requests
UPHP Medicaid (Medicaid, Healthy Michigan Plan, Children’s Special Health Care Services) 2025 Prior Authorization Metrics
UPHP processed a total of 11,706 standard (non-urgent) and expedited (urgent) prior authorization requests in 2025.
Standard (non-urgent) Prior Authorization Requests
UPHP processed a total of 10,541 standard prior authorization requests in 2025.
| How many times this happened | Out of total request | Percentage | |
| Request approved | 7,150 | 10,541 | 68% |
| Request denied | 1,770 | 10,541 | 17% |
*Data will not total 100% due to some of the requests being withdrawn or voided by provider or member. This means there was no approved or denied decision made.
| How many times this happened | Out of total standard requests | Percentage | |
| Standard request approved only after appeal | 16 | 10,541 | 0.2% |
Expedited (urgent) Prior Authorization Requests
(Response Due to Provider Within 72 Hours)
UPHP processed a total of 1,165 expedited prior authorization requests in 2025.
| How many times this happened | Out of total request | Percentage | |
| Request approved | 940 | 1,165 | 81% |
| Request denied | 36 | 1,165 | 3% |
*Data will not total 100% due to some of the requests being withdrawn or voided by provider or member. This means there was no approved or denied decision made.
| How many times this happened | Out of total request | Percentage | |
| Request approved only after time for review was extended | 0 | 11,706 | 0 |
*No requests were extended.
Time Between Receiving a Prior Authorization Request and Sending a Decision
| Mean (Average) Time | Median (Middle) Time | |
| Standard (non-urgent) Prior Authorization Requests (response due to provider and member within 14 calendar days for calendar year 2025) | 6 days | 7 days |
| Expedited (urgent) Prior Authorization Requests (response due to provider and member within 72 hours) | 17 hours | 24 hours |
Page Last Updated: 02/10/2026