Claims Review and Appeal Procedures

Each type of benefit described in the Summary Guide to Benefits has special claims and appeals procedures. It is important that you understand the complaint/grievance, claims, and appeals processes in order to protect your right to benefits in a timely manner and to receive appropriate care on a timely basis.

The applicable complaint/grievance, claims, and appeals procedures are described in the “Resolving Disputes with UPMC Health Plan” section of the certificate of coverage for the University of Pittsburgh Health and Welfare Plan (“Plan”). The Plan has a specific amount of time to evaluate and process claims for benefits, which commences on the date the claim is first filed. There are processes in place to address urgent health care claims for which application of nonurgent care time frames could seriously jeopardize the life or health of the covered patient. You also have a limited period in which to appeal any adverse claim determinations.

Please familiarize yourself with these special procedures and your responsibility to take appropriate and timely action. For UPMC Health Plan, you may call the Member/Provider Services Department at 1-888-499-6885 for more information about filing a health care claim including an urgent care claim and appealing an adverse determination.