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providers UPMC for Life PFFS Terms & Conditions

Below are materials to help familiarize you with the UPMC for Life Private Fee-for-Service (Medicare) plan. If you have any questions regarding UPMC Health Plan, please call UPMC for Life (Medicare) Provider Services at 877-539-3080.

UPMC for Life
P.O. Box 2997
Pittsburgh, PA 15230-2997

Your cooperation makes a direct contribution to the success of Health Plan initiatives that deliver world-class health care and resources to our members.

Last Update: 12/31/2009

Table of Contents

Introduction

When a provider is deemed to accept UPMC for Life Private Free-for-Service plan's terms and conditions

Provider qualifications and requirements

Payment to providers

Filing a claim for payment

Maintaining medical records and allowing audits

Getting an advance coverage determination

Provider payment dispute resolution process

Member and provider appeals and grievances

Providing members with notice of their appeal rights — Requirements for Hospitals, SNFs, CORFs, and HHAs

If you need additional information or have questions

 

Introduction

UPMC for Life is a Medicare Advantage Private Fee-for-Service (PFFS) plan offered by UPMC Health Plan. UPMC for Life Private Fee-for-Service plan allows members to use any provider, such as a physician, health professional, hospital, or other Medicare provider in the United States that agrees to treat the member after having the opportunity to review these terms and conditions of payment, as long as the provider is eligible to provide health care services under Medicare Part A and Part B (also known as ‘Original Medicare’) or eligible to be paid by UPMC for Life for benefits that are not covered under Original Medicare.

The law provides that if you have an opportunity to review these terms and conditions of payment and you treat a UPMC for Life Private Fee-for-Service member, you will be “deemed” to have a contract with us. Section 2 explains how the deeming process works. The rest of this document contains the contract that the law allows us to deem to hold between you, the provider, and UPMC for Life. Any provider in the United States that meets the deeming criteria in Section 2 becomes deemed to have a contract with UPMC Health Plan for the services furnished to the member when the deeming conditions are met. No prior authorization, prior notification, or referral is required as a condition of coverage when medically necessary, plan-covered services are furnished to a member. However, a member or provider may request an advance organization determination before a service is provided in order to confirm that the service is medically necessary and will be covered by the plan. Note that the terms prior authorization, prior notification, and advance organization determination have different meanings. Prior authorization and prior notification rules are described in Section 4, and advance organization determination is described in Section 7.

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When a provider is deemed to accept UPMC for Life Private Fee-for-Service plan's terms and conditions

A provider is deemed by law to have a contract with UPMC Health Plan when all of the following three criteria are met:

  1. The provider is aware, in advance of furnishing health care services, that the patient is a member of UPMC for Life Private Fee-for-Service plan. All of our members receive a member ID card that includes the UPMC for Life logo that clearly identifies them as PFFS members. The provider may validate eligibility by calling our Provider Services at 1-877-539-3080.
  2. The provider either has a copy of, or has reasonable access to, our terms and conditions of payment (this document). The terms and conditions are available on our website at http://www.upmchealthplan.com/providers/pffs_terms.html. The terms and conditions may also be obtained by calling UPMC Provider Services at 1-877-539-3080.
  3. The provider furnishes covered services to a UPMC for Life Private Fee-for-Service plan member.

If all of these conditions are met, the provider is deemed to have agreed to UPMC for Life Private Fee-for-Service plan’s terms and conditions of payment for that member specific to that visit. Note: You, the provider, can decide whether or not to accept UPMC for Life Private Fee-for-Service plan’s terms and conditions of payment each time you see a UPMC for Life Private Fee-for-Service member. A decision to treat one plan member does not obligate you to treat other UPMC for Life Private Fee-for-Service members, nor does it obligate you to accept the same member for treatment at a subsequent visit.

For example: If a UPMC for Life Private Fee-for-Service member shows you an enrollment card identifying him/her as a member of UPMC for Life Private Fee-for-Service plan and you provide services to that member, you will be considered a deemed provider. Therefore, it is your responsibility to obtain and review the terms and conditions of payment prior to providing services, except in the case of emergency services (see below).

