Compliance and Fraud, Waste and Abuse Form
Report potential compliance, fraud, waste and abuse, or privacy violations at https://secure.ethicspoint.com/domain/media/en/gui/51176/index.html, or call the toll-free Compliance & Ethics HelpCenter hotline at 1-800-455-4521, 24 hours a day, seven days a week. All Peoples Health employees, contractors and business partners are required to report suspected violations. You may choose to remain anonymous. We have a nonretaliation policy to protect any person that reports a potential violation.
Visit the Provider Portal’s Resources tab for downloadable versions of the following forms.
Detailed Notice of Discharge
This notice must be provided to patients who choose to appeal a hospital discharge decision. It describes why the provider believes the patient should be discharged and explains that the health plan’s Quality Improvement Organization will review the case.
EFT Enrollment Form
Use this form to enroll in EFT—a free and secure way to receive faster claims payments. Please use one enrollment form per tax ID. EFT eliminates long wait times for payment checks to arrive via mail. You can find the form and instructions at www.peopleshealth.com/providers/enroll-in-electronic-funds-transfer. Refer to Section B.5 (Claims) for more information.
Medical Necessity Form
Use the online Medical Necessity Form, available on the Provider Portal, to submit an authorization request for services requiring screening against InterQual criteria or CMS guidelines. To search authorization requirements for specific procedure codes, use the Peoples Health Authorization Requirements Search. You can also access a printable Medical Necessity Form on our website and fax it to the dedicated lines printed on the form.
Medicare Outpatient Observation Notice (MOON)
The Notice of Observation Treatment and Implication for Care Eligibility Act requires that hospitals notify patients who are receiving observation services as outpatients for more than 24 hours of their status. The standardized notice, known as the MOON, explains the status of the patient as an outpatient, as well as the implications of such status. It must be provided no later than 36 hours after observation services are initiated.
Notice of Medicare Non-Coverage (NOMNC)
Providers must issue advance written notice to patients when their Medicare-covered services with a skilled nursing facility, home health agency or comprehensive outpatient rehabilitation organization or hospice are ending. The NOMNC explains how patients can request an expedited determination from their health plan’s Quality Improvement Organization.
Request for Medicare Prescription Drug Coverage Determination Form
Submit this form to request prior authorization, to request a formulary exception for a non-formulary drug, or to waive coverage restrictions or quantity limits on a drug covered by our formulary.
Screening and Lab Work Standing Order Form
This form is used to provide Peoples Health consent to administer certain screenings and tests or trainings and vaccinations to eligible Peoples Health representative . Contact your provider representative to complete one for a patient.
Find the following at www.peopleshealth.com, Under the Providers tab, Medicare-Required Notices section:
Important Message From Medicare (IM)
The Important Message from Medicare tells members who are hospital inpatients about their discharge appeal rights. Hospitals must give the IM to all inpatient members.