Utilization Management
The Upper Peninsula Health Plan (UPHP) uses an integrated approach to coordinate and promote optimal utilization 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 appropriately applying the criteria.
UM decision making is based on appropriateness of care and service and existence of coverage. UPHP does not reward practitioners or other individuals conducting utilization review for issuing denials of coverage or service care. UPHP does not provide financial incentives to UM decision makers that result in underutilization.
Members and/or practitioners may request a copy of the actual benefit provision, 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, he/she may request a phone conference 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 coordinate a mutual scheduled time upon the practitioner’s request.
Out-of-Network Services
Upper Peninsula Health Plan MI Health Link Out-of-Network Prior Authorization Criteria
Medically Necessary Portable Air Conditioner
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 Behavioral Health Care Guidelines- used by NorthCare Network for inpatient psychiatric admissions. Learn more about the guidelines and how to obtain a copy of the criteria.
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
Gender Affirmation Surgery Criteria
Page Last Updated: 12/10/2024