Provider Plan Documents and Forms | 2022
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2022 Plan Coverage Documents
Peoples Health Choices 65 (HMO) Greater New Orleans and Baton Rouge Area | 2022
Plan Overview for Peoples Health Choices 65 – An overview of plan benefits
For members with permanent residence in East Baton Rouge, Jefferson or Orleans parish:
Annual Notice of Changes for Peoples Health Choices 65 Greater New Orleans and Baton Rouge Area – A summary of plan benefit changes compared to the previous year and other important plan details
For members with permanent residence in Ascension, East Feliciana, Iberville, Livingston, St. Charles, St. Helena or West Baton Rouge parish:
Annual Notice of Changes for Peoples Health Choice 65 Rural Southeast to Greater New Orleans and Baton Rouge Area – A summary of plan benefit changes compared to the previous year and other important plan details
Evidence of Coverage for Peoples Health Choices 65 – 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 – A general summary of plan benefits
Vendor Information – A listing of providers offering benefit-related services for your plan
Peoples Health Choices 65 (HMO) Northshore | 2022
Plan Overview for Peoples Health Choices 65 – An overview of plan benefits
Annual Notice of Changes for Peoples Health Choices 65 – A summary of plan benefit changes compared to the previous year and other important plan details
Evidence of Coverage for Peoples Health Choices 65 – 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 – A general summary of plan benefits
Vendor Information – A listing of providers offering benefit-related services for your plan
Peoples Health Choices 65 (HMO) Southland | 2022
Plan Overview for Peoples Health Choices 65 – An overview of plan benefits
Annual Notice of Changes for Peoples Health Choices 65 – A summary of plan benefit changes compared to the previous year and other important plan details
Evidence of Coverage for Peoples Health Choices 65 – 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 – A general summary of plan benefits
Vendor Information – A listing of providers offering benefit-related services for your plan
Peoples Health Choices 65 (HMO) Rural Southeast | 2022
Plan Overview for Peoples Health Choices 65 – An overview of plan benefits
For members with permanent residence in Plaquemines, Pointe Coupee, St. Bernard, St. James, St. John the Baptist or West Feliciana parish:
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
For members with permanent residence in Ascension, East Feliciana, Iberville, Livingston, St. Charles, St. Helena or West Baton Rouge parish:
Annual Notice of Changes for Peoples Health Choice 65 Rural Southeast to Greater New Orleans and Baton Rouge Area – A summary of plan benefit changes compared to the previous year and other important plan details
Evidence of Coverage for Peoples Health Choices 65 – 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 – A general summary of plan benefits
Vendor Information – A listing of providers offering benefit-related services for your plan
Peoples Health Choices Gold (HMO) | 2022
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
Annual Notice of Changes for Peoples Health Choices Value – 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 for your plan
Peoples Health Choices (PPO) | 2022
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 services for your plan
Peoples Health Patriot (PPO) | 2022
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 for your plan
Peoples Health Group Medicare (HMO-POS) | 2022
Plan Overview for Peoples Health Group Medicare – An overview of plan benefits
Annual Notice of Changes for Group Medicare – A summary of plan benefit changes compared to the previous year and other important plan details
Evidence of Coverage for 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 for your plan
Peoples Health Group Medicare (HMO-POS) Office of Group Benefits (OGB) | 2022
Plan Overview for Peoples Health Group Medicare Office of Group Benefits (OGB) – An overview of plan benefits
Annual Notice of Changes for Peoples Health Group Medicare 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 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 for your plan
Peoples Health Secure Choice (HMO D-SNP) | 2022
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 Choice – 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 – A general summary of plan benefits
Vendor Information – A listing of providers offering benefit-related services for your plan
Peoples Health Secure Complete (HMO D-SNP) | 2022
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 for your plan
Peoples Health Secure Health (HMO D-SNP) | 2022
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
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 for your plan
Other Important Documents, Links and Forms | 2022
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 Â
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
Three Lakeway Center
3838 N. Causeway Blvd., Suite 2500
Metairie, LA 70002
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.
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 website. CMS requires facilities to comply with these instructions when completing and distributing the MOON.
Medicare Outpatient Observation NoticeÂ
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 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
2022 Medication Search – Search medications online
Prior Authorization Criteria – Detailed criteria for select covered drugs
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
2022 Peoples Health Secure Health (HMO D-SNP) and Louisiana Medicaid Benefits Comparison ChartÂ
2022 Peoples Health Secure Choice (HMO D-SNP) and Louisiana Medicaid Benefits Comparison ChartÂ
2022 Peoples Health Secure Complete (HMO D-SNP) and Louisiana Medicaid Benefits Comparison ChartÂ