Provider Plan Documents and Forms | 2018

Access important 2018 plan documents and forms—including coverage documents for each plan, the Medical Necessity Form and other important documents—on this page.

You must have Adobe Acrobat to view some of these documents. Click here to download Adobe Acrobat Reader.

Plan Coverage Documents

Peoples Health Choices 65 #14 (HMO)

Plan Overview for Peoples Health Choices 65 #14 – An overview of plan benefits

Annual Notice of Changes for Peoples Health Choices 65 #14 – A summary of plan benefit changes compared to the previous year and other important plan details

Annual Notice of Changes for Peoples Health Choices Platinum #009 (HMO) – A summary of plan benefit changes compared to the previous year and other important plan details

Evidence of Coverage for Peoples Health Choices 65 #14 – 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 #14 – A general summary of plan benefits

Peoples Health Choices 65 #14 (HMO) for St. Tammany Parish

Plan Overview for Peoples Health Choices 65 #14 for St. Tammany Parish – An overview of plan benefits

Annual Notice of Changes for Peoples Health Choices 65 #14 for St. Tammany Parish – A summary of plan benefit changes compared to the previous year and other important plan details

Evidence of Coverage for Peoples Health Choices 65 #14 for St. Tammany Parish – 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 #14 for St. Tammany Parish – A general summary of plan benefits

Peoples Health Choices Gold (HMO)

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

Peoples Health Choices Select (HMO)

Plan Overview for Peoples Health Choices Select – An overview of plan benefits

Annual Notice of Changes for Peoples Health Choices Select – A summary of plan benefit changes compared to the previous year and other important plan details

Evidence of Coverage for Peoples Health Choices Select – 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 Select – A general summary of plan benefits

Peoples Health Group Medicare (HMO-POS)

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

Peoples Health Group Medicare (HMO-POS) for Office of Group Benefits (OGB)

Plan Overview for Peoples Health Group Medicare for OGB – An overview of plan benefits

Annual Notice of Changes for Peoples Health Group Medicare for 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 for OGB – Information about plan benefits, membership, covered and noncovered services, member rights and responsibilities, and other important plan details

Peoples Health Secure Choice #011 (HMO SNP)

Annual Notice of Changes for Peoples Health Secure Choice #011 – A summary of plan benefit changes compared to the previous year and other important plan details

Evidence of Coverage for Peoples Health Secure Choice #011 – 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 Choice #011 – A general summary of plan benefits

Other Important Documents, Links and Forms

Authorization and Recertification Documents

Medical Necessity Form – For determining medical necessity to ensure that requested services are covered

Authorization Requirements Search – A detailed list of procedures that require authorization is on the back of the Medical Necessity Form; there are exceptions to the list, which can be determined by using this search

Home Health Agency Update/Recertification Form – To update home health services for members, as well as to request recertification for continuation of services

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 websiteCMS requires providers to comply with these instructions when completing and distributing the DND.

Detailed Notice of Discharge

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 websiteCMS 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-Coverage  

Please note: 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
Three Lakeway Center
3838 N. Causeway Blvd., Suite 2200
Metairie, LA 70002
Toll-free: 1-800-222-8600
TTY: 711

QIO contact information:
KEPRO
Toll-free: 1-844-430-9504

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.

Click the link below to download the MOON. Detailed instructions for how to use, deliver and complete it are also available. You may also download the MOON and instructions from the CMS websiteCMS requires facilities to comply with these instructions when completing and distributing the MOON.

Medicare Outpatient Observation Notice 

Instructions for the Medicare Outpatient Observation Notice

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 CAHs to provide written and oral notification under specified guidelines. CMS requires that hospitals and CAHs begin providing the MOON to members no later than March 8, 2017.

Part D Documents

2018 Medication Search Search medications online

2018 Comprehensive Formulary – A complete list of covered drugs

2018 Prior Authorization Criteria– Detailed criteria for select covered drugs

2018 Step Therapy Criteria – Detailed criteria for select covered drugs

Request for Redetermination of Medicare Prescription Drug Denial Form – To request reconsideration of our decision on how we will cover or pay for a prescription drug

Request for Medicare Prescription Drug Coverage Determination Form – To request a decision on coverage of a prescription drug; you also have the option to request a coverage determination by completing a form through the CMS website

Documents for Out-of-Network Providers

Waiver of Liability Statement  Must be completed by out-of-network providers and submitted with any appeal related to a payment denial

Other Resources

2018 Peoples Health Special Needs Plans (SNPs) and Louisiana Medicaid Benefit Comparison Chart – A comparison of Peoples Health SNP benefits and Louisiana Medicaid benefits