Medicare AdvantagePrior AuthHigh impact
Musculoskeletal procedures update
UPMC Health Plan·Orthopedics, Podiatry, Sports Medicine +1 more·Provider Announcement
Effective date
Feb 1, 2024
We identified it
Aug 7, 2026
Summary
Effective February 1, 2024, UPMC Health Plan is implementing prior authorization requirements for eight categories of musculoskeletal procedures, including wrist and ankle arthroscopy, bunionectomy, arthrodesis, plantar fascia release, and radius/ulna fracture fixation. All claims for these procedures must obtain prior authorization using InterQual Connect criteria before services are rendered to avoid denial.
Action Required
By January 31, 2024: Billing team must update billing software and procedures to require prior authorization for all 54 listed CPT codes before claim submission. Specific actions: (1) Configure billing system to flag claims with these codes and prevent submission without prior auth documentation; (2) Update encounter forms and provider templates to remind clinicians that prior authorization is required before scheduling these musculoskeletal procedures; (3) Train front desk and scheduling staff to initiate prior auth requests when these procedures are scheduled; (4) Establish process for submitting authorization requests through upmchp.us/PriorAuth and Provider OnLine portal using InterQual Connect criteria; (5) Brief all providers on the new requirement and InterQual guidelines. Contact UPMC Provider Services at 1-866-918-1595 for implementation questions. Failure to obtain prior authorization before service delivery will result in claim denials and potential revenue loss.