UPHP

UPHP Prior Authorization and Notification Requirements

Welcome to the Upper Peninsula Health Plan (UPHP) Prior Authorization and Notification website. This page is to educate and notify providers of what services require prior authorization/ notification for UPHP members.

Prior Authorization is the process where a preservice decision is made upon determination of compliance with appropriate criteria. Authorization must be obtained before services are provided.

Prior Authorization FAQ

Notification is required in order to receive payment for services; however, notification does not involve the application of clinical criteria for an authorization decision. Notification is required to trigger necessary care coordination/care management activities on the part of UPHP.

Medical Services/Items: The Upper Peninsula Health Plan Medical Services/Items Prior Authorization and Notification Grid is a resource available for providers to reference what medical services/items need prior authorization or notification. The grid is several pages organized by:

Services requiring prior authorization
Services requiring notification
UPHP Matrix identifying specific codes by UPHP product line that require prior authorization for the following:
- Genetic and Molecular Testing
- Orthotics and Prosthetics
- Durable Medical Equipment

The grid will be updated as changes are made.

UPHP Medical Services/Items Prior Authorization/Notification Grid

The Upper Peninsula Health Plan Medical Services/Items Prior Authorization/Notifications Update document is a resource document for providers to see a history of medical services/items prior authorization/notification changes during the year. The document will be updated as changes are made.

UPHP Medical Services/Items Prior Authorization/Notification Updates document

Drugs Billed by Providers, Clinics, Infusion Centers (Medical Pharmacy): Prior authorization information and criteria for drugs billed on a medical claim (not a pharmacy claim) can be found here: Medical Drug Benefit (J/Q Code)

Drugs Billed at a Pharmacy: Prior authorization information, criteria, and formularies for drugs billed at a pharmacy can be found by selecting the appropriate plan below:

Prior Authorization Process

The process for prior authorization or notification is as follows:

Provider verifies the following information before requesting authorization:
- Beneficiary is currently a UPHP member
- Service, item, or drug request is for a UPHP covered benefit
- Service, item, or drug request requires prior authorization or notification
For Medical Services, Items, and Medical Drugs:
Provider submits electronically, using secure UPHP Assist Portal (preferred) or the UPHP Clinical Submission Form:
- - In-Network Providers access the secure UPHP Assist Portal at https://assist.uphp.com; Out-of-Network Providers requesting Medical Services or Items access the UPHP Clinical Submission Form located on our website at www.uphp.com/clinicalsubmissionform
    - A user guide for the UPHP clinical submission form is available at www.uphp.com/providers/forms-links/.
  - Provider completes the appropriate prior authorization/notification request form to include with their request.
    - UPHP forms are available from Customer Service or on the UPHP website at www.uphp.com/providers/forms-links/. Forms that can be accepted via the UPHP Clinical Submission form are linked in the form text when applicable.
  - Provider includes clinical information to support the request as indicated in the UPHP Assist Portal or on the form.
Provider receives a response electronically via the UPHP Assist Portal or fax, or in writing by mail within required timeframes.

Authorization does not guarantee payment. All authorized medical services, items and medical drugs are subject to review for medical necessity, appropriate billing, member eligibility, member plan benefits, and provider eligibility for payment at the time of service.

For questions or assistance related to medical services and items, please contact the UPHP Utilization Management (UM) Department:

Toll Free Phone: 1-800-835-2556 (TTY 711)
Direct UM Phone: 906-225-7774
UM Fax: 906-225-9269

For questions or assistance related to medical drugs, please contact the UPHP Pharmacy Department:

Toll Free Phone: 1-800-835-2556 (TTY 711)
Direct Pharmacy Phone: 906-232-1628
Pharmacy Fax: 906-225-4516

Pharmacy Drugs: Provider may submit prior authorization requests by fax, mail, phone, or electronically:
- Written and electronic requests:
  - Prior authorization forms and links for electronic submission can be found here: www.uphp.com/providers/forms-links/
  - Mailing address and fax number can be found on the form
    - Please ensure you are selecting the appropriate form based on the member’s plan
    - Providers may also submit electronically through their electronic health record (EHR)
- Requests by phone:
  - Medicaid, CSHCS, Health Michigan, and Medicaid Secondary (Duals) Plans
    - 1-866-902-6743 (TTY: 1-800-716-3231)
    - Available 24 hours a day, 7 days a week

- - MI Health Link
    - 1-855-380-0275
    - Available 24 hours a day, 7 days a week

- - MI Coordinated Health
    - 1-800-935-6103 (TTY: 1-800-716-3231)
    - Available 24 hours a day, 7 days a week

For questions or assistance related to pharmacy drugs, please contact the UPHP Pharmacy Department:

Toll Free Phone: 1-800-835-2556 (TTY 711)
Direct Pharmacy Phone: 906-232-1628
Pharmacy Fax: 906-225-4516

For all prior authorization requests: Provider is responsible for including any necessary clinical documentation, statements of medical necessity, and/or medical literature to support the prior authorization request.