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Provider Reference Guide.
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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
Forms
Forms Overview