Peoples Health Authorization Requirements Search
Click
here if you have problems viewing the search options below.
This search tool allows you to identify authorization requirements for specific procedure codes by place of service for contracted providers.
Please note: Any service that cannot be provided
in network requires authorization, except for members of Peoples Health preferred provider organization (PPO) plans. However, please note that out-of-network services for PPO plan members must still be reviewed for medical necessity.
Use the options below to define your search.
Search Results Key
- Y – Prior authorization required for services rendered in this place of service
- Submit authorization requests for injectable chemotherapy, cancer-supportive drugs and therapeutic radiopharmaceuticals to the Optum® Cancer Guidance Program through its MBMNow platform,
available through the
Provider Portal. Log in to
Provider Portal and click the
Authorizations tab, then click the Cancer Treatment icon to be redirected to the MBMNow website.*
- Submit authorization requests for oral chemotherapy drugs to OptumRx.
- Submit authorization requests for all other services by logging in to
Provider Portal and clicking the
Authorizations tab. If you do not have the ability to submit requests through Provider Portal, complete a
Medical Necessity Form and fax it to us.
N – No authorization required for services rendered in this place of service for contracted providers
** – Not applicable; the code should not be billed for this place of service per
American Medical Association coding guidelines
Place-of-Service Key
- Telecomunications (remote) – 02
- Physician office or approved provider-based clinic – 11
- Outpatient surgery or services – 19/22
- Ambulatory surgery center – 24
- All services in locations 12 and 32 require authorization.
For highlighted codes, please refer to the comments.
If no results are provided,
contact us, and
we will ensure that the search function is up-to-date.
Authorization information does not guarantee payment, as services must be medically
necessary. Special authorization configurations that are indicated in individual
contracts or agreements will not be indicated on this search. For more information, contact your provider representative at 1-800-631-8443, Monday through Friday, from 8 a.m. to 5 p.m.
Services requiring prior authorization are screened against medical necessity criteria, Medicare guidelines and/or Peoples Health policy. Procedures that do not require initial medical necessity review must still meet these criteria, guidelines and/or policy, and are subject to retrospective review. To request medical necessity criteria for a specific procedure, contact our medical management department at 1-866-553-5705.
*If you already have an MBMNow account for another health plan, it will work for Peoples Health patients, as long as you are accessing the MBMNow website from the link located within your People Health Provider Portal account, as described above; on the MBMNow website, click Sign in and select the One Healthcare ID icon to login. If you do not already have an MBMNow account, you can create one through the self-registration link on the MBMNow website, as accessed through the link within your People Health Provider Portal account.
System Refresh Date:
6/28/2022