GHP Family Provider Manual - Geisinger Health Plan

Practitioner’s RightsPractitioners who care for Members have the right to:• Obtain information regarding Case Management/Disease Management programs and services inconjunction with GHP Family as outlined herein; and• Obtain information regarding the qualifications of the Case Management staff; and• Obtain information regarding how the Case Management staff facilitates interventions via treatmentplans for individual Members; and• Know how to contact the Case Managers/Health Managers responsible for managing andcommunicating with their patients; and• Request the support of the Case Manager/Health Manager to make decisions interactively withMembers regarding their health care; and• Receive courteous and respectful treatment from Case Management staff at all times; and• File a Complaint when dissatisfied with any component of the Case Management/Health Managementprograms by contacting the Case Management Department at (570) 271-8763, toll free at (800) 883-6355, or the customer service team at the number listed on your patient’s insurance card.PRIOR AUTHORIZATION (PRECERTIFICATION)Precertification is GHP Family’s response to information presented relating to a request for specified health careservices.Precertification does not guarantee a Member’s coverage or GHP Family payment.A Member’s coverage is pursuant to the terms and conditions of coverage set forth in a Member’s applicable benefitdocument. Please contact the Customer Service Department (CST) at (855) 227-1302 for verification of precertificationrequirements.A Member is not financially responsible for a Participating Provider’s failure to (i) obtain precertification, or (ii)provide required and accurate information to GHP Family. Copayments are the financial responsibility of the Member,when applicable.A complete list of services requiring Prior Authorization is available online at www.GHPfamily.com.Precertification Determination and Communication ProcessPrecertification of services may be required and will be performed by GHP Family Medical Management staff, orthrough delegated vendor relationships. Delegated vendors may review services such as, but not be limited to,radiology, and non-emergent ambulance transportation.Precertification staff, which includes appropriate practitioner reviewers, utilizes nationally recognized medicalguidelines as well as internally developed medical benefit policies, individual assessment of the Member, and otherresources to guide precertification, Concurrent Review, and Retrospective Review processes in accordance with theMember’s eligibility and benefits.Upon submission of required information, the precertification staff will provide the Member, the Member’s PCP andthe prescribing provider with notification of the determination of coverage as expeditiously as the Member’s healthcondition requires, or at least orally, within two (2) Business Days of receiving the request, unless additionalinformation is needed. If no additional information is needed, GHP Family will mail written notice of the decision tothe Member, the Member’s PCP, and the prescribing provider within two (2) Business Days after the decision is made.28