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.

UPHP Provider Newsletter front page

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

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.

2020

September 2020 – Medicaid Formulary Update

September 2020 – MDHHS PPE Grant

September 2020 – CHAMPS 101 Webinar Series

August 2020 – Pediatric and Adult Influenza Webinar

August 2020 – Provider In-Service Invite

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

June 2020 – Revised VBP Measures

June 2020 – Eyecare and Eyewear Benefits

June 2020 – Health Equity and Social Justice Workshop series

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.

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.

Actively practicing in-plan practitioners are involved in the development and adoption of clinical practice guidelines.  These guidelines are reviewed and approved by the UPHP Clinical Advisory Committee (CAC) at least biennially or as new scientific evidence or national standards are published.  Guidelines will be consistent with member education and utilization management criteria.  Practitioner performance will be measured against at least two important aspects of four guidelines annually.  These measures will be either practitioner based or population based.  The guidelines can be obtained from Customer Service by calling 1-877-349-9324.

Clinical Practice Guidelines (CPG’s) noted after the CAC date are not considered approved by UPHP. Revised Guidelines will be reviewed at the next scheduled quarterly CAC meeting.

Advance Care Planning

Advance Care Planning
Michigan Quality Improvement Consortium Guideline, January 2020
Adopted March 2014, Reviewed March 2020

Attention-Deficit/Hyperactivity Disorder (ADHD)

Diagnosis of ADHD for Children and Adolescents
Michigan Quality Improvement Consortium Guidelines, March 2019
Adopted June 2015, Reviewed June 2019

Treatment of ADHD for Children and Adolescents
Michigan Quality Improvement Consortium Guidelines, March 2019
Adopted June 2015, Reviewed June 2019

Asthma

General Principles for the Diagnosis and Management of Asthma
Michigan Quality Improvement Consortium Guidelines, 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 2020
Adopted March 2020

Diabetes

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

Heart Failure

Adults with Heart Failure
Michigan Quality Improvement Consortium, January 2019
Adopted June 2007, Reviewed March 2019

Lipid Screening and Management

Lipid Screening and Management
Michigan Quality Improvement Consortium, August 2019
Adopted December 2017, Reviewed December 2019

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

Hypertension

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

Kidney Disease

Diagnosis and Management of Adults with Chronic Kidney Disease
Michigan Quality Improvement Consortium, November 2018
Adopted September 2010, Reviewed March 2019

Low Back Pain

Management of Acute Low Back Pain
Michigan Quality Improvement Consortium, March 2018
Adopted September 2009, Reviewed June 2018

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, November 2020
Adopted March 2018, Reviewed March 2020

Osteoarthritis

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

Osteoporosis

Management and Prevention of Osteoporosis
Michigan Quality Improvement Consortium, January 2020
Adopted September 2010, Reviewed March 2020

Overweight Persons and Obesity

Prevention and Identification of Childhood Overweight and Obesity
Michigan Quality Improvement Consortium, June 2020
Reviewed September 2020

Treatment of Childhood Overweight and Obesity
Michigan Quality Improvement Consortium, June 2020
Adopted March 2009, Reviewed September 2020

Management of Overweight and Obesity in the Adult
Michigan Quality Improvement Consortium, March 2019
Adopted June 2019

Pharyngitis

Acute Pharyngitis in Children
Michigan Quality Improvement Consortium, January 2019
Adopted September 2009, Reviewed March 2019

Prenatal and Postpartum Care

Routine Prenatal and Postnatal Care 
Michigan Quality Improvement Consortium, June 2020
Adopted September 2008, Reviewed September 2020

Prevention of Falls in Older Persons

US Preventive Services Task Force
Adopted December 2018

Preventive Services for Adults 

Adult Preventive Services (Ages 18-49)
Adopted June 2015, Reviewed June 2019

Adult Preventive Services (Ages 50-65+)
Michigan Quality Improvement Consortium, March 2019
Adopted June 2019

Preventive Services for Children 

Routine Preventive Services for Infants and Children (Birth—24 Months)
Upper Peninsula Health Plan, June 2019
Adopted June 2019

Routine Preventive Services for Children and Adolescents (Ages 2—21) 
Upper Peninsula Health Plan, June 2019
Adopted June 2019

Respiratory Tract Infections

Management of Uncomplicated Acute Bronchitis in Adults
Michigan Quality Improvement Consortium, May 2018
Adopted March 2014, Reviewed June 2018

Pediatric Treatment Recommendations
Adopted June 2016, Reviewed June 2018

The Diagnosis and Management of Acute Otitis Media

Self Management

Chronic Care: Self Management
Guideline for Self Management of Chronic Care
Adopted June 2013, Reviewed September 2019

Substance Use Disorder
Screening, Diagnosis, and Referral for Substance Use Disorders
Michigan Quality Improvement Consortium, August 2019
Adopted December 2017, Reviews December 2019

Tobacco Control

Management of Tobacco & Nicotine Use
Michigan Quality Improvement Consortium, September 2019
Adopted December 2012, Reviewed December 2019

Urinary Incontinence in Adults

Assessment and Management of Urinary Incontinence in Adults
Upper Peninsula Health Plan, December 2018
Adopted December 2010, Reviewed December 2018

patient education

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

Quality Management

quality icon

The Quality Assessment and Improvement and Utilization Management (QAI/UM) Program facilitates the safe, efficient, effective, and economical delivery of person-centered services throughout the Upper Peninsula Health Plan (UPHP) network. The QAI/UM Program processes examine the multifaceted components of health care delivery to improve its quality and safety in accordance with federal, state, and accrediting agency standards. The program serves to create a system of interventions to address the underlying factors of disparate utilization, health inequity, health-related behaviors, and health outcomes.

For additional information on the QAI/UM Program or to receive a copy of the most recent QAI/UM Summary Report, call UPHP Customer Service at 1-800-835-2556 (TTY: 711).

For additional information, review the MDHHS Medicaid Quality Check Up.

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

Fraud, Waste, and Abuse

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.


Page Last Updated: 10/12/2020