Provider Plan Documents and Forms | 2023
You must have Adobe Acrobat to view some of these documents. Click here to download Adobe Acrobat Reader.
How to setup Adobe Acrobat to read PDFs
Looking for 2024 plan documents and forms? Click here.Â
2023 Plan Coverage Documents
Peoples Health Choices 65 (HMO-POS) Greater New Orleans and Baton Rouge | 2023
Plan Overview for Peoples Health Choices 65 Greater New Orleans and Baton Rouge – An overview of plan benefits
Annual Notice of Changes for Peoples Health Choices 65 Greater New Orleans and Baton Rouge– A summary of plan benefit changes compared to the previous year and other important plan details
Evidence of Coverage for Peoples Health Choices 65 Greater New Orleans and Baton Rouge– Information about plan benefits, membership, covered and noncovered services, member rights and responsibilities, and other important plan details
Summary of Benefits for Peoples Health Choices 65 Greater New Orleans and Baton Rouge– A general summary of plan benefits
Vendor Information – A listing of providers offering benefit-related services
Peoples Health Choices 65 (HMO-POS) Northshore | 2023
Plan Overview for Peoples Health Choices 65 Northshore – An overview of plan benefits
Annual Notice of Changes for Peoples Health Choices 65 Northshore – A summary of plan benefit changes compared to the previous year and other important plan details
Evidence of Coverage for Peoples Health Choices 65 Northshore – Information about plan benefits, membership, covered and noncovered services, member rights and responsibilities, and other important plan details
Summary of Benefits for Peoples Health Choices 65 Northshore – A general summary of plan benefits
Vendor Information – A listing of providers offering benefit-related services
Peoples Health Choices 65 (HMO-POS) Southland | 2023
Plan Overview for Peoples Health Choices 65 Southland – An overview of plan benefits
Annual Notice of Changes for Peoples Health Choices 65 Southland – A summary of plan benefit changes compared to the previous year and other important plan details
Evidence of Coverage for Peoples Health Choices 65 Southland – Information about plan benefits, membership, covered and noncovered services, member rights and responsibilities, and other important plan details
Summary of Benefits for Peoples Health Choices 65 Southland – A general summary of plan benefits
Vendor Information – A listing of providers offering benefit-related services
Peoples Health Choices 65 (HMO-POS) Rural Southeast | 2023
Plan Overview for Peoples Health Choices 65 Rural Southeast – An overview of plan benefits
Annual Notice of Changes for Peoples Health Choices 65 Rural Southeast – A summary of plan benefit changes compared to the previous year and other important plan details
Evidence of Coverage for Peoples Health Choices 65 Rural Southeast – Information about plan benefits, membership, covered and noncovered services, member rights and responsibilities, and other important plan details
Summary of Benefits for Peoples Health Choices 65 Rural Southeast – A general summary of plan benefits
Vendor Information – A listing of providers offering benefit-related services
Peoples Health Choices Gold (HMO-POS) | 2023
Plan Overview for Peoples Health Choices Gold – An overview of plan benefits
Annual Notice of Changes for Peoples Health Choices Gold  – A summary of plan benefit changes compared to the previous year and other important plan details
Evidence of Coverage for Peoples Health Choices Gold – Information about plan benefits, membership, covered and noncovered services, member rights and responsibilities, and other important plan details
Summary of Benefits for Peoples Health Choices Gold – A general summary of plan benefits
Vendor Information – A listing of providers offering benefit-related services
Peoples Health Choices (PPO) | 2023
Plan Overview for Peoples Health Choices  – An overview of plan benefits
Annual Notice of Changes for Peoples Health Choices – A summary of plan benefit changes compared to the previous year and other important plan details
Evidence of Coverage for Peoples Health Choices – Information about plan benefits, membership, covered and noncovered services, member rights and responsibilities, and other important plan details
Summary of Benefits for Peoples Health Choices – A general summary of plan benefits
Vendor Information – A listing of providers offering benefit-related servicesÂ
Peoples Health Patriot (PPO) | 2023
Plan Overview for Peoples Health Patriot – An overview of plan benefits
Annual Notice of Changes for Peoples Health Patriot – A summary of plan benefit changes compared to the previous year and other important plan details
