GHP Family Provider Manual - Geisinger Health Plan

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Early Identification: 53Quality Improvement and Regulatory Requirements: 54Service Description 54Provider Relations 55Community Outreach 56Member Incentives 56Reporting 56Audit Checks 58MEMBER RESTRICTION PROGRAM 58PROGRAM EXCEPTION PROCESS 59SPECIAL NEEDS UNIT 59COVERED SERVICES 60FAMILY PLANNING SERVICES 71ADVANCE DIRECTIVES 73REIMBURSEMENT & CLAIMS SUBMISSION 74REIMBURSEMENT/FEE-FOR-SERVICE PAYMENT 74BILLING INSTRUCTIONS 74Medical Assistance Enrollment & PROMISe ID Number Required 74Member Eligibility Verification 74Payment for Medically Necessary Services 75Provider Billing 75Co-payments 76Coordination of Benefits/Third Party 76Timely Claim Submission Requirements 77Claims Payment Timeframes 77National Provider Identifier (NPI) 77Compliance 77EDI Claims 77Acceptable Claims Forms 78Encounter Data Submission 78Explanation of Payment (EOP) 79Claims Resubmission 79
Page 1 and 2: HealthChoices Provider ManualRevise
Page 3: Case Management 23Complement the Ca
Page 8 and 9: NamePhone Number[Fax Number]Hours o
Page 10 and 11: County Behavioral Health Plan Phone
Page 12 and 13: Lycoming1-800-525-7938Drug & Alcoho
Page 14 and 15: provides the non-assigning party(s)
Page 16 and 17: the affected party.P. Waiver. Failu
Page 18 and 19: • A designated SCP to provide and
Page 20: EPSDT ScreensAll under theage of 21
Page 23 and 24: DIRECT ACCESS AND SELF-REFERRALThe
Page 25 and 26: For advanced illness, case managers
Page 27 and 28: practitioners are participating Mem
Page 29 and 30: Practitioner’s RightsPractitioner
Page 31 and 32: Authorization Required for PaymentA
Page 33 and 34: ooooAdmission date (not to exceed 3
Page 35 and 36: Department will complete a clinical
Page 37 and 38: Family Medical Management Reviewer.
Page 39 and 40: To be covered, hospice services mus
Page 41 and 42: For more information about the abov
Page 43 and 44: Please note: Questions regarding an
Page 45 and 46: ordering Participating Provider. Ho
Page 47 and 48: Please Note: If the ambulance provi
Page 49 and 50: Prior authorization forms can be fo
Page 51 and 52: Participating Providers are reminde
Page 53 and 54: If the requested service is not rep
Page 55 and 56:
• Data extractions including, but
Page 57 and 58:
GHP Family uses a variety of method
Page 59 and 60:
Audit ChecksThe GHP Family Women’
Page 61 and 62:
• Require coordination of care an
Page 63 and 64:
Covered ServicesPlease note the inf
Page 65 and 66:
Page 67 and 68:
Page 69 and 70:
Page 71 and 72:
Page 73 and 74:
• Biopsy of vaginal mucosa; simpl
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Strawberry Square, 16th FloorHarris
Page 77 and 78:
Within 24 hours of file receipt, GH
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Acceptable Claims FormsGHP Family r
Page 81 and 82:
Pay-for-Quality reports will be pos
Page 83 and 84:
PROCESS AND TIMEFRAMES FOR COMPLAIN
Page 85 and 86:
Complaints - First Level• Non-cli
Page 87 and 88:
DPW Fair Hearing ProcessThe Member
Page 89 and 90:
• Informal Provider Dispute Proce
Page 91 and 92:
Accountability Act (HIPAA) Notice o
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• Access to the information may e
Page 95 and 96:
• Prescription diversion and inap
Page 97 and 98:
GLOSSARYAbuse — Any practices tha
Page 99 and 100:
County Assistance Office (CAO) —
Page 101 and 102:
Formulary — An exclusive list of
Page 103:
PROMISe Provider ID — A 13-digit
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GHP Family Provider Manual - Geisinger Health Plan

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