If you DO NOT wish to accept UPMC for Life Private Fee-for-Service plan’s terms and conditions of payment, then you should not furnish services to a UPMC for Life Private Fee-for-Service member, except for emergency services. If you nonetheless do furnish non-emergency services, you will be subject to these terms and conditions whether you wish to agree to them or not. Providers furnishing emergency services will be treated as non-contract providers and paid at the payment amounts they would have received under Original Medicare.

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Provider qualifications and requirements

In order to be paid by UPMC Health Plan for services provided to one of our members, you must:

  • Have a National Provider Identifier in order to submit electronic transactions to UPMC Health Plan, in accordance with HIPPA requirements.
  • For paper claims, follow the instructions listed in the Provider Manual found on the UPMC Health Plan website located at http://www.upmchealthplan.com/providers/manual.html, following all applicable filing timeliness guidelines.
  • Furnish services to a UPMC for Life Private Fee-for-Service plan member within the scope of your licensure or certification.
  • Provide only services that are covered by our plan and that are medically necessary by Medicare definitions.
  • Meet applicable Medicare certification requirements (e.g., if you are an institutional provider such as a hospital or skilled nursing facility).
  • Not have opted out of participation in the Medicare program under §1802(b) of the Social Security Act, unless providing emergency or urgently needed services.
  • Not be on the HHS Office of Inspectors General excluded and sanctioned provider lists.
  • Not be a Federal health care provider, such as a Veterans Administration provider, except when providing emergency care.
  • Comply with all applicable Medicare and other applicable Federal health care program laws, regulations, and program instructions, including laws protecting patient privacy rights and HIPAA that apply to covered services furnished to members.
  • Agree to cooperate with UPMC Health Plan to resolve any member grievance involving the provider within the time frame required under Federal law.
  • For providers who are hospitals, home health agencies, skilled nursing facilities, or comprehensive outpatient rehabilitation facilities, provide applicable beneficiary appeals notices (See Section 10 for specific requirements).
  • Not charge the member in excess of cost sharing or balance bill under any condition, including in the event of plan bankruptcy.

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Payment to providers:

Plan payment
UPMC Health Plan reimburses deemed providers at the amount they would have received as participating or non-participating physicians, as applicable, under Original Medicare for Medicare-covered services, minus any member required cost sharing, for all medically necessary services covered by Medicare.

We will process and pay clean claims within 30 days of receipt. If a clean claim is not paid within the 30-day time frame, then we will pay interest on the claim according to Medicare guidelines. Section 5 has more information on prompt payment rules. Payment to providers for which Medicare does not have a publicly published rate will be based on the estimated Medicare amount. For more detailed information about our payment methodology for all provider types, go to http://www.upmchealthplan.com/providers/pffs_terms.html.

Services covered under UPMC for Life Private Fee-for-Service plan that are not covered under Original Medicare are reimbursed using UPMC for Life’s fee schedule. Please call us at 1-877-539-3080 to receive information on our fee schedule.

Deemed providers furnishing such services must accept the fee schedule amount, minus applicable member cost sharing, as payment in full.

Member benefits and cost sharing
Payment of cost-sharing amounts is the responsibility of the member. Providers should collect the applicable cost sharing from the member at the time of the service when possible. You can only collect from the member the appropriate UPMC for Life Private Fee-for-Service plan copayments or coinsurance amounts described in these terms and conditions. After collecting cost sharing from the member, the provider should bill UPMC Health Plan for covered services. Section 5 provides instructions on how to submit claims to us.

