Utilization Management Criteria

UPHP uses written objective criteria based on sound clinical evidence and specific UM procedures for appropriately applying the criteria. Appropriate practitioners are involved in developing, adopting, and reviewing the criteria as well as the procedures for applying them. This occurs on at least an annual basis as overseen by the UPHP Clinical Advisory Committee (CAC). The CAC meets quarterly and is led by the UPHP Medical Director and consists of at least 6 participating network physicians who broadly represent the composition of the UPHP provider network including behavioral health. To assure clinical expertise in the area being reviewed, specialty consultant knowledge is obtained through local physician experts and, when local expertise is not available, through profession peer review organizations. Specialty consultations are provided in writing and are included in the Criteria Review document submitted to the Committee.

Utilization management 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 utilization management decision makers that result in under-utilization.

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 to UPHP Customer Service at phone numbers 1-906-225-7500, toll free (reception) 1-888-904-7526 or (automated attendant) 1-800-835-2556
  • Hard copy via mail or fax upon request to 1-906-225-9269 (fax)
  • Download from the UPHP website at www.uphp.com

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 UPHP Utilization Management at 906-225-7500-/toll-free 1-888-904-7526 or in writing.

Out-of-Network Services

Out-of-Network Prior Authorization Criteria
(Reviewed June 2018.)

Inpatient Admissions

2018 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]

2018 InterQual Home Care Criteria

Michigan Department of Health and Human Services (MDHHS) Criteria

The following MDHHS criteria 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
(Revised September 2018.)

Medically Necessary Reconstructive Surgery

Panniculectomy Criteria
(Revised March 2018.)

Reduction Mammaplasty
(Revised September 2018.)

Automated Insulin Pump System

Automated Insulin Pump System
(Reviewed December 2017.)

General Anesthesia for Dental Services

General Anesthesia for Dental Services
(Reviewed December 2017.)

Page Last Updated: 10/16/2018