Provider Resources

Important Documents & News

UPHP Provider Manual Front Cover - Doctor with Patient

Provider Manual

The Upper Peninsula Health Plan (UPHP) Provider Manual contains health plan benefits, policies, and instructions on how to utilize our services for all UPHP product lines.

Bi-Monthly Provider Newletter

UPHP’s Bimonthly Provider Newsletter is your one stop shop for all of the latest news and updates from Provider Relations. This newsletter is a collaborative project that allows us to distribute important information from various departments at UPHP. This newsletter is sent to all Office Manager email addresses that are currently on file, and occur bimonthly on the 15th.

Please reach out to UPHP Provider Relations to update any email addresses or request additional email addresses to be added to the distribution.

UPHP Provider Newsletter front page

Archived Quarterly Provider Newsletter

Provider newsletters are published quarterly for UPHP contracted providers. The newsletters provide benefit updates and other helpful information pertaining to health care staff and our members. Sign up to receive it via email by contacting providerrelations@uphp.com

Provider Bulletin Thumbnail

Provider Bulletin

In order to keep our provider network up-to-date on all changes and potential issues, UPHP occasionally issues provider bulletins in addition to the quarterly provider newsletters. These bulletins contain time-sensitive information that is important to get to our contracted providers as soon as possible. Bulletins from previous years included below are still relevant.

2022

June 2022 – Trans Health and PrEP Training

May 2022 – Attending Provider Update

Feb 2022 – Eyecare and Eyewear Benefits

Feb 2022 – Hospital Billing

2021

Dec 2021 – Clinic Billing Guidance

Dec 2021 – In-Network Home Health Providers

Dec 2021 – In-Network Hearing Aid Providers

July 2021 – New Provider COVID-19 Vaccine Incentives

July 2021 – New Provider COVID-19 Vaccine Incentives

July 2021 – New Pharmacy COVID-19 Vaccine Incentives

July 2021 – NEMT Skilled Nursing Facilities

June 2021 – Opioid Edit Notice

May 2021 – Professional Therapy Services

April 2021 – Blood Pressure Monitoring

April 2021 – Medical Pharmacy Prior Authorizations

April 2021 – In-Network Skilled Nursing Facilities Update

March 2021 – CHAMPS Training Opporunities

February 2021 – Senior Center Non-Emergent Medical Transportation

February 2021 – Member Incentives for PCPs

February 2021 – Best Practice Webinar: Developmental Screening in the First Three Years of Life

February 2021 – IPPE and AWV Coding Guidance

January 2021 – Coverage of COVID-19 Vaccines (Updated April 2021)

January 2021 – Institutional Billing Guidance

January 2021 – Clinical Billing Guidance

January 2021 – Chiropractic Billing Guidance

January 2021 – Opioid Point-of-Sale Edits

January 2021 – Prior Authorization Update

2020

December 2020 – MIPS Payment Adjustments

October 2020 – Provider Relief Fund

September 2020 – Medicaid Formulary Update

September 2020 – MDHHS PPE Grant

September 2020 – CHAMPS 101 Webinar Series

August 2020 – Pediatric and Adult Influenza Webinar

July 2020 – Implementation of a Single Preferred Drug List (PDL)

June 2020 – Revised VBP Measures

June 2020 – Eyecare and Eyewear Benefits

May 2020 – HRA Incentive Available for PCPs

April 2020 – (Revised) Behavioral Health Provider MDHHS Reimbursement Alignment

March 2020 – Covid-19 Guidance

March2020 – Corona Virus UPHP Coverage for Providers

March 2020 – UPHP Provider Value-based Payment  (VBP) Program

February 2020 – MLN Dementia Care Call

February 2020 – CHAMPS: Billing Issues

January 2020 – EMDR Training for Behavioral Health

January 2020 – Medicaid RHC, FQHC & THC Reimbursement Update

2019

December 2019 – UPHP Announces New Exclusive Specialty Pharmacy

December 2019 – New Chiropractic PA Requirement for MHL Members

October 2019 – COB Medical Claims

September 2019 – UPHP Provider In-Service Invite

September 2019 – Breaking Down Barriers of the Sharing of PHI and Behavioral Health Information Webinar

September 2019 – Prescriber Webinar for Overview of Enrollment Process

August 2019 – Pharmacy Common Formulary Update

August 2019 – Metabolic Monitoring in Patients Prescribed Antipsychotic

August 2019 – Webinar for upcoming changes to the Healthy Michigan Plan

July 2019 – CMS Training Opportunities

July 2019 – UPHP Medicaid Payer of Last Resort

July 2019 – Remicade/Infliximab (Infectra and Renflexic) Changes

May 2019 – Interactive UPHP Prior Authorization &
Notification Form

May 2019 – MHL Education for Dually Eligible Older Adults

May 2019 – DME New Policies

April 2019 – ACP First and Advanced Step Certification

April 2019 – MI-POST Updates and Education

April 2019 – Michigan Rural Community Health Documentation, Coding & Billing Bootcamp

