CommercialPrior AuthHigh impact
Pause in Prior Authorization Policies
UPMC Health Plan·Sleep Medicine, Radiation Oncology, Oncology +1 more·Prior Authorization
Effective date
May 1, 2025
We identified it
Aug 7, 2026
Summary
UPMC Health Plan is pausing or eliminating prior authorization requirements for multiple services effective May 1, 2025. Sleep study codes (95800, 95801, 95805, 98506, G0398, G0399, G0400) will no longer require prior auth. Radiation therapy and brachytherapy prior auth requirements are suspended until June 1, 2025, and diagnostic colonoscopy prior auth is suspended until July 1, 2025. Billing teams must stop requiring prior authorizations for affected services on their respective effective dates.
Action Required
By May 1, 2025: Billing team must update the billing system to REMOVE prior authorization requirements for sleep study codes (95800, 95801, 95805, 98506, G0398, G0399, G0400). Remove prior auth triggers in the system for MP.PA.143, MP.PA.139, and MP.PA.142 (radiation therapy and brachytherapy) effective May 1 through June 1, 2025. Remove prior auth trigger for MP.PA.147 (diagnostic and surveillance colonoscopy, age 18+) effective May 1 through July 1, 2025. Update all internal workflow documents and provider encounter forms to reflect that these services no longer require (or temporarily do not require) prior authorization. Verify changes in billing software and test claims before May 1. Contact Provider Services at 1-866-918-1595 with implementation questions. Failure to remove prior auth requirements may result in unnecessary claim delays or incorrect authorization denials.