Evidence of Coverage for Peoples Health Patriot – Information about plan benefits, membership, covered and noncovered services, member rights and responsibilities, and other important plan details
Summary of Benefits for Peoples Health Patriot – A general summary of plan benefits
Vendor Information – A listing of providers offering benefit-related services
Peoples Health Secure Complete (HMO-POS D-SNP) | 2023
Plan Overview for Peoples Health Secure Complete – An overview of plan benefits
Annual Notice of Changes for Peoples Health Secure Complete – A summary of plan benefit changes compared to the previous year and other important plan details
Evidence of Coverage for Peoples Health Secure Complete – Information about plan benefits, membership, covered and noncovered services, member rights and responsibilities, and other important plan details
Summary of Benefits for Peoples Health Secure Complete – A general summary of plan benefits
Vendor Information – A listing of providers offering benefit-related services
Peoples Health Secure Health (HMO-POS D-SNP) | 2023
Plan Overview for Peoples Health Secure Health – An overview of plan benefits
Annual Notice of Changes for Peoples Health Secure Health – A summary of plan benefit changes compared to the previous year and other important plan details
Annual Notice of Changes for Peoples Health Secure Choice – A summary of plan benefit changes compared to the previous year and other important plan details
Evidence of Coverage for Peoples Health Secure Health – Information about plan benefits, membership, covered and noncovered services, member rights and responsibilities, and other important plan details
Summary of Benefits for Peoples Health Secure Health – A general summary of plan benefits
Vendor Information – A listing of providers offering benefit-related services
Peoples Health Group Medicare (HMO-POS) | 2023
Plan Overview for Peoples Health Group Medicare – An overview of plan benefits
Annual Notice of Changes for Peoples Health Group Medicare – A summary of plan benefit changes compared to the previous year and other important plan details
Evidence of Coverage for Peoples Health Group Medicare – Information about plan benefits, membership, covered and noncovered services, member rights and responsibilities, and other important plan details
Vendor Information – A listing of providers offering benefit-related services
Peoples Health Group Medicare (HMO-POS) for Office of Group Benefits (OGB) | 2023
Plan Overview for Peoples Health Group Medicare (HMO-POS) Office of Group Benefits (OGB) – An overview of plan benefits
Annual Notice of Changes for Peoples Health Group Medicare (HMO-POS) Office of Group Benefits (OGB) – A summary of plan benefit changes compared to the previous year and other important plan details
Evidence of Coverage for Peoples Health Group Medicare (HMO-POS) Office of Group Benefits (OGB) – Information about plan benefits, membership, covered and noncovered services, member rights and responsibilities, and other important plan details
Vendor Information – A listing of providers offering benefit-related services
Other Important Documents, Links and Forms | 2023
Authorization and Recertification Documents
Medical Necessity Form – For determining medical necessity to ensure that requested services are covered
Authorization Requirements Search – Identify authorization requirements for specific procedure codes by place of service
Home Health Agency Update/Recertification Form – To update home health services for members, as well as to request recertification for continuation of services
Electronic Funds Transfer Documents
Electronic funds transfer (EFT) is a free and secure way to receive faster claim payments. Note that to enroll in EFT, you must also receive electronic remittance advice (ERA). Complete the form below and return it to the email address provided on the form.
Sign up for ERA – search for payer ID 72126
Medicare-Required Notices
Member Detailed Notice of Discharge for Hospitals
Members in an inpatient care setting who appeal a discharge decision (by asking the Quality Improvement Organization (QIO) to review the decision) must receive a Detailed Notice of Discharge (DND) by noon of the day following the QIO’s notification to the hospital of the appeal.
Click the link below to download the DND. Detailed instructions for how to complete it are also available. You may also download the DND and instructions from the CMS website. CMS requires providers to comply with these instructions when completing and distributing the DND.
