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DMEMedical Supply Request Form Upper Peninsula Health Plan

DMEMedical Supply Request Form Upper Peninsula Health Plan

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Approved Fee All covered benefits must meet CMS MDCH guidelines. Upper Peninsula Health Plan 228 West Washington Street Marquette MI 49855 Phone 906 225-7500 Fax 906 225-7690 www. The fee schedules are available on our website UPHP Representative Date Received // AUTHORIZATION Start Date / / End Date // COMMENTS Approved Denied Decision Date // All requests are subject to review for medical necessity eligibility and plan benefits at the time of service....
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