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Provider Reference Guide.

  • Introduction – Contact and General Information
    • Corporate Headquarters
    • Claims and Provider Services
    • Pharmacy Services
    • Medical Management
    • Contracted Hospitals
    • Peoples Health Care Coordination Model
  • Health Plans and Documents
    • Peoples Health Medicare Plans
    • Quick Reference to D-SNPs
    • Plan Documents
  • Pharmacy and Part D Coverage Details
    • OptumRx Provider-Only Phone Numbers
    • Prescription Drug Cost-Sharing for Peoples Health Plans
    • Online Formulary Search
    • Network Pharmacies
    • Pharmacy Prior Authorization Requests and Tiering or Formulary Exception Requests
    • Prior Authorization
    • Step Therapy
    • Quantity Limits
    • Patient Permission for Automatic Mail-Order Refills
    • Common Questions Regarding Drug Coverage
    • Medicare Coverage Gap
    • Medicare Coverage Gap Discount Program
    • E-dispensing Program for Part D Vaccines
    • High-Risk Medication Use and Potentially Harmful Drug-Disease Interactions in the Elderly
    • Generic Drugs Pharmacy Utilization Program
    • Medication Therapy Management Program
    • Medication Information in Member Viewer
  • Resources for Partnering With Peoples Health
    • Primary Care and the Peoples Health Care Coordination Model
    • Peoples Health Website
    • Peoples Health Provider Portal
    • Member Viewer
    • Physician Initiatives
  • Physician Administrative Information
    • Medical Necessity Review
    • Requesting Medical Necessity Criteria
    • Authorization Confirmation Faxes
    • Physician’s Role When Utilizing Nurse Practitioners
    • Maintaining Status as a Contracted Provider
    • Preclusion List Policy
    • Quarterly Requests for Up-to-Date Provider Demographic Information
    • Peoples Health Policy Concerning Information on Contracted Providers
    • Contracting With Peoples Health
  • Hospital and Ancillary Administrative Information
    • Medical Necessity Review
    • Notification and Medical Necessity Review Process
    • Services Requiring Prior Authorization
    • Facility Authorization Requests
    • Requesting Medical Necessity Criteria
    • Authorization Confirmation Faxes
    • Maintaining Status as a Contracted Provider
    • Preclusion List Policy
    • Peoples Health Policy Concerning Information on Contracted Providers
    • Contracting With Peoples Health
  • Ancillary Sites and Services
    • Approved In-Office Lab Procedures
    • Ancillary Provider Listings: Laboratory Sites, Radiology and Diagnostic Imaging Sites, Urgent Care Centers, and Home Health Agencies
    • Vision Care and Optical Services
    • Dental Services
    • Hearing Services
    • Behavioral Health Provider
    • Diabetes Testing Supplies Providers
  • Claims
    • Claims Filing Guidelines
    • Timely Claims Filing
    • The Budget Control Act of 2011
    • Billing for Noncovered Services
    • Electronic Data Interchange
    • Submitting Claims Electronically
    • Claims Overpayment Recovery
    • Guidelines for Filing Corrected Claims
    • Electronic Funds Transfer (EFT)
    • Part A to Part B Rebilling for Hospitals
  • Access to Care Standards and Definitions
    • Provider Availability
    • Appointment Availability Standards
    • Definitions of Appointment Type
    • In-Office Waiting Time
    • After-Hours Care
    • Coverage Arrangements
    • After-Hours and Urgent Care Centers
    • Behavioral Health Care Standards
    • Behavioral Health Care Telephone Standards
  • Provider Office Quality Standards
    • CMS Star Ratings
    • Risk Adjustment
    • Documentation and Coding
    • Collecting Data for Risk Adjustment
    • Remote Access to Medical Records
    • Advance Directives
    • Provider Medical Office Site Reviews
    • How Peoples Health Conducts Provider Medical Office Site Reviews
    • What Reviewers Look for During a Provider Medical Office Site Review
    • Quality Improvement Program
  • Medical Management Programs
    • Medical Management Programs
    • Behavioral Health Services
    • Optum® Cancer Guidance Program
    • Elara Caring Healing at Home Program
  • Provider Inquiries, Claim Adjustment Requests and Appeals
    • Filing an Inquiry or a Claim Adjustment Request
    • Receipt of a Claim Adjustment Request
    • Claim Adjustment Decision
    • Filing an Appeal
    • Appeal Decision
    • Second Level Appeal Decision
  • Programs, Premiums and Deductibles
    • “Extra Help” for Low-Income Medicare Beneficiaries
    • Medicare Savings Programs
    • Medicare Part A and Part B Premiums and Part A Deductible
    • Medicare Therapy Cap Limits
  • Training and Educational Information
    • CMS Required Training
    • Medication Error Identification and Reduction System
    • Compliance Program Information
  • Regulatory and Compliance Information
    • NCQA: Current Accreditations and Standards
      • NCQA Accreditation
      • Why Peoples Health Is Accredited
      • Peoples Health Current Accreditations and Standards
      • How Peoples Health Upholds Quality Improvement Standards
    • CMS Regulations
      • Overview
      • Information About the MA Program
      • General Requirements
      • Discrimination Against Beneficiaries Prohibited
      • Disclosure Requirements
      • Access to Services
      • Confidentiality and Accuracy of Enrollee Records
      • Information on Advance Directives
      • Participation Procedures
      • Contract Provisions
      • Basic Contract Requirements
      • General Provisions
      • Basis for Imposing Intermediate Sanctions and Civil Monetary Penalties
    • CMS Marketing Guidelines for Provider Promotional Activities
      • Overview
      • Provider-Initiated Activities (With Healthcare Providers or in the Healthcare Setting)
      • Plan-Initiated Provider Activities (With Healthcare Providers or in the Healthcare Setting)
      • MA Organization Activities in the Health Care Setting
      • Provider Affiliation Announcements
  • Information for Plan Members
    • Member Rights and Responsibilities
    • Plan Member Appeals and Grievances
      • Submitting an Appeal
      • Grievances
      • Types of Problems That Might Lead a Member to File a Grievance
      • Filing a Grievance With Peoples Health
      • Peoples Health Grievance Review Process
  • Forms
    • Forms Overview

Claims

Claims Filing Guidelines
Timely Claims Filing
The Budget Control Act of 2011
Billing for Noncovered Services
Electronic Data Interchange
Submitting Claims Electronically
Claims Overpayment Recovery
Guidelines for Filing Corrected Claims
Electronic Funds Transfer (EFT)
Part A to Part B Rebilling for Hospitals

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