Instructions for the Detailed Notice of Discharge
Member Notice of Medicare Non-Coverage (NOMNC) for Skilled Nursing Facilities, Home Health Agencies, Comprehensive Outpatient Rehabilitation Facilities and Hospices
Medicare providers must deliver a completed copy of the Notice of Medicare Non-Coverage (NOMNC) to members receiving covered skilled nursing, home health (including psychiatric home health), comprehensive outpatient rehabilitation facility, or hospice services when the services are ending.
The NOMNC must be delivered at least two calendar days before Medicare-covered services end or the second-to-last day of service if care is not being provided daily. You should retain a copy of each completed NOMNC for your records, as we may request copies of any NOMNCs you distribute to your Peoples Health patients.
Click the link below to download the NOMNC. Detailed instructions for how to use, deliver and complete it are also available. You may also download the NOMNC and instructions from the CMS website. CMS requires providers to comply with these instructions when completing and distributing the NOMNC.
Notice of Medicare Non-Coverage
Instructions for the Notice of Medicare Non-CoverageÂ
Please note:Â You are responsible for populating the NOMNC with contact information for Peoples Health and the Louisiana quality improvement organization in the appropriate sections. For reference, this information is provided below:
Peoples Health contact information:
Peoples Health
Toll-free: 1-877-369-1907
TTY: 711
QIO contact information:
KEPRO
Toll-free: 1-888-315-0636
TTY: 711
Medicare Outpatient Observation Notice
Hospitals and critical access hospitals are required to provide a completed Medicare Outpatient Observation Notice (MOON) to members receiving observation services for more than 24 hours to inform the members that they are not an inpatient of the facility. The MOON must be provided no later than 36 hours after observation services begin. This includes members who are subsequently admitted as an inpatient prior to the required delivery of the MOON.
You may download the MOON and instructions from the CMS website. CMS requires facilities to comply with these instructions when completing and distributing the MOON.
You should retain a copy of each completed MOON for your records, as we may request copies of any you distribute to your Peoples Health patients.
The MOON is mandated by the Federal Notice of Observation Treatment and Implication for Care Eligibility Act (NOTICE Act), passed on August 6, 2015. The NOTICE Act requires hospitals and critical access hospitals to provide written and oral notification under specified guidelines. CMS requires that hospitals and critical access hospitals begin providing the MOON to members no later than March 8, 2017.
Member Important Message From Medicare
The Important Message from Medicare (IM) tells members who are hospital inpatients about their discharge appeal rights. Hospitals must give the IM to all inpatient members.
Click the link below to download the IM. Detailed instructions for how to complete it are also available. You may also download the IM and instructions from the CMS website. CMS requires providers to comply with these instructions when completing and distributing the IM.
Important Message From MedicareÂ
Instructions for the Important Message From Medicare
Please note: You are responsible for populating the IM with contact information for Peoples Health and the Louisiana quality improvement organization (QIO), including the name of the QIO, in the appropriate sections. For reference, this information is provided below:
Peoples Health
Toll-free: 1-877-369-1907
TTY: 711
QIO
KEPRO
Toll-free: 1-888-315-0636
TTY: 711
Part D Documents
2023 Medication Search – Search medications online
Prior Authorization Criteria – Detailed criteria for select covered drugsÂ
Step Therapy Criteria – Detailed criteria for select covered drugs
Medicare Part D Coverage Determination Request Form (for use by members and providers) – For requesting a decision on coverage of a prescription drug, including requesting prior authorization
Printable Form  [Updated 3/07/2019]
Request for Redetermination – For requesting a review of our coverage decision for a prescription drug
Translated Resources and Materials
Find resources to assist in offering culturally and linguistically appropriate services. Most of the materials are available in a variety of non-English languages, including Spanish, French and Vietnamese. The information is available in a variety of formats for office staff use, including to share with patients.
Download the Translated Resources and Materials document
Benefit Comparison Grids for Peoples Health Special Needs Plans
Information on what services are covered by our plan and what Louisiana Medicaid covers.Â
2023 Peoples Health Secure Health (HMO-POS D-SNP) and Louisiana Medicaid Benefits Comparison Chart
2023 Peoples Health Secure Complete (HMO-POS D-SNP) and Louisiana Medicaid Benefits Comparison Chart