GHP Family Provider Manual - Geisinger Health Plan

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provides the non-assigning party(s) with thirty (30) days prior written notice of said assignment.B. Compliance. The parties agree to comply with all applicable federal and state laws and rules including, but notlimited to (i) Title VII of the Civil Rights Act of 1964; (ii) The Age Discrimination Act of 1975; (iii) The RehabilitationAct of 1973; (iv) The Americans With Disabilities Act; (v) other laws applicable to recipients of Federal funds; (vi)Medicare laws, regulations and Centers for Medicare and Medicaid Services (“CMS”) instructions; (vii) Patients’ billof Rights in accordance with OPM; (viii) the Genetic Information Nondiscrimination Act of 2008; (ix) HealthInsurance Portability and Accountability Act of 1996 (HIPAA); and all other applicable laws and rules. Furthermore,Participating Provider hereby warrants and represents that it shall comply and shall be responsible for requiring anyparty that it may subcontract with to furnish services to Members to comply with GHP Family’s policies andprocedures and all other terms and conditions of the Agreement. Additionally, it is hereby disclosed that paymentsmade by GHP Family to related entities, contractors and subcontractors are, in whole or in part, from federal fundsreceived by the GHP Family through its contracts with the Centers for Medicare and Medicaid Services.C. Entire Agreement/Amendments/Multiple Originals. The Agreement, together with any attachments, exhibits, orapplicable Provider Manual(s), as amended from time to time, set forth the entire Agreement between the parties withrespect to the subject matter. Any prior purchase orders, agreements, promises, negotiations or representations, whetheroral or written, not expressly set forth in the Agreement, are of no force or effect. The Agreement shall be executed inmultiple originals, one for Participating Provider and the other for GHP Family. The parties agree that the Agreementshall be automatically amended to comply with applicable federal and state laws and regulations; otherwise, theAgreement may not be amended except in writing, signed by the parties.D. Exhibits. All exhibits within the Agreement are incorporated by reference and made part of the Agreement as if theywere fully set forth in the text of the Agreement.E. Governing Law. The Agreement shall be deemed to have been made and shall be construed and interpreted inaccordance with the laws of the Commonwealth of Pennsylvania, and the parties hereto agree to the jurisdiction of theCommonwealth of Pennsylvania.F. Indemnification. Participating Provider and GHP Family agree to protect, indemnify and hold harmless the otherparty(s) from and against any and all loss, damage, cost and expense (including attorneys’ fees) which may be sufferedor incurred under the Agreement as a result of the negligent or intentional acts of the indemnifying party, its employees,agents, consultants or subcontractors. Said indemnity is in addition to any other rights that the indemnified party mayhave against the indemnifying party and will survive the termination of the Agreement.G. Insurance. The parties agree to maintain, at its own cost and expense, insurance coverage as necessary andreasonable to insure itself and its employees and agents in connection with the performance of its duties andresponsibilities under the Agreement. Upon request, the parties agree to provide one another with a Certificate ofInsurance evidencing said insurance coverage. Participating Provider shall notify GHP Family within ten (10) days ofthe cancellation or material alteration of such coverage.H. Notices. All notices and communications hereunder shall be in writing and deemed given, when personallydelivered to or upon receipt when deposited with the United States Postal Service, certified or registered mail, returnreceipt requested, postage prepaid; a nationally recognized overnight courier, with all fees prepaid; or e-mail addressedas set forth on the first page of the Agreement or to such other person and/or address as the party to receive maydesignate by notice to the other.I. Notification of Incidents. The parties agree to notify the other party (s) within twenty-four (24) hours after thediscovery of any incidents, occurrences, Claims or other causes of action involving the Agreement. Upon receipt of13
discovery by any party of any incident, occurrence, Claim (either asserted or potential), notice of lawsuit or lawsuitinvolving the Agreement, said party agrees to immediately notify the other party(s). The parties hereto agree to providecomplete access, as may be provided by law, to records and other relevant information as may be necessary or desirableto resolve such matters. This Section shall survive the termination of the Agreement.J. Other Parties. The Agreement is solely between the parties hereto and is not intended to be enforceable by any otherparty or to create any express or implied rights hereunder of any nature whatsoever in any other party.K. Partial Invalidity/Interpretation. If any term or provision of the Agreement is determined to be invalid orunenforceable, the remainder of the Agreement will not be affected thereby. The section headings in the Agreement aresolely for reference purposes. Participating Provider acknowledges that portions of the Agreement are subject to reviewby Governmental Agencies and/or their designated representatives, as applicable, and in the event that suchGovernmental Agencies and/or their designated representatives require any material change to the terms and conditionsof the Agreement, Participating Provider agrees to renegotiate the affected terms and conditions upon being notified ofsuch required change by GHP Family.L. Promotional Materials. Participating Provider consents to GHP Family’s use of its name, address and the namesand professional designations of its healthcare professionals in traditional membership and marketing materials. Theparties hereto agree not