CommercialCoverageMedium impact
Review our commercial product billing guide
UPMC Health Plan·PA · Radiology, OB-GYN, General Practice·Reimbursement
Effective date
May 1, 2023
We identified it
Aug 7, 2026
Summary
Pennsylvania Act 1 of 2023 requires commercial insurance plans to cover one supplemental breast screening per year for women at increased risk of breast cancer via MRI or ultrasound. UPMCHealthPlan has released this policy update with billing guidance recommendations to help providers comply with the new state mandate.
Action Required
By January 31, 2025: Billing team must review UPMCHealthPlan's commercial product billing guide for specific coding and billing recommendations related to Pennsylvania Act 1 of 2023 supplemental breast screening coverage. Update internal billing protocols, encounter templates, and prior authorization workflows to reflect coverage requirements for supplemental breast MRI and ultrasound screening for high-risk women. Providers should document increased breast cancer risk in patient records to support medical necessity. Contact Provider Services at 1-866-918-1595 with questions about compliant billing. Failure to follow updated guidance may result in claim denials or compliance issues with Pennsylvania regulators.