If a member is a dual-eligible Medicare beneficiary (that is, the member is enrolled in our PFFS plan and a state Medicaid program), then the provider cannot collect any cost sharing for Medicare Part A and Part B services from the member at the time of service when the State is responsible for paying such amounts (nominal copayments authorized under the Medicaid State plan may be collected). Instead, the provider may only accept the MA plan payment (plus any Medicaid copayment amounts) as payment in full or bill the appropriate State source. For your quick reference, the table below lists some of the important services covered under UPMC for Life Private Fee-for-Service plan for ISG/Weirton Steel VEBA and the associated member cost sharing amounts.

Services covered by UPMC for Life Private Fee-for-Service plan The amount(s) you may charge the plan member
Inpatient hospital services $200 per admission
Skilled nursing facility $0 for days 1-10
$50 per day for days 11-100
Office services (Physician, specialist, chiropractic & podiatry) $15 primary care per visit
$30 specialist care per visit
Immunizations $0 copay
Mammography $0 copay
Physical Exams (1 per year) $15 primary care
Emergency room visit $50
$0 if admitted
Urgent care center visits $50 per visit
$0 if admitted
Hearing Services $30 for 1 routine hearing test every year
$30 for 1 hearing aid fitting evaluation every three years

To view a complete list of covered services and member cost sharing amounts under UPMC for Life Private Fee-for-Service plan, go to http://www.upmchealthplan.com/providers/pffs_terms.html. You may call us at 1-877-539-3080 to obtain more information about covered benefits, plan payment rates, and member cost-sharing amounts under UPMC for Life Private Fee-for-Service plan. Be sure to have the member’s ID number when you call.
UPMC for Life follows Medicare coverage decisions for Medicare-covered services.  Services not covered by Medicare are not covered by UPMC for Life, unless specified by the plan.  Information on obtaining an advance coverage determination can be found in Section 7. UPMC for Life Private Fee-for-Service plan does not require members or providers to obtain prior authorization, prior notification, or referrals from the plan as a condition of coverage. Under prior authorization, a plan requires beneficiaries or providers to seek authorization from the plan prior to obtaining services. There is no such requirement for UPMC for Life Private Fee-for-Service plan members. For information on UPMC for Life Private Fee-for-Service plan’s prior notification policies, see section on “Prior notification rules” below. 

Note: Medicare supplemental policies, commonly referred to as Medigap plans, cannot cover cost-sharing amounts for Medicare Advantage plans, including PFFS plans.  All cost sharing is the member’s responsibility.

Prior notification rules
No prior authorization or referral is required as a condition of coverage when medically necessary, plan-covered services are furnished to members. However, to assist us in better managing care for our members, we request that you notify us prior to the member receiving any of the following services:

  • Inpatient hospital care
  • Inpatient mental health
  • Transplants
  • SNF Admissions
  • Acute Rehab Admissions
  • LTAC Admissions
  • Continuous glucose monitor – long term interstitial
  • Bone growth stimulators, noninvasive
  • Cranial remolding orthoses
  • Lymphedema pumps and appliances
  • Microprocessor controlled knee (c-leg)
  • Negative pressure wound therapy (Wound Vac)
  • Parenteral nutrition, nutritional products
  • Power  mobility  devices (PMDs)
  • Pressure reducing support surfaces (groups 2 & 3)
  • ThAIRapy vests
  • Wearable cardiac defibrillator
  • Wheelchair accessories, repair and replacement
  • Wheelchair seating
  • Abdominoplasty/Panniculectomy
  • Breast Reduction
  • BRCA Testing (Molecular Susceptibility for Breast Cancer and/or Ovarian Cancer)
  • Home Based Real Time Cardiac Surveillance
  • Oncotype DX Assay for Breast Cancer
  • Magneto-Encephalography (MEG)
  • Maze procedure for Cardiac Ablation (Mini Maze)
  • Septoplasy/Rhinoplasy
  • Wireless Capsule Endoscopy
  • The follow Part B prescription drugs:
    • Actimmune, Adagen, Aldurazyme, Amevive, Arcalyst, Botox, Ceredase, Cerezyme, Cimzia, Elaprase, EPO, Euflexxa, Fabrazyme, Flolan, Growth Hormone, HCG, Hyalgan, Hycamtin (oral), Immune Globulins, Increlex/Iplex, LHRH agents, Lucentis, Myobloc, Naglayzme, Neulasta, Neupogen, Orencia, Orthovisc, Remicade, Remodulin, Rituxan, Soliris, Supartz, Synagis, Synvisc, Temodar (oral), Tysabri, Ventavis, Xeloda (oral), Xolair, Zorbitive

UPMC Health Plan does not require the member or the provider to prior notify the plan as a condition for covering services. To provide prior notification or to obtain more information about our prior notification rules, call us at 1-877-539-3080.