March 2019 – UPHP 2019 Value Based Payment Program

2018

December 2018 – New Eyewear Billing Policy

December 2018 – Medicare Part D POS Edits

December 2018 – DME Prior Authorization

December 2018 – Home Health UM Policy Change

October 2018 –  Schizophrenia

October 2018 –  Hearing Aid Benefit

September 2018 – Notice of DME Network Change

September 2018 – Medicaid Notification Policy Update

August 2018 – Town Hall Meeting

August 2018 – MI AIM Orientation & Patient Safety Bundle Training

July 2018 – Promising Practices for Meeting the Behavioral Health Needs of Dually Eligible Older Adults Webinar

June 2018 – Medicaid Pregnant Women Dental

June 2018 – Genetic and Molecular Testing

June 2018 – MDHHS nPEP Guidance

May 2018 – HRA Fact Sheets

April 2018 – J Codes

March 2018 – MBI Number

March 2018 – Health Risk Assessment (HRA)

February 2018 – ICD 10 Codes

February 2018 – Nursing Home Prior Authorizations

2017

March 2017 – Billing Custodial Claims

January 2017 – Healthy Michigan Plan HRA Billing Code Update

2016

April 2016 – MI Health Link Claims

Patient Management

UPHP offers Condition Management Programs that can help members manage their chronic condition and live a more active and healthy life. Members are automatically enrolled into the program(s). They are also able to opt out or opt in at anytime by calling Clinical Services at (906) 225-7500 or 1-888-904-7526, or by sending an email to the Condition Management Program.

When members are in the program(s), they will:

  • Get educational mailings.
  • Get reminders for needed care.
  • Have support working toward health goals.

UPHP wants to help members develop skills that will help them be in charge of their own health.

UPHP’s Complex Case Management (CCM) program is designed to help you in managing the care of your members who have:

  • Diabetes
  • Congestive heart failure
  • Hypertension
  • Uncontrolled asthma
  • Chronic pain
  • Other complex conditions

The program’s objective is to help members with chronic and complex conditions to obtain access to care and obtain services needed to help them self-manage their disease. CCM clinicians help to identify members and provide support and interventions.  They complement the primary care provider’s plan of care to help members better manage their individual complex diseases and achieve the best outcomes possible. Clinician interventions include:

  • Care of coordination between providers
  • Individualized plans of care with prioritized goals
  • Provide educational materials to members
  • Care coordination between providers and community organizations
  • Coordinate transportation help when needed
  • Telephone calls to members

If you have a member patient whom you feel would benefit from the CCM program, call Customer Service at 1-877-349-9324 or fill out the Clinical Services Care-Coordination/Case-Management Referral Form.

PGIP

UPHP has a Transition of Care program for UPHP Medicaid, Healthy Michigan Plan (HMP) and Children’s Special Health Care Services (CSHCS) members who are newly enrolled with UPHP to ensure they do not experience any disruption in care. This care could include:

  • Out-of-network providers/services
  • Durable medical equipment/medical supplies
  • Medications

UPHP has a designated Interdisciplinary Transition of Care team who can assist in assessing members’ medical, behavioral health, dental, social needs, and prescriptions. Members must have seen the provider at least once within the last six months prior to UPHP enrollment and/ or have been on a maintenance drug. UPHP will cover any services/providers/medications for at least 90 days. To request continued care, members, their authorized representatives, or providers can contact UPHP by writing or calling:

Upper Peninsula Health Plan
Attn: Utilization Management
853 West Washington St.
Marquette, MI  49855
Toll-Free Phone: 1-800-835-2556 (TTY: 711)
Direct UM Line: 906-225-7774
Fax: 906-225-9269

The more detail that can be provided regarding the member’s care and health needs, the better UPHP will be able to assist. This information includes:

  • Provider names
  • Contact persons
  • Phone numbers
  • Service types
  • Appointment dates (if applicable)

Review the UPHP Transition of Care Policy  for more information.

 

To ensure that the appropriate amount, scope, and duration of medically necessary services are provided to UPHP members, UPHP will now conduct surveillance and benefits utilization review, known as the Benefits Monitoring Program (BMP). The BMP is in place to closely monitor program usage and to identify members who may be overutilizing or misusing their UPHP Medicaid services and benefits.

The purpose of the BMP is to:

  • Promote high-quality health care.
  • Prevent harmful practices such as duplication of medical services, drug interaction, and possible drug abuse.
  • Identify members for review who may misuse or overutilize their Medicaid benefits.
  • Analyze member patterns of utilization of health services.
  • Modify a member’s improper utilization of Medicaid services through educational contacts and monitoring.
  • Prevent fragmentation of services and improve the continuity of care and coordination of services.
  • Assure that members are receiving health care services that are medically necessary and supported by evidence-based practices, thereby curtailing unnecessary costs to the program.

Members are enrolled in BMP when UPHP determines any of the following (alone or in combination) criteria apply to an individual:

  1. The member is suspected, or has been convicted, of fraud, such as altering prescriptions to obtain medical services, products, or pharmaceuticals.
  2. The member is misusing emergency-department services, such as going to the emergency room for non-emergent conditions.
  3. The member is misusing pharmacy services, such as utilizing more than three different pharmacies in one quarter.
  4. The member is misusing physician services, such as obtaining duplicate or similar services from more than one physician or physician extender in different practices. 

