Medical Necessity Review

Important Peoples Health web addresses:

  • Services requiring prior authorization are screened against medical necessity criteria, Medicare guidelines and Peoples Health policies.
  • All authorization requests must be submitted to the Peoples Health medical management department by completing a medical necessity request via the Provider Portal. You must upload all appropriate attachments, such as physician orders or supporting documentation, with your request.
  • You can determine if procedures require authorization by using the Peoples Health Authorization Requirements Search (accessible via the Provider Portal or Peoples Health website) to check procedure codes. To search the database, select a place of service code and input a CPT code. Results display the following information:
    • Procedure Code: The procedure code being searched.
    • Authorization Required: “Y” indicates service requires authorization; “N” indicates it does not.
    • Description: The procedure associated with the code being searched.
    • Comments: Notes about changes implemented to the code, including dates, information about discontinued and replacement codes, etc.
    • Effective Date: The date the procedure code was implemented.
    • End Date: The date the procedure code was discontinued, if applicable.
    • Last Update Date: The date the database was last updated.

If a “Y” appears in the results, authorization is required and an authorization. Note: Submit authorization requests for:

  • Injectable chemotherapy, cancer-supportive drugs and therapeutic radiopharmaceuticals to the Optum® Cancer Guidance Program through MBMNow, available through the Provider Portal, under the Authorizations tab; click the Cancer Treatment icon
  • Oral chemotherapy drugs to OptumRx
  • All other services through Provider Portal, under the Authorizations tab

If “**” is indicated, it means not applicable, and the code should not be billed for the place of service per American Medical Association coding guidelines. 

You may also fax a Medical Necessity Form and supporting clinical information to the medical management department at 1-866-464-5709 for standard, direct admission, level-of-care change, discharge orders and updates. A printable version of the form is located on our website.

Note about expedited authorization requests: A request is only considered expedited if, per CMS, “the physician believes that waiting for a decision under the standard time frame could place the enrollee’s life, health or ability to regain maximum function in serious jeopardy.”

Note: The out-of-network benefit level is available only to Peoples Health patients in certain plans. Reference your Provider Benefit Packet or a plan’s Evidence of Coverage to determine if a plan has this benefit.

If patients have the option to access care from an out-of-network provider:

Services utilized at this level have a higher out-of-pocket cost than services accessed within the plan network. To ensure coverage, all services received out-of-network, except emergency and urgently needed care, must be deemed medically necessary, and we must authorize most services in advance.