Provider Resources
Important Documents & News
Flu Toolkit
This toolkit equips healthcare professionals with great information, communication strategies, and tools to effectively address patient concerns and promote influenza vaccination, as we partner together against the threat of seasonal flu. This toolkit was compiled using a variety of resources to bring you up-to-date information and strategies. Together, we can ensure a healthier community for all throughout the Upper Peninsula.
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 Newsletter
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.
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
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.
2024
June 2024 – NEMT Skilled Nursing Facilities
2023
Feb 2023 – Reversal of Temporary Covid19 DMEPOS Policies
2022
Jan 2023 – Timely filing for claim appeals
Jan 2023 – Medicaid Medical Pharmacy Update
Dec 2022 – Unlisted Dental Caries Billing Policy Retirement
June 2022 – Trans Health and PrEP Training
May 2022 – Attending Provider Update
Feb 2022 – Eyecare and Eyewear Benefits
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 – 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
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 – 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
June 2018 – Medicaid Pregnant Women Dental
June 2018 – Genetic and Molecular Testing
June 2018 – MDHHS nPEP Guidance
March 2018 – Health Risk Assessment (HRA)
February 2018 – Nursing Home Prior Authorizations
2017
March 2017 – Billing Custodial Claims
2016
LGBTQ+ Toolkit
Upper Peninsula Health Plan’s vision is “A healthy Upper Peninsula with people living their best lives.” Ensuring our provider network is well-supported and equipped to deliver high-quality, culturally responsive health care for sexual and gender minority populations supports our commitment to building a healthier Upper Peninsula. This toolkit provides practical and adaptable patient care strategies and resources to create an inclusive environment for LGBTQ+ people.
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.
- The Keeping Up with Diabetes Program provides support and educational materials to UPHP members with diabetes and their doctor.
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.
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:
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:
- The member is suspected, or has been convicted, of fraud, such as altering prescriptions to obtain medical services, products, or pharmaceuticals.
- The member is misusing emergency-department services, such as going to the emergency room for non-emergent conditions.
- The member is misusing pharmacy services, such as utilizing more than three different pharmacies in one quarter.
- 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, September 2024
Adopted June 2003, Reviewed December 2024
Asthma Action Plan
Adopted June 2003, Reviewed June 2023
Depression
Primary Care Diagnosis and Management of Adults with Depression
Michigan Quality Improvement Consortium Guideline, February 2024
Adopted March 2020, Reviewed September 2024
Diabetes
Management of Diabetes Mellitus
Michigan Quality Improvement Consortium Guideline, September 2024
Adopted March 2009, Reviewed December 2024
Hypertension
Medical Management of Adults with Hypertension
Michigan Quality Improvement Consortium Guideline, January 2024
Adopted March 2019, Reviewed March 2024
Lipid Screening and Management
Lipid Screening and Management
Michigan Quality Improvement Consortium Guideline, January 2024
Adopted December 2017, Reviewed March 2024
Framingham Risk Assessment Tool
(Calculates Estimated 10-Year Risk)
Low Back Pain
Management of Acute Low Back Pain
Michigan Quality Improvement Consortium Guideline, April 2024
Adopted September 2009, Reviewed September 2024
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, January 2024
Adopted March 2018, Reviewed March 2024
Osteoarthritis
Medical Management of Adults with Osteoarthritis
Michigan Quality Improvement Consortium Guideline, March 2024
Adopted December 2019, Reviewed June 2024
Prenatal and Postpartum Care
Routine Prenatal and Postnatal Care
Michigan Quality Improvement Consortium Guideline, August 2024
Adopted September 2008, Reviewed December 2024
Preventive Services for Adults
Adult Preventive Services (Ages 18-49)
Michigan Quality Improvement Consortium Guideline, August 2021
Adopted June 2015, Reviewed August 2023
Adult Preventive Services (Ages 50-65+)
Michigan Quality Improvement Consortium Guideline, March 2023
Adopted June 2023
Preventive Services for Children
Routine Preventive Services for Infants and Children (Birth—24 Months)
Michigan Quality Improvement Consortium Guideline, March 2024
Adopted June 2019, Reviewed June 2024
Routine Preventive Services for Children and Adolescents (Ages 2—18)
Michigan Quality Improvement Consortium Guideline, March 2024
Adopted June 2019, Reviewed June 2024
Tobacco Control
Prevention of Tobacco & Nicotine Use Including Vaping
Michigan Quality Improvement Consortium Guideline, February 2024
Adopted December 2012, Reviewed June 2024
The resources below will give guidance regarding safety, nutrition, exercise, and physical and mental development for UPHP members.
- Tobacco Cessation: If you have UPHP member that is ready to quit tobacco or wants to learn more about quitting, you can provide them with the helpful information found below. UPHP offers our members medicine and counseling visits with their PCP to help kick the tobacco habit. For more help, your patients can call the Michigan Tobacco Quitline at 1-800-QUIT-NOW (1-800-784-8669).
- MI Healthier Tomorrow
- Support for Overcoming Substance Misuse
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: 12/19/2024