UPHP will also review additional criteria as misutilization patterns emerge or are identified by the plan.

If you think that one of your patients is a candidate for the BMP program, call Customer Service at 800-835-2556 or fill out the Care-Coordination/Case-Management Referral Form.

UPHP adopts clinical practice guidelines that consider the needs of the membership and assist practitioners and members in making informed decisions about appropriate preventive, acute, or chronic medical and behavioral services.

To promote consistency across Michigan health plans, UPHP utilizes guidelines developed by the Michigan Quality Improvement Consortium (MQIC). MQIC one-page guidelines assist primary care providers by outlining evidence-based recommendations, so the focus is on the patient. Many recommendations align with clinical quality measures programs, so implementing the guidelines into practice can support providers with quality measures. MQIC membership includes physicians, health plans, researchers, quality improvement experts, and specialty societies. The MQIC clinical guideline development process is a laborious and rigorous process designed to produce concise evidence-based recommendations that will improve the quality of care delivered in Michigan.

Clinical practice guidelines selected for adoption are reviewed and approved at least biennially, or as new scientific evidence or national standards are published, by the UPHP Clinical Advisory Committee.

To view other available MQIC Guidelines, please visit the MQIC website at: www.mqic.org.

Clinical practice guidelines can be obtained from UPHP Customer Service by calling 1-877-349-9324.

 

Asthma

General Principles for the Diagnosis and Management of Asthma
Michigan Quality Improvement Consortium Guideline, July 2020
Adopted June 2003, Reviewed September 2020

Asthma Action Plan
Adopted June 2003, Reviewed September 2020

Depression

Primary Care Diagnosis and Management of Adults with Depression
Michigan Quality Improvement Consortium Guideline, January 2022
Adopted March 2020, Reviewed September 2022

Diabetes

Management of Diabetes Mellitus
Michigan Quality Improvement Consortium Guideline, June 2020
Adopted March 2009, Reviewed September 2020

Hypertension

Medical Management of Adults with Hypertension
Michigan Quality Improvement Consortium Guideline, June 2021
Adopted March 2019, Reviewed December 2021

Lipid Screening and Management

Lipid Screening and Management
Michigan Quality Improvement Consortium Guideline, July 2021
Adopted December 2017, Reviewed December 2021

Framingham Risk Assessment Tool
(Calculates Estimated 10-Year Risk)

Low Back Pain

Management of Acute Low Back Pain
Michigan Quality Improvement Consortium Guideline, March 2022
Adopted September 2009, Reviewed September 2022

Opioid Therapy in Adults Excluding Palliative and End-of-Life Care

Opioid Prescribing in Adults Excluding Palliative and End-of-Life Care
Michigan Quality Improvement Consortium Guideline, November 2021
Adopted March 2018, Reviewed September 2022

Osteoarthritis

Medical Management of Adults with Osteoarthritis
Michigan Quality Improvement Consortium Guideline, August 2019
Adopted December 2019

Prenatal and Postpartum Care

Routine Prenatal and Postnatal Care 
Michigan Quality Improvement Consortium Guideline, June 2022
Adopted September 2008, Reviewed September 2022

Preventive Services for Adults 

Adult Preventive Services (Ages 18-49)
Upper Peninsula Health Plan, September 2021
Adopted June 2015, Reviewed September 2021

Adult Preventive Services (Ages 50-65+)
Upper Peninsula Health Plan, September 2021
Adopted June 2019, Reviewed September 2021

Preventive Services for Children 

Routine Preventive Services for Infants and Children (Birth—24 Months)
Michigan Quality Improvement Consortium Guideline, August 2021
Adopted June 2019, Reviewed March 2022

Routine Preventive Services for Children and Adolescents (Ages 2—21) 
Michigan Quality Improvement Consortium Guideline, August 2021
Adopted June 2019, Reviewed March 2022

Self Management

Chronic Care: Self Management
Upper Peninsula Health Plan, September 2021
Adopted June 2013, Reviewed September 2021

Tobacco Control

Prevention of Tobacco & Nicotine Use Including Vaping
Michigan Quality Improvement Consortium Guideline, December 2021
Adopted December 2012, Reviewed June 2022

patient education

The resources below will give guidance regarding safety, nutrition, exercise, and physical and mental development for UPHP members.

PGIP

The Physician Group Incentive Program is offered by Blue Cross and Blue Shield of Michigan to transform clinics into all-payer Patient Centered Medical Homes (PCMH). Upper Peninsula Health Group administers the program in the UP region. The goal is to achieve IHI Triple Aim: improve patient experience of care (quality and satisfaction), improve the health of populations, and reduce health care costs.

Learn more about the BCBSM Physician Group Incentive Program.

Additional Information

Compliance Resources
Learn more about fraud, waste, and abuse and how to report suspected cases.

Access Standards
This shows the UPHP’s standards for patient access to medical care and behavioral health care.

Medical Record Documentation Standards
Network Provider Medical Record Documentation Standard Policy.


Page Last Updated: 10/1/2022