GHP Family Provider Manual - Geisinger Health Plan

Department will complete a clinical review and authorize or deny the admission retrospectively pursuant to theMember’s condition at the time of the admission.Concurrent ReviewParticipating Providers are required to contact the Medical Management Department within one (1) Business Day ofany inpatient rehabilitation admission at (800) 544-3907 to verify admission and establish the next review date. Eachrehabilitation admission is subject to the Concurrent Review process.During Concurrent Review a determination of continued coverage and a subsequent assigned Concurrent Review datewill be provided by the Medical Management Department staff. The following information will be discussed during theinitial Concurrent Review:• current inpatient care needs• plan of care• overall goals and anticipated length of stay (if known)• discharge planningSkilled Level of Care AdmissionsRequesting PrecertificationSNF or hospital Participating Providers accepting skilled admissions are responsible for requesting precertification bycontacting the Medical Management Department anytime by faxing pertinent clinical information to the fax numberbelow. Please note: Only fax the pertinent information; do not fax an entire chart.GHP Family Medical Management DepartmentFax: (570) 271-5534Precertification must be requested no less than two (2) Business Days prior to admission unless the Member is beingadmitted from the Emergency Department or home. Requests received after 3 p.m. may be pended to the next BusinessDay. Please note:• A three (3) day hospital stay is not required by GHP Family prior to a skilled admission.• Specialty consultative, surgical, and evaluation/management services provided in the skilled or Intermediatelevel of Care setting do not require an Outpatient Referral Form to be issued by a Member’s PCP.• Precertification is also required when GHP Family is not the Member’s primary insurance coverage.• Copayments are the financial responsibility of the Member, when applicable.SNF or hospital providers are required to notify GHP Family within one (1) Business Day of a skilled level of careadmission that occurred during non-business hours (Monday through Friday 4:30 p.m. to 8:00 a.m., or on a weekend orHoliday (New Year’s Day, Memorial Day, Fourth of July, Labor Day, Thanksgiving Day and Christmas Day).The Medical Management Department will complete a clinical review, and authorize or deny the admissionretrospectively pursuant to the Member’s condition at the time of admission. If the admission is denied, GHP Familywill send the Member the appropriate denial notice with appeal rights information in the required timeframes; a copywill be sent to the requesting Participating Provider.GHP Family is responsible for payment for up to thirty (30) days of nursing home care (including hospital reserve orbed hold days) and for notifying the Department in accordance with the Department’s disenrollment guidelines if a34