UPMC

UPMC

  • University of Pittsburgh Medical Center
  • Is committed to providing its members better health, more financial security, and the peace of mind they deserve.
  • UPMC Health Plan partners with UPMC and community network providers to produce a combination of knowledge and expertise that provides the highest quality care at the most affordable price

Recipients

  • CHC Participants who are eligible and 21 yrs and older.
  • Who are dual eligible for Medicaid and Medicare
  • Who are qualified for LTSS

How to Check Eligibility

  • Log on to https://www.upmchealthplan.com to check eligibility of patient and put the patient’s MA ID.

Prior Authorization

  • Prior Authorization is not required for DME Supplies.

Fee Schedule

  • 110% of PA Medicaid

Clearing Houses

  • WebMD® (UPMCHealth Plan Payer ID: 23281)
  • RelayHealth
  • ALLScripts

Filing Method

  • Electronic

(Prelog) – Allows direct submission of both professional (CMS-1500) and institutional (UB-04) claims via a user friendly interface.

  • Paper Claim

CMS-1500 Form send to:
UPMC for YOU
P.O. Box 2995
Pittsburgh, PA 15230

CLAIM FILING

ORIGINAL CLAIMS

  • 90 days after the date of service

RESUBMISSION OF DENIED CLAIMS

  • 45 days of the initial submission

CLAIMS W/ THIRD PART LIABILITY

  • Claim are received within 90 days of the primary EOB remittance date, or up to the new claim timely filling limit which ever is greater.

Appeal Rights

  • 30 days after receiving denial from UPMC
  • The appeal must be submitted in writing to UPMC at:

Provider Appeals
P.O. Box 2906
Pittsburgh, PA 15230 15230-2906

  • UPMC will response after 5 days after receiving the appeal.

Contact Person

CHIP REYNOLDS
PHONE: 412-454-7260
EMAIL: Reynoldsgl@upmc.edu
PROVIDER: 866-918-1595 / 412-454-5664
EMAIL: CHCProviders@upmc.edu

AMERIHEALTH CARITAS

AMERIHEALTH

  • Known as “the Plan”
  • Is PA;s chc, MCO that will coordinate physical health care and long-term services and supports (LTSS) for older persons, persons with physical disabilities, and Pennsylvanians who are dually eligible for Medicare and Medicaid (Community Well Duals)

Recipients

  • CHC Participants who are eligible and 21 yrs and older
  • Who are dual eligible for Medicaid and Medicare
  • Who are qualified for LTSS

How to Check Eligibility

  1. Verify a participant’s coverage with the plan by their plan identification number, social security number, name, birthdate or medical assistance identification number
    1. • Obtain the name and phone number of the Participant’s PCP
  2. Promise Visit www.promise.DHS.state.pa.us and click on PROMISe Online

MA HIPAA compliant PROMISe software (Provider Electronic Solutions Software) is available free-of-charge by downloading from the OMAP PROMISe website at:
www.promise.DHS.state.pa.us/ePROM/providersoftware/softwaredownloadform.asp

Prior Authorization

  • Validity is 180 days or 6 months
  • Any request in excess of 300 a month for diapers or pull-ups or a combination of both.

Fee Schedule

  • 100% of PA Medicaid

Clearing Houses

  • Change Healthcare

Filing Method

  • Electronic

Electronic claims submitted without an NPI will be rejected back to the provider via their EDI clearinghouse. Network Providers who submit claims via paper CMS 1500 or UB-04 are also required to include their NPI on their claims

  • Paper Claims

CMS-1500 Form send to:
Amerihealth Caritas PS CHC
Claims Processing Department
P.O. Box 7110
London, KY 40742-7110

CLAIM FILING

  • ORIGINAL CLAIMS

180 days after the date of service

  • RESUBMISSION OF DENIED and REJECTED CLAIMS

365 days of the initial submission for denied/ 180 days for rejected

  • CLAIMS W/ THIRD PARTY LIABILITY

60 days of the date of the primary insurance EOB.

Appeal Rights

Claim submission is 365 days from date of service w/a written explanation of the error to:

AmeriHealth Caritas
Pennsylvania Community HealthChoices
Claims Disputes
P.O. Box 7110
London, KY 40742

For accurate and timely resolution of issues, Network Providers should include the following information:

Provider Name
Provider Number
Tax ID Number
Number of Claims involved
Claim numbers, as well as a sample of the Claim(s)
A description of the denial issue

All disputed claims will be acknowledged & decision will be conveyed within 60 days.

CHC – MCO Flow Chart

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