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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

Information for Plan Members

Plan Member Rights and Responsibilities
Plan Member Appeals and Grievances

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