Be assured that Peoples Health makes decisions about coverage for health care services as such:
- Utilization management decision-making is based only on medical necessity, appropriateness of care and services, and existence of coverage.
- Peoples Health does not reward practitioners or other individuals for issuing denials of coverage.
- Financial incentives for utilization management decision-makers do not encourage decisions that result in underutilization.
As a reminder, 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 medical necessity criteria, Medicare guidelines and/or Peoples Health 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.