Get Upmc Health Plan Provider Online Application Process

This guide provides a step-by-step approach to completing the UPMC Health Plan Provider OnLine Application Process. It is designed to support you as you navigate the online application, ensuring that all necessary components are properly filled out.

Follow the steps to successfully complete your application.

1. Click ‘Get Form’ button to obtain the application form and open it for completion.
2. Begin with Page 1, which is the Provider Agreement. Enter the name of your practice or facility. If you are an individual provider, enter your name here.
3. Move to Page 2 of the Provider Agreement. Fill out the following fields: the name of the participating provider, their title, and the street address of the practice or facility.
4. Ensure the designated provider signs the application, and then provide the phone number for contact.
5. Designate a security officer by entering their name and title. This can be the provider themselves or another individual.
6. Complete and provide the security officer's phone number, along with the corresponding Tax ID number for the practice or facility.
7. Include the date of the security officer's signature for the application and leave the final two fields as they will be completed by UPMC Health Plan staff.
8. Proceed to Page 3, Exhibit A. For each individual requesting POL access, input the required details such as practice name, security officer's name, and get their signatures.
9. Remember to enter the last four digits of the user's Social Security Number, along with their phone number and email address. This information will aid in the creation of their account.
10. Finalize by entering other relevant details as requested, ensuring accuracy, before reviewing the entire document for completeness.
11. Once all fields are filled, review your application for accuracy. Save any changes, download, print, or share the completed form as needed.

Start completing your UPMC Health Plan Provider OnLine Application today.