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 49866
  • 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.

Out-of-Network Services

Upper Peninsula Health Plan Medicare Out-of-Network Prior Authorization Criteria 

Upper Peninsula Health Plan MI Health Link Out-of-Network Prior Authorization Criteria

Inpatient Admissions

2019 InterQual® Level of Care Adult and Pediatric Criteria (including inpatient and observation status)  – available upon request [InterQual® is a registered trademark of McKesson Health Solutions, LLC]

Hearing-Aid Criteria (UPHP Advantage Plan Only)

Criteria for Medical Necessity of Hearing Aids 

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)  – available upon request [InterQual® is a registered trademark of McKesson Health Solutions, LLC]

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
Medically Necessary Weight-Reduction Services

Bariatric Surgery Criteria

Medically Necessary Reconstructive Surgery

Panniculectomy Criteria

Reduction Mammaplasty

Automated Insulin Pump System

Automated Insulin Pump System

General Anesthesia for Dental Services

General Anesthesia for Dental Services


Page Last Updated: 06/20/2019