to use the name of or any trademark, service mark or design registered to the other parties ortheir affiliates or any other party in any additional publicity, promotional or advertising material, unless review andwritten approval of the intended use shall first be obtained from the releasing party(s) prior to the release of any suchmaterial. Said approval shall not be unreasonably withheld by any of the parties. Notwithstanding anything to thecontrary in the preceding sentences, GHP Family shall have the right to publish Participating Provider’s summaryrating as part of GHP Family’s Physician Quality Summary Program without obtaining the consent by ParticipatingProvider prior to the release of such rating.M. Relationship Among Parties. The parties hereto expressly acknowledge and agree that: (i) GHP Family’s dutiesand responsibilities under the Agreement apply solely to GHP Family Members; (ii) in its capacity as third partyadministrator, Company’s duties and responsibilities under the Agreement apply to Members of an Employer-Sponsored Program; and (iii) with the exception of (ii) of this Section, Company’s duties and responsibilities under theAgreement apply to Company Members. Each party hereto shall be considered independent entities with respect to eachother. None of the provisions of the Agreement are intended to create nor shall be deemed or construed to create anyrelationship between the parties other than that of independent entities contracting with each other solely for thepurpose of effecting the provisions of the Agreement. Neither the parties nor any of their respective agents oremployees shall be construed to be the agent, employee, joint Employer or representative of the other. The partiesshall not have any express or implied rights or authority to assume or create any obligation or responsibility on behalfof or in the name of the other, except as may be otherwise set forth in the Agreement.N. Release of Information. The provisions of the Agreement are confidential and protected from disclosure to anyother party unless: (i) otherwise provided for in the Agreement; (ii) disclosure is required by GHP Family, an Employeror Participating Provider to meet any federal, state or local rule, law or regulation; or (iii) any party hereto engages athird party for purposes such as quality assurance or auditing.O. Unforeseen Circumstances. In the event either party’s operations are substantially interrupted by war, fire,insurrection, the elements, earthquakes, acts of God or, without limiting the foregoing, any other cause beyond thecontrol of the affected party (including the GHP Family no longer meeting all material requirements imposed on GHPFamily by Federal or State law resulting in a significant impact on the GHP Family’s operations), the affected partyshall be relieved of its obligations only as to those affected portions of this Agreement for the duration of suchinterruption. In the event that the performance of the affected party hereunder is substantially interrupted pursuant tosuch event, the other party shall have the right to terminate this Agreement upon ten (10) days’ prior written notice to14
Page 1 and 2: HealthChoices Provider ManualRevise
Page 3 and 4: Case Management 23Complement the Ca
Page 7 and 8: CONTACT INFORMATIONAll paper Claims
Page 9 and 10: Name Phone Number Hours of Operatio
Page 11 and 12: County Behavioral Health Plan Phone
Page 13: County Local Phone Number Toll Free
Page 17 and 18: Assignment of NewbornsNewborns are
Page 19 and 20: AllSCP:OtolaryngologyDermatologyPed
Page 22 and 23: • Report any unusual or group exp
Page 24 and 25: MEDICAL MANAGEMENT & PRIOR AUTHORIZ
Page 26 and 27: • Coronary Artery Disease (CAD)Ma
Page 28 and 29: Risk stratificationCase Managers/He
Page 30 and 31: If additional information is needed
Page 32 and 33: Prior to a planned inpatient admiss
Page 34 and 35: Preferred Modes of Data Submission
Page 36 and 37: Member is admitted to a Nursing Fac
Page 38 and 39: A Participating Provider rendering
Page 40 and 41: phone to the Medical Management Dep
Page 42 and 43: Completing Medical Management Depar
Page 44 and 45: (800) 270-9981 or (570) 271-5301Fax
Page 46 and 47: GHP Family will assist Members in a
Page 48 and 49: Pharmacy Department(855) 552-6028 o
Page 50 and 51: A GHP Family Pharmacist will perfor
Page 52 and 53: • New prescriptions for atypical
Page 54 and 55: Requesting PrecertificationRequests
Page 56 and 57: Network AccessGHP Family Members ha
Page 58 and 59: Requirements for Medicaid Maternity
Page 60 and 61: • Continue a Member restriction f
Page 62 and 63: Covered ServicesPlease note the inf
Page 64 and 65:
Covered ServicesPlease note the inf
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Page 68 and 69:
Page 70 and 71:
Page 72 and 73:
• Antineoplastics (cancer drugs)
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• Smear, primary source, with int
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Payment for Medically Necessary Ser
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GHP Family will neither unreasonabl
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• Name and address of facility wh
Page 82 and 83:
DPW defines “Complaint” and “
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Second Level45 days from the date t
Page 86 and 87:
Timeframes for Resolution of Compla
Page 88 and 89:
and make a determination. If the pr
Page 90 and 91:
arrangements for personal interpret
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• Documenting requests and action
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employee, or a Member, among others
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PROVIDER SELF-AUDIT PROTOCOLThe Pen
Page 98 and 99:
• Agreement termination by the GH
Page 100 and 101:
Early and Periodic Screening, Diagn
Page 102 and 103:
Medically Necessary or Medical Nece
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GHP Family Provider Manual - Geisinger Health Plan

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