Out-of-Network Services
Upper Peninsula Health Plan MI Health Link Out-of-Network Prior Authorization Criteria
Medically Necessary Portable Air Conditioner
Upper Peninsula Health Plan MI Health Link Criteria for Medical Necessity for Portable Air Conditioner Unit
Inpatient Admissions
InterQual® Level of Care Adult and Pediatric Criteria
(including inpatient and observation status) – [InterQual® is a registered trademark of Change Healthcare, Inc.]
MCG Care Guidelines – Behavioral Health for inpatient psychiatric admissions.
Centers for Medicare and Medicaid Services (CMS) Criteria
UPHP uses CMS National and Local Coverage Determinations and Medicare Benefit Policy Manuals for the items below:
- Bariatric surgery for the treatment of obesity
- Cosmetic and reconstructive surgery
- Durable medical equipment
- Genetic and molecular testing
- Home health services
- Inpatient readmission within 30 days
- Swing bed/skilled nursing facility admission
Out-of-Network Services
Upper Peninsula Health Plan Medicaid Out-of-Network Prior Authorization Criteria
Inpatient Admissions
2019 InterQual® Level of Care Adult and Pediatric Criteria
(including inpatient and observation status) – [InterQual® is a registered trademark of Change Healthcare, Inc.]
Michigan Department of Health and Human Services (MDHHS) Medicaid Provider Manual Guidelines
The following MDHHS Medicaid Provider Manual Guidelines are available by clicking here.
- Inpatient readmissions within 15 days
- Durable medical equipment
- Medical services not meeting MDHHS Medicaid Provider Manual
- Physical and occupational therapy exceeding the 144 units of initial therapy
- Speech therapy exceeding 36 visits of initial therapy
- Chiropractic visits exceeding 18-visit limit
- Genetic and molecular testing
- Weight Loss Surgery
Medically Necessary Reconstructive Surgery
Panniculectomy Criteria
Reduction Mammaplasty
Gender Affirmation Surgery Criteria
Gender Affirmation Surgery Criteria