We transitioned our claims processing and portal platforms to UnitedHealthcare systems at the start of this year. Thank you for your participation and willingness to work with us through the transition. We have tools available to help ensure your continued success in using these platforms. Our provider team can also answer questions.
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Take a moment to review the important process changes highlighted below.
Service Ordering and Authorizations
An order and supporting clinical information are required for patient services, as is authorization for any service requiring precertification. As part of our integration with the UnitedHealthcare claims system, we have new processes for providing information.
Ordering providers are responsible for sending orders and supporting clinical information to servicing providers, as applicable, and servicing providers are responsible for submitting authorization requests for ordered services, as applicable.
Read more in the steps outlined in these guides:
- Outpatient Services for Peoples Health Patients: Ordering and Authorization Process
- Acute Inpatient, Post-Acute Inpatient and Post-Discharge Services for Peoples Health Patients: Authorization and Ordering Process (Hospitals)
- Post-Acute Inpatient and Post-Discharge Services for Peoples Health Patients: Authorization and Ordering Process (Post-acute care facilities)
Submitting Authorization Requests
Be sure to follow our new processes for submitting prior authorization requests for 2024 dates of service, including referencing patients’ 2024 plan member ID number and using payer ID 87726. Note that ID numbers changed for all members who were enrolled in a Peoples Health plan last year.
- For outpatient injectable chemotherapy, cancer-supportive drugs and therapeutic radiopharmaceuticals, visit mbm.linkplatform.com/home.
- For all other authorization requests, sign in to the UnitedHealthcare Provider Portal. Click Prior Authorizations, and use the Check by Member tool to confirm authorization requirements, which have changed for some services. Create a new request when ready to submit.
- A PDF of codes that require authorization is also available. Visit the Advance Notification and Clinical Submission Requirements page, and open the drop down-menu UnitedHealthcare Medicare Advantage, UnitedHealthcare West Medicare Advantage, and UnitedHealthcare Dual Complete/Peoples Health Prior Authorization Requirements. Click the file linked under Current Prior Authorization Requirements.
Need to submit a request for 2023 or prior dates of service?
You must submit the request through the Peoples Health Provider Portal and use payer ID 72126, along with the patient’s 2023 member ID number.
Determining D-SNP Cost-Sharing
Per your provider contract, you may not balance bill your Peoples Health patients enrolled in a dual-eligible special needs plan (D-SNP) for Medicare cost-sharing, and you may not collect cost-sharing from patients in certain Medicaid programs, as some programs help pay Medicare premiums, deductibles, coinsurance and copays.
To find out if you can collect cost-sharing from a patient enrolled in a D-SNP, follow these steps:
- Conduct an eligibility search for the patient through the UnitedHealthcare Provider Portal.
- Review the Policies tab on the results page.
- The number shown in the Group field can help determine whether the patient has full or partial Medicaid:
| Group # for patients with partial Medicaid | Group # for patients with full Medicaid | |
| Peoples Health Secure Health (HMO-POS D-SNP) | 78011 | 78001 |
| Peoples Health Secure Complete (HMO-POS D-SNP) | 78012 | 78008 |
- Then refer to the Detailed Benefits tab on the results page.
- Search for the benefit and read the detailed benefit description, which includes information about the costs for patients with partial Medicaid, as well as those with full Medicaid or who are enrolled as a Qualified Medicare Beneficiary with Medicaid.
Medicaid status can change frequently. Verify status prior to every visit with a patient in a D-SNP.
