Emergency Department Admissions
All contracted hospitals must notify Peoples Health by 6 p.m. on the next business day* should any Peoples Health patient be admitted through the emergency department as an unscheduled admission. Clinical information to support medical necessity determination for the admission should also be communicated to us when the notification call is made, but no later than 24 hours after the notification call.
Hospital staff should call 1-877-346-5707. Additionally, please submit an authorization request and supporting clinical information to the Peoples Health medical management department. Please note: If you submit your authorization request and supporting clinical information through the Provider Portal, this online submission will serve as your notification.
If a facility fails to notify us by 6 p.m. on the next business day* of the patient being admitted, or if an authorization request and adequate clinical information are not submitted within 24 hours of the initial notification, we will issue an administrative denial for the admission, resulting in nonpayment of all hospital claims for the admission.
Level of Care Changes
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- If the patient’s level of care is changing (e.g., transitioning from inpatient services to observation services or vice versa, or transitioning from an outpatient procedure to an inpatient or observation stay), the hospital must call us at 1-877-346-5707 by 6 p.m. on the next business day.* Additionally, the hospital must either submit supporting clinical information or a prior authorization request in advance to the Peoples Health medical management department to obtain authorization for the new level of services. Please note: If you submit your authorization request and supporting clinical information through the Provider Portal, this online submission will serve as your notification.
- Failure to obtain authorization may result in claim denial.
Note: For unplanned inpatient admissions, observation admissions and outpatient authorizations, the hospital or treating facility must obtain authorization from Peoples Health for the services. The treating provider should notify Peoples Health of any unscheduled admission by 6 p.m. on the next business day.* Additionally, adequate clinical information to support medical necessity of the requested services must be received within 24 hours of notification. Please note: If you submit your authorization request and supporting clinical information through the Provider Portal, this online submission will serve as your notification.
Claims for nonauthorized services will be denied.
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.”
*Business day is defined as Monday through Friday, including holidays.