GHP Family Provider Manual - Geisinger Health Plan

For more information about the above listed programs or to make recommendations for a new program(s), pleasecontact the Home Health/Hospice Management Department at (877) 466-3001 or (570) 271-5506.Durable Medical Equipment (“DME”)Precertification and Concurrent Review for outpatient DME services are the sole responsibility of the rendering DMEParticipating Provider. DME Participating Providers are required to submit the applicable precertification forms to theMedical Management Department’s DME Management Department when all documentation required by traditionalMedicare can be provided with the request. This includes urgent DME requests (i.e., oxygen) received during the DMEManagement Department's non-business hours. A coverage decision provided by the DME Management Department isrequired in advance of release, delivery or purchase of DME, except in the case of after-hours or weekend urgent DMErequests (i.e., oxygen). Items delivered prior to determination of coverage by GHP Family require clear and detailedadvance notice of potential cost with signature of insured. No reimbursement will be provided for delivery of purchaseditems without such advance notice and signature.Please note:• Precertification is also required when GHP Family is not the Member’s primary insurance coverage.• Prosthetic and orthotic devices are not considered DME and do not require precertification.• Copayments are the financial responsibility of the Member, when applicable.When a Member requires outpatient DME, a Participating Provider should issue a verbal or written order to a DMEParticipating Provider that includes the following:• Member Demographics: Member’s name, primary residence address, telephone number, and GHP Familyidentification number.• Requested DME service/item.• Clinical Findings: Diagnosis and applicable diagnosis code.• Prescribing or ordering Participating Provider name and telephone number.• Anticipated duration of DME need.• Additional clinical information to support request for DME.DME Participating Providers are can be found on www.ghpfamily.com. Participating Providers with questions relatedto outpatient DME authorization or precertification may contact the GHP Family Medical Management Department atthe following:GHP Family Medical Management DepartmentMonday through Friday, 8:00 a.m. to 4:30 p.m.(866) 248-1972 or (570) 271-7127Fax: (570) 271-7171Consignment DMEConsignment DME provided by a non-branch location (i.e., physician office stocked with DME by a DMEParticipating Provider) are limited to those approved in advance by the Medical Management Department. Nopurchased items with value greater than $100 can be provided on a consignment basis. The scheduled delivery dateshould be the dispense date appearing on the applicable precertification form(s). Consignment DME provided by a nonbranchlocation is required to be submitted for Retrospective Review within thirty (30) days of issuance utilizing theapplicable precertification form(s). The form must be clearly marked to show “consignment” with clear indication ofthe date equipment was provided to the Member. Misrepresentation of issue date will result in denial of payment andthe Member will not be held liable for payment in these circumstances.40