Decisions About Coverage

Be assured that Peoples Health makes decisions about coverage for health care services as such:

1. Utilization management decision-making is based only on medical necessity, appropriateness of care and services, and existence of coverage.
2. Peoples Health does not reward practitioners or other individuals for issuing denials of coverage.
3. 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.