Balance billing of members
A provider may collect only applicable plan cost-sharing amounts from UPMC for Life Private Fee-for-Service members and may not otherwise charge or bill members. Balance billing is prohibited by providers who furnish plan-covered services to UPMC for Life Private Fee-for-Service members.

Hold harmless requirements
In no event, including, but not limited to, nonpayment by UPMC Health Plan, insolvency of UPMC for Life, and/or breach of these terms and conditions, shall a deemed provider bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against a member or persons acting on their behalf for plan-covered services provided under these terms and conditions.  This provision shall not prohibit the collection of any applicable coinsurance, copayments, or deductibles billed in accordance with the terms of the member's benefit plan.

If any payment amount is mistakenly or erroneously collected from a member, you must make a refund of that amount to the member. 

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Filing a claim for payment

  • You must submit a claim to UPMC Health Plan for an Original Medicare covered service within the same time frame you would have to submit under Original Medicare, which is within 15-27 months from the date of service. Failure to be timely with claim submissions may result in nonpayment. The criteria for Original Medicare submission of claims can be found in section 70 of Chapter 1 of the Medicare Claims Processing Manual located at http://www.cms.hhs.gov/manuals/downloads/clm104c01.pdf.
  • Prompt Payment UPMC Health Plan will process and pay clean claims within 30 days of receipt.  If a clean claim is not paid within the 30-day time frame, UPMC Health Plan will pay interest on the claim according to Medicare guidelines.  A clean claim includes the minimum information necessary to adjudicate a claim, not to exceed the information required by Original Medicare.  UPMC Health Plan will process all non-clean claims and notify providers of the determination within 60 days of receiving such claims.
  • Submit claims using the standard CMS-1500, CMS-1450 (UB-04), or the appropriate electronic filing format. 
  • Use the same coding rules and billing guidelines as Original Medicare, including Medicare CPT Codes, HCPCS codes and defined modifiers.  Bill diagnosis codes to the highest level of specificity.  
  • Include the following on your claims:
    • National Provider Identifier(mandatory for electronic submission; can be included on paper submission if the provider has obtained one (include in box 24J for the servicing provider) 
    • The member’s ID number
    • Date(s) of service
    • Procedures/services performed
    • Diagnosis code(s)
    • Payee information
    • Other information as described in the provider manual, which can be found on the UPMC Health Plan website located at http://www.upmchealthplan.com/providers/manual.html
  • For providers that are paid based upon interim rates, include with your claim a copy of your current interim rate letter if the interim rate has changed since your previous claim submission.
  • Coordination of Benefits: All Medicare secondary payer rules apply. These rules can be found in the Medicare Secondary Payer Manual located at http://www.cms.hhs.gov/Manuals/IOM/list.asp. Providers should identify primary coverage and provide information to UPMC Health Plan at the time of billing.  
  • Where to submit a claim:
    • For electronic claim submission, UPMC Health Plan’s EDI team would need to be contacted to perform the required testing for a provider to become a direct submitter of electronic claims.  For questions about this process, contact UPMC Health Plan Web Services at  1-800-937-0438
    • For paper claim submission, mail to:

      UPMC for Life Private Fee-for-Service
      PO Box 2997
      Pittsburgh,  PA  15230

  • If you have problems submitting claims to us or have any billing questions, contact our technical billing resource at 1-877-539-3080.

