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.
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.
The Upper Peninsula Health Plan Prior Authorization and Notification Grid is a resource available for providers to reference what services 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
- Medical Pharmacy
The grid will be updated as changes are made.
The Upper Peninsula Health Plan Prior Authorization/Notifications Update document is a resource document for providers to see a history of prior authorization/notification changes during the year. The document will be updated as changes are made.
Prior Authorization Process
The process for prior authorization or notification is as follows:
- Provider verifies:
- Beneficiary is currently a UPHP member
- Service request is for a UPHP covered benefit
- Service request requires prior authorization or notification
- Provider submits in writing by fax (preferred), phone or mail:
- Appropriate prior authorization/notification request form. UPHP forms are available from Customer Service or UPHP Web site at www.uphp.com/providers/forms-links/
- Clinical information to support the request as indicated on the form.
Authorization does not guarantee payment. All authorized items and services are subject to review for medical necessity, member eligibility, member plan benefits, and provider eligibility for payment at the time of service.
If you have any questions or need assistance please contact the UPHP Utilization Management (UM) Department:
Toll Free: 1-800-835-2556
Direct UM Line: 906-225-7774
UM Fax Line: 906-225-9269
Page Last Updated: 12/31/2018