Medicare AdvantagePrior AuthHigh impact
Special notice: Important policy changes
UPMC Health Plan·Vascular Surgery, General Surgery, Gastroenterology +2 more·Provider Announcement
Effective date
Jun 1, 2025
We identified it
Aug 7, 2026
Summary
Effective June 1, 2025, UPMC Health Plan is implementing five prior authorization policy changes: retiring the Varicose Veins policy (MP.066) and replacing it with MP.PA.145, and adding four new prior authorization requirements for Genetic Testing (MP.PA.118), Laparoscopic Cholecystectomy (MP.PA.146), Diagnostic/Surveillance Colonoscopy (MP.PA.147), and Cardiac Ablation Procedures (MP.PA.148). All affected services now require prior authorization before delivery to avoid claim denials.
Action Required
By May 31, 2025: Billing team must update billing system and encounter workflows to require prior authorization for the following UPMC Health Plan services: (1) Varicose Veins procedures under new policy MP.PA.145 instead of retired MP.066; (2) Genetic Testing for Hereditary and Multifactorial Diseases (MP.PA.118); (3) Laparoscopic Cholecystectomy for patients 18+ (MP.PA.146); (4) Diagnostic and Surveillance Colonoscopy for patients 18+ (MP.PA.147); (5) Cardiac Ablation Procedures for patients 18+ (MP.PA.148). Providers must obtain prior authorization before scheduling or performing these procedures. Billing team should update authorization templates, provider reminders, and pre-visit workflows. Front desk staff should flag these procedures during registration. Claims submitted without prior authorization will be denied by UPMC Health Plan. Contact UPMC Provider Services at 1-866-918-1595 or consult upmchp.us/policiesandprocedures for specific clinical criteria. Providers should review each policy document to understand coverage requirements.