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Maintaining medical records and allowing audits

Deemed providers shall maintain timely and accurate medical, financial, and administrative records related to services they render to UPMC for Life Private Fee-for-Service members.  Unless a longer time period is required by applicable statutes or regulations, the provider shall maintain such records for at least 10 years from the date of service.

Deemed providers must provide UPMC Health Plan, the Department of Health and Human Services, the Comptroller General, or their designees access to any books, contracts, medical records, patient care documentation, and other records maintained by the provider pertaining to services rendered to Medicare beneficiaries enrolled in a Medicare Advantage plan, consistent with Federal and state privacy laws. Such records will primarily be used for Centers for Medicare & Medicaid Services (CMS) audits of risk adjustment data upon which CMS capitation payments to UPMC Health Plan are based.  UPMC Health Plan will not reimburse the provider for the cost of furnishing member medical records for government-related activities. Providers are required to furnish member medical records without charge when the medical records are required for government use.

UPMC Health Plan may also request records for activities in the following situations: UPMC Health Plan audits of risk adjustment data; determinations of whether services are covered under the plan are reasonable and medically necessary, and whether the plan was billed correctly for the service; to investigate fraud and abuse; and in order to make advance coverage determinations. UPMC Health Plan will not use these records for any purpose other than the intended use. UPMC Health Plan will not reimburse the provider for the cost of furnishing member medical records for plan-related activities

UPMC Health Plan will not use medical record reviews to create artificial barriers that would delay payments to providers. Both mandatory and voluntary provision of medical records must be consistent with HIPAA privacy law requirements.

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Getting an advance coverage determination

Providers may choose to obtain a written advance coverage determination (known as an organization determination) from us before furnishing a service in order to confirm whether the service is medically necessary and will be covered by UPMC Health Plan. To obtain an advance organization determination, call us at 1-877-539-3080. UPMC Health Plan will make a decision and notify you and the member within 14 days of receiving the request, with a possible 14-day extension either due to the member’s request or UPMC Health Plan’s justification that the delay is in the member’s best interest. In cases where you believe that waiting for a decision under this time frame could place the member’s life, health, or ability to regain maximum function in serious jeopardy, you can request an expedited determination. To obtain an expedited determination, call us at 1-877-539-3080.  We will notify you of our decision within 72 hours.

In the absence of an advance organization determination, UPMC Health Plan can retroactively deny payment for a service furnished to a member if we determine that the service was not covered by our plan or was not medically necessary. However, providers have the right to dispute our decision by exercising member appeals rights.

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Provider payment dispute resolution process

If you believe that the payment amount you received for a service is less than the amount indicated in our terms and conditions of payment, you have the right to dispute the payment amount by following our dispute resolution process.
To file a payment dispute with UPMC Health Plan, send a written dispute to UPMC Health Plan, Attn:  Provider Disputes, P.O. Box 2906, Pittsburgh, PA  15230-2906. Additionally, please provide appropriate documentation to support your payment dispute, e.g., a remittance advice from a Medicare carrier would be considered such documentation. Claims must be disputed within 120 days from the date payment is initially received by the provider. Note that in cases where we re-adjudicate a claim, for instance, when we discover that we processed it incorrectly the first time, you have an additional 120 days from the date you are notified of the re-adjudication in which to dispute the claim.
We will review your dispute and respond to you within 30 calendar days of our receipt of your dispute. If we agree with the reason for your payment dispute, we will pay you the additional amount you are requesting, including any interest that is due. We will inform you in writing if our decision is unfavorable and no additional amount is owed.
After UPMC Health Plan’s payment dispute resolution process is completed, if you still believe that we have reached an incorrect decision regarding payment on your claim, you may file an additional request for review with an independent review organization contracted by CMS. To file this additional request for review of a payment dispute with the independent review organization, you may contact the organization directly at:

  • Mail.
    First Coast Service Options, Inc.
    Payment Dispute Resolution Contractor
    P.O. Box 44017
    Jacksonville, Florida 32231-4017

  • FCSO may also be reached by email at PDRC@fcso.com and by phone at (904) 791-6430. Note that you must first complete UPMC Health Plan’s payment dispute resolution process before you can request a review by the independent review organization.

