UPMC Health Plan

Source: https://embed.widencdn.net/download/upmc/afpj4ema5y/out-of-network-claim-form_web.pdf?u=xdh7v1

Read date: 10-09-2026

Research steps

1. Confirm plan type first. UPMC Premium PPO allows in-network and out-of-network providers; EPO and HMO products require prior authorization for nonparticipating care except emergencies. https://www.upmchealthplan.com/en/individuals/plans-and-services/health-insurance and https://www.upmchealthplan.com/transparency-in-coverage/medical-2025
2. Obtain an itemized bill showing the member full name, provider or facility name and address, service description, service date, charge, diagnosis or nature of the condition, and proof of payment if already paid. https://upmc.widen.net/view/pdf/ucttsxril2/2026_663_WEB.pdf?t.download=true&u=oid6pr
3. Log in at the UPMC Health Plan member site and choose Documents and Forms, then Forms and Guides, then Get Form. Follow the on-screen Out-of-Network Care Claim Form. https://embed.widencdn.net/download/upmc/afpj4ema5y/out-of-network-claim-form_web.pdf?u=xdh7v1
4. Complete the patient, claim, release, and payment authorization sections. To request member payment, choose Policyholder payment (me). https://embed.widencdn.net/download/upmc/afpj4ema5y/out-of-network-claim-form_web.pdf?u=xdh7v1
5. Have the treating provider complete the Provider's Statement. If the provider does not complete it, fill it out to the best of your ability and attach the itemized bill. https://embed.widencdn.net/download/upmc/afpj4ema5y/out-of-network-claim-form_web.pdf?u=xdh7v1
6. Attach proof of payment and the other carrier's bill and EOB when another plan was billed. File types, size limit, maximum files, packaging rule, and confirmation are NOT PUBLISHED. https://embed.widencdn.net/download/upmc/afpj4ema5y/out-of-network-claim-form_web.pdf?u=xdh7v1
7. Submit within one year of the service date. The 2026 Advantage PPO policy also states notice within 20 days and proof of loss within 90 days, subject to its reasonable-delay clause. https://upmc.widen.net/view/pdf/ucttsxril2/2026_663_WEB.pdf?t.download=true&u=oid6pr
8. Check claim status in the UPMC Health Plan member site or app. Processing time is NOT PUBLISHED. https://www.upmchealthplan.com/contact

Filing facts

• Portal upload: YES
• Portal: UPMC Health Plan member site
• Portal path: Documents and Forms > Forms and Guides > Get Form > Out-of-Network Care Claim Form
• Mail address: UPMC Health Plan/UPMC Health Benefits, Claims Department, PO Box 2999, Pittsburgh, PA 15230
• Fax: 1-844-201-4655
• Attach: Member full name; provider or facility name and address; service description; service date; amount charged; diagnosis or nature of illness or injury; proof of payment if paid; form instructions also name service type and charge for each service
• File types: NOT PUBLISHED
• File size limit: NOT PUBLISHED
• Maximum files: NOT PUBLISHED
• One file or separate files: On-screen claim form plus itemized bill and proof of payment; attachment packaging is NOT PUBLISHED
• Confirmation: NOT PUBLISHED
• Status check: UPMC Health Plan member site or app
• Processing time: NOT PUBLISHED
• Member deadline: One year from date of service; notice within 20 days and proof of loss within 90 days with reasonable-delay exception
• Deadline basis: YES: product and employer contract control
• Mental health route: Generic form authorizes release of behavioral health information; employer carve-out differences are NOT PUBLISHED

Confirm the address, fax number or portal path on the insurer's own claims page before you send; read on 10-09-2026.