GHP Family Provider Manual - Geisinger Health Plan

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MEDICAL MANAGEMENT & PRIOR AUTHORIZATIONSMEDICAL MANAGEMENT PLANThe Medical Management Plan defines and clarifies the structure and function of the Medical ManagementDepartment. This document provides a definition of authority and accountability for medical management activitieswithin the organization, articulates the scope and content of the Medical Management program, identifies the roles andresponsibilities of individuals involved, and outlines the program evaluation process.A copy of the complete MM Plan can be requested from GHP Family's Medical Management Department.QUALITY MANAGEMENT PLANThe Geisinger Health System’s mission is to enhance the quality of life through an integrated health serviceorganization based on balanced patient care, education, research, and community service. GHP Family supports theoverall mission of Geisinger Health System. The GHP Family Quality Management (QM) Plan provides the structureand processes for continuously monitoring, analyzing, and improving the clinical care and services provided underGHP Family products in order to further that mission.The scope of the QM Plan is comprehensive in nature, allowing for improvement, and is consistent with the DPW’sgoals related to access, availability, and quality of care.A copy of the complete QM Plan can be requested from GHP Family's Quality Improvement Department.POPULATION MANAGEMENT PROGRAMSGHP Family’s Case Management Department offers Population Management Programs for Members across thehealthcare continuum including Case Management and Disease Management programs to assist Members with chronicconditions.GHP Family’s Case Management Department engages patients as part of a collaborative process that assesses, plans,implements, coordinates, monitors, and evaluates the options and services required to meet an individual’s health needs,using communication and available resources to promote quality and cost-effective outcomes.GHP’s Family Case Management Department is responsible for the delivery of Case Management/DiseaseManagement programs to Insured Individuals. GHP Family provides the following services and programs.Case ManagementCase Managers work in collaboration with the PCP to manage patients with complex co-morbid conditions.The Case Manager completes a comprehensive assessment and prioritizes the patient’s needs that allow theprovider, Member and/or Member representative, and Case Manager to develop a patient centric plan of careand self-management action plan. Post discharge transitions of care are integral to this patient centered modeland include: medication reconciliation, confirmation that services are in place i.e. home health and durablemedical equipment, and that there is adequate social support in place. Case Managers facilitate a five (5) toseven (7) day follow-up appointment with the PCP as this is essential to the continuity of care.23
For advanced illness, case managers will facilitate palliative care, home health and hospice referrals and thePhysician Orders for Life-Sustaining Treatment (POLST) form, if appropriate. Contact your ProviderRelations Representative for a supply of this form. Advanced directives are facilitated for all Members and arediscussed further in the Advanced Directives section of this manual.Heart failure and COPD are progressive conditions that are managed by case managers in collaboration withthe PCP/SCP.• Heart FailureAn ongoing combination of education and management that provides patient education and activation,teaching Members the importance of medications, symptom monitoring that includes daily weights andexacerbation management. Diuretic protocols may be implemented as part of the treatment plan thatcan be initiated by the Member or family, if determined appropriate by the provider. Diet and life-stylehabits are also part of the education process to improve the management of heart failure. Overall effortis to manage the condition and improve the Member’s quality of life.• Chronic Obstructive Pulmonary Disease (COPD)The Chronic Obstructive Pulmonary Disease (COPD) Program helps Members with COPD to bettermanage the condition through the inclusion of pulmonary function testing, education, medicationmanagement and symptom monitoring including COPD Rescue Kits, if appropriate, in the treatmentplan. Information about tobacco cessation and life-style modification is provided by a Case Manager.Complement the Care provided by the PCP and/or SCPCase Managers/Health Managers work with Members and the PCP/SCP to assist Members in the communitywith chronic health/social problems. The Case Managers/Health Managers also provides monitoring andeducation to help Members better manage the following health conditions: The following programs areavailable for all Members:• Adult and Pediatric AsthmaEducation is a key factor in the Asthma Care Program. Nurse Case Managers/Health Managers workwith Members and their families to help them understand and manage asthma triggers and symptomsand adhere to treatment plans. Case Managers/Health Managers work with Members to educate themabout medications, proper use of inhalers, spacers, nebulizers, and peak flow monitoring. The CaseManager/Health Manager collaborates with the PCP/SCP to develop an individualized Asthma ActionPlan with the Member.• Chronic Kidney Disease (CKD)The purpose of the CKD program is to improve the coordination of appropriate services with a PCP ornephrologist for Members with kidney disease. Case Managers/Health Managers provide educationabout the importance of proper nutrition, medications, blood pressure control, and other importanthealth care information.• DiabetesMembers in the Diabetes Care Program work with a Case Manager/Health Manager who provideseducation including: pathophysiology, medications, dietary management, exercise and other self-carestrategies that will assist Members in taking control of their diabetes. The Case Managers/HealthManagers coordinate services for Members that facilitate standards of care and HEDIS® measures toensure quality.24
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 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 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 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
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DPW defines “Complaint” and “
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Second Level45 days from the date t
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Timeframes for Resolution of Compla
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and make a determination. If the pr
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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
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• Agreement termination by the GH
Page 100 and 101:
Early and Periodic Screening, Diagn
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Medically Necessary or Medical Nece
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GHP Family Provider Manual - Geisinger Health Plan

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