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Member and provider appeals and grievances

UPMC for Life Private Fee-for-Service members have the right to file appeals and grievances with UPMC for Life when they have concerns or problems related to coverage or care. Members may appeal a decision made by UPMC Health Plan to deny coverage or payment for a service or benefit that they believe should be covered or paid for. Members should file a grievance for all other types of complaints not related to the provision or payment for health care.

A physician who is providing treatment may, upon notifying the member, appeal pre-service organization determination denials to the plan on behalf of the member. The physician may also appeal a post-service organization determination denial as a representative, or sign a waiver of liability (promising to hold the member harmless regardless of the outcome) and appeal the denial using the member appeal process. There must be potential member liability (e.g., an actual claim for services already rendered, as opposed to an advance organization determination), in order for a provider to appeal utilizing the member appeal process.

A non-physician provider may appeal organization determinations on behalf of the member as a representative, or sign a waiver of liability (promising to hold the member harmless regardless of the outcome) and appeal post-service organization determinations (e.g., claims) using the member appeal process. As noted above, there must be potential member liability in order for a provider to appeal utilizing the member appeal process.
If a provider appeals using the member appeal process, the provider agrees to abide by the statues, regulations, standards, and guidelines applicable to the Medicare PFFS Member appeals and grievance processes.
The UPMC for Life Private Fee-for-Service plan member Evidence of Coverage (EOC) provides more detailed information about the member appeal and grievance processes. You can call our Member Services Department at 1-877-539-3080 for more information on our member appeals and grievance policies and procedures.

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Providing members with notice of their appeals rights - Requirements for hospitals, SNFs, CORFs, and HHAs

Hospitals must notify Medicare beneficiaries, including Medicare Advantage beneficiaries enrolled in PFFS plans, who are hospital inpatients about their discharge appeal rights by complying with the requirements for providing the Important Message from Medicare (IM), including complying with the normal time frames for delivery. For copies of the notice and additional information regarding this requirement, go to http://www.cms.hhs.gov/BNI/12_HospitalDischargeAppealNotices.asp.

Skilled nursing facilities, home health agencies, and comprehensive outpatient rehabilitation facilities must notify Medicare beneficiaries, including Medicare Advantage beneficiaries enrolled in PFFS plans, about their right to appeal a termination of services decision by complying with the requirements for providing the Notice of Medicare Non-Coverage (NOMNC), including complying with the normal time frames for delivery.  For copies of the notice and the notice instructions, go to http://www.cms.hhs.gov/MMCAG/Downloads/NOMNCForm.pdf and http://www.cms.hhs.gov/MMCAG/Downloads/NOMNCInstructions.pdf. As directed in the instructions, the NOMNC should contain UPMC Health Plan’s contact information somewhere on the form (such as in the additional information section on page 2 of the NOMNC).

Hospitals, home health agencies, comprehensive outpatient rehabilitation facilities, or skilled nursing facilities must provide members with a detailed explanation on behalf of the plan if a member notifies the Quality Improvement Organization (QIO) that the member wishes to appeal a decision regarding a hospital discharge (Detailed Notice of Discharge) or termination of home health agency, comprehensive outpatient rehabilitation facility or skilled nursing facility services (Detailed Explanation of Non-coverage) within the time frames specified by law.  

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If you need additional information or have questions

If you have general questions about UPMC for Life Private Fee-for-Service plan’s terms and conditions of payment, contact UPMC Provider Services at 1-877-539-3080, 8 a.m. to 5 p.m., Monday – Friday.

    UPMC for Life
    P.O. Box 2997
    Pittsburgh, PA 15230-2997

  • If you have questions about submitting claims, call us at 1-877-539-3080.
  • If you have questions about plan payments, call us at 1-877-539-3080.

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