UPMC and Highmark provider contract dispute
November 2014 News
Highmark booklet summarizing consent decree provisions that members may take to their provider
UPMC Letter recently sent to patients summarizing consent decree provisions that members may take to their provider
Highmark members age 65 or older were sent a letter about their State System provided medical benefits.
October 2014 News
UPMC sent a letter to western Pennsylvania seniors about Highmark's Medicare Advantage Plan.
*NOTE* - This letter does not apply to any benefits provided by the State System and therefore should be ignored. After UPMC sent this letter, a state court ruled that Highmark did not violate the consent decree by offering a Medicare plan excluding UPMC providers.
September 2014 News
Pennsylvania Insurance Department finished their review of Highmark’s transition plan. The transition plan is Highmark’s operational details that will be followed in order to insure the objectives of the consent decree are achieved.
Resources Available for Employees
Videos summarizing Consent Decree
Highmark Out-of-Network Balance Billing Claim Example with/without Consent Decree Protection
Network - Provider Information
- Highmark's UPMC Network Access FAQs
- 2015 In-Network Hospitals Listing
myCare Navigator Information (Highmark members only) – click here to view
- Representatives that can assist with your questions regarding:
- Finding a provider
- Transferring medical records
- Making an appointment
- Assist with health care concerns
Historical Information - July 2014
On June 27, 2014 a consent decree was reached by UPMC and Highmark which provides for transition of care for members in the event that a continuing agreement between the two parties is not reached by December 31, 2014. This document addresses many of the issues concerning members in western Pennsylvania, including oncology services, emergency services, and services provided by certain medical providers in the area of pediatrics and behavioral health.
Click here for the Highmark PPO Blue Summary of Benefits
Click here for the Highmark Indemnity Summary of Benefits
UPMC HMO Health Plan
800-644-1046 Pre-enrollment questions
888-876-2756 Current members
Click here for the UPMC Health Plan HMO Summary of Benefits
The UPMC HMO Health Plan is an alternative health plan available to most employees who live in the UPMC HMO Health Plan service area. As you consider your health plan enrollment options, it’s important that you understand what is included in UPMC HMO Health Plan’s network.
The UPMC HMO Health Plan provider network includes the specialty hospitals of UPMC, but also includes many other facilities and providers in western Pennsylvania. The network includes other community hospitals, physician practices, urgent care centers, behavioral health facilities, and long-term care facilities. It DOES NOT include the Allegheny Health System facilities and doctors as part of the network. (Note: Highmark Blue Shield acquired the Allegheny Health System). Members receive in-network access to more than 125 hospitals and more than 11,500 physicians in western Pennsylvania. Click here to search the provider directory for UPMC HMO or to determine if your provider is part of the UPMC network.
The Enhanced Access HMO plan does not require a referral to see a specialist.
Coverage outside of western Pennsylvania in the UPMC HMO Health Plan is very limited except in very specific situations.
- All UPMC HMO Health Plan members are covered for urgent or emergency care no matter where they go.
- Full-time college students are covered both within and outside western Pennsylvania. Simply call a Health Care Concierge at UPMC who can help to set up coverage in the student’s area for any care he or she may need.
- Membership in UPMC HMO Health Plan entitles you to a unique global emergency services program called Assist America. This program protects members covered under the UPMC Health Plan with resources like doctors, hospitals, pharmacies and other services while traveling 100 miles or more from your home.
Assist America is not travel or medical insurance – it is provider of global emergency services. Assist America’s services do not replace medical insurance during medical emergencies away from home. All medical costs incurred should be submitted to UPMC and are subject to the policy limits of your health coverage. Click here to view the Assist America flyer.
Some of the key services include:
- Medical consultation, evaluation and referral
- Hospital admission assistance with non-US hospital admission
- Emergency medical evacuation if adequate medical facilities are not available locally
- Medical Repatriation – transport home or to a rehabilitation facility if you require medical assistance after being discharged from a hospital
If you will be traveling 100 miles or more from your home for more than 90 consecutive days, you will need to contact Assist America or UPMC for more information.