GHP Family Provider Manual - Geisinger Health Plan

Authorization Required for PaymentAny service, with or without an authorization, rendered by a Participating Provider and determined to be clinicallyinappropriate by the Medical Director will be paid at an appropriate alternate level of care or payment will be deniedcompletely. Medical Director determinations are in accordance with individual Member’s needs, characteristics of thelocal delivery system, applicable medical criteria and clinical expertise. At the time of a claim payment denial, theParticipating Provider is verbally notified of the option to speak with a Medical Director regarding such paymentdenial. The Provider Appeal process is also available to Participating Providers for claims payment issues.Medical Benefit PoliciesA medical policy is the written description of GHP Family’s position concerning the use or application of a biologic,device, pharmaceutical, or procedure, based on any or all of the following: Regulatory guidelines, clinical practiceguidelines, nationally accepted standards, and the findings and conclusions drawn from a complete TechnologyAssessment (TA). Additionally, a medical policy is an informational resource that establishes the Medical Necessitycriteria for the biologic, device, pharmaceutical, or procedure. It also functions as an informational resource bydescribing any special requirements for Claims processing.New and revised medical benefit policies, which include services deemed to require precertification, are communicatedin the quarterly provider newsletter, Briefly. Briefly is accessible online at www.ghpfamily.com, or a hard copy may beobtained from your Provider Relations Representative. A minimum of thirty (30) days advance notice is providedregarding those services, which have been added to GHP Family’s precertification list. For a current listing refer to theGHP Family web site at www.ghpfamily.com.Participating Providers with questions about the above medical policies can contact theMedical Management Department at the number listed below:Monday through Friday 8:00 a.m. to 4:30 p.m.(800) 544-3907 or (570) 271-6497Fax: (570) 271-5534Verification of Eligibility and Benefit LimitPrior to coordinating health care services, a Member’s eligibility and benefits should always be verified through theonline Provider Service Center at www.ghpfamily.com (registration required; contact your Provider RelationsRepresentative to register) or by contacting the DPW Eligibility Verification System (EVS) at (800) 766-5EVS (5387),or by calling the applicable Customer Service Team. Providers, acting upon a referral from the Member’s PCP, shouldcontact the GHP Family Customer Service Team at (855) 227-1302 to verify eligibility and benefits.Except in an Emergency or as otherwise permitted in accordance with the terms and conditions of coverage set forth ina Member’s benefit document, all healthcare services for a Member must be provided by and rendered in a ParticipatingProvider or must be approved in advance by the GHP Family Medical Director.Inpatient HospitalizationRequests for precertification of a planned inpatient hospital admission are the responsibility of the admittingParticipating Provider.Requesting Precertification30