GHP Family Provider Manual - Geisinger Health Plan

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ContentsABOUT GEISINGER HEALTH PLAN FAMILY 5CONTACT INFORMATION 6PROVIDER RESPONSIBILITIES 12GENERAL PROVISIONS 12PRIMARY CARE PROVIDERS (PCP) 15MEMBER ASSIGNMENT TO PCP 15Assignment of Newborns 16CHANGING PCPS 16SPECIALTY CARE PROVIDERS (SCP) 16SCP AS PCP 17APPOINTMENT STANDARDS 17PCP WAIT TIMES 19APPOINTMENT NOTIFICATION AND FOLLOW-UP 19EARLY PERIODIC SCREENING, DIAGNOSIS, and TREATMENT (EPSDT) 19SCHOOL-BASED HEALTH SERVICES 20SUSPECTED CHILD ABUSE OR NEGLECT 20REPORTABLE CONDITIONS 20INFECTION CONTROL MEASURES 21RETURN COMMUNICATION 21PCP PRACTICE ACCEPTANCE STATUS AND MEMBER LIMITATIONS 21REFERRALS 21DIRECT ACCESS AND SELF-REFERRAL 22SUBSTANCE ABUSE AND BEHAVIORAL HEALTH REFERRALS 22MEDICAL MANAGEMENT & PRIOR AUTHORIZATIONS 23MEDICAL MANAGEMENT PLAN 23QUALITY MANAGEMENT PLAN 23POPULATION MANAGEMENT PROGRAMS 23
Case Management 23Complement the Care provided by the PCP and/or SCP 24Disease Management Program Development 25Practitioner Program Content 26Enrollment and Patient Participation 26Risk stratification 27Interventions 27Practitioner decision support 27Evaluation of program effectiveness 27Practitioner’s Rights 28PRIOR AUTHORIZATION (PRECERTIFICATION) 28Inpatient Hospitalization 30Inpatient Rehabilitation Admissions 33Skilled Level of Care Admissions 34Home Health/Hospice, Home Infusion and Home Phlebotomy Services 37Durable Medical Equipment (“DME”) 40Outpatient Physical, Occupational and Speech Therapy Services 42Outpatient Radiology and Imaging Services 43Ambulance 44Specialty Pharmacy Vendor Program 46Outpatient Prescription Drugs 47Pharmacy Formulary Prior Authorization and non-Formulary Exception Process 47Outpatient Laboratory and Radiology Services 49Urgent/Emergency Services 50Orthotic and Prosthetic Service 50Behavioral Health and Substance Abuse Services 50Outpatient Dialysis Services 51Experimental/Investigational or Unproven Services 51Transplant Services 52Vision Services 52Other Services Requiring Precertification 52MATERNAL HEALTH PROGRAM (Including Healthy Beginnings Plus) 53
Page 1: HealthChoices Provider ManualRevise
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 and 14: County Local Phone Number Toll Free
Page 15 and 16: discovery by any party of any incid
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:
Page 66 and 67:
Page 68 and 69:
Page 70 and 71:
Page 72 and 73:
• Antineoplastics (cancer drugs)
Page 74 and 75:
• Smear, primary source, with int
Page 76 and 77:
Payment for Medically Necessary Ser
Page 78 and 79:
GHP Family will neither unreasonabl
Page 80 and 81:
• Name and address of facility wh
Page 82 and 83:
DPW defines “Complaint” and “
Page 84 and 85:
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
Page 92 and 93:
• Documenting requests and action
Page 94 and 95:
employee, or a Member, among others
Page 96 and 97:
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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