Medicare AdvantagePrior AuthHigh impact
Clinical documentation required for hip, knee, and shoulder prior authorizations
UPMC Health Plan·PA · Orthopedics, Sports Medicine, General Surgery·Prior Authorization
Effective date
Jul 24, 2025
We identified it
Aug 7, 2026
Summary
UPMC Health Plan now requires clinical documentation to be submitted at the time of prior authorization requests for hip, knee, and shoulder procedures. Beginning July 24, 2025, the system will not issue authorization without supporting clinical documentation uploaded through the Provider OnLine portal. This is a mandatory workflow change to avoid delays or denials.
Action Required
By July 24, 2025: Billing and prior authorization teams must implement the following changes: (1) Update all staff workflows to require clinical documentation submission at the time of prior authorization request initiation—do not submit authorization requests without documentation attached; (2) Train all staff on the updated Provider OnLine portal submission process, specifically the clinical documentation upload feature during auth entry; (3) Update internal authorization request checklists and templates to include mandatory clinical documentation gathering before submission; (4) Establish a pre-submission verification step to confirm all required clinical notes are attached before portal submission; (5) Notify all ordering providers and clinical staff that hip, knee, and shoulder prior auth requests must include supporting clinical documentation per UPMC policy. Failure to submit required documentation will result in authorization delays or outright denials, impacting claim processing and patient care timelines.