Utilization Management

The Upper Peninsula Health Plan (UPHP) uses an integrated approach to coordinate and promote optimal use of health care resources, make utilization decisions that affect the health care of members in a fair, impartial, and consistent manner, and assist with transition to alternative care when benefits end, should a member no longer be eligible for UPHP benefits. UPHP uses written objective criteria based on sound clinical evidence and specific utilization management (UM) procedures for properly applying the criteria. 

UM decision making is based on relevance of care and service and active coverage. UPHP does not reward practitioners or other persons conducting utilization review for issuing denials of coverage or service care. UPHP does not provide financial incentives to UM decision makers that result in decreased use of services.

Members and/or practitioners may request a copy of the benefit rule, guideline, protocol, or other criteria used in UM determinations, by any of the following methods:

• Verbally via phone:
  • UPHP Customer Service (Medicaid): 1-800-835-2556 (TTY: 711)
  • UPHP Customer Service (Medicare): 1-877-349-9324 (TTY: 711)
  • UPHP UM Department Direct: (906) 225-7774
• Hard copy via mail or fax upon request
  • Fax: 906-225-9269
  • Mail: Upper Peninsula Health Plan, Attention Utilization Management, 853 West Washington Street, Marquette, MI 49855

• Download from the UPHP website for the appropriate plan below.

If the treating practitioner does not agree with the UM determination, they may ask for a phone call with the practitioner making the determination. This request may be made via phone by calling the UPHP Utilization Management Department at 906-225-7774 (toll-free 1-888-904-7526) or in writing. UPHP UM staff will arrange an agreed scheduled time upon the practitioner’s request.