GHP Family Provider Manual - Geisinger Health Plan

Participating Providers are reminded that when ordering an outpatient MRA, MRI, CT Scan, PET Scan or nuclearcardiology services, precertification is required. Refer to the Section in Manual titled “Outpatient Radiology Services”for additional information.Urgent/Emergency ServicesPCP authorization and/or an Outpatient Referral Form are not required for Emergency Services. PCPs agree to havehealth care services available and accessible to Members, twenty-four (24) hours per day, and seven (7) days per week.When the PCP is not available and accessible to Member, the PCP is responsible for ensuring appropriate arrangementsare made for another PCP to provide Health care services to Member, in accordance GHP Family Access andAvailability Standards.PCPs can utilize the following to ensure Members have access to medical direction or care:• PCP can utilize an answering service that forwards callers (i.e., Members) directly to the PCP or a designatedcovering PCP for medical direction or care during PCPs non-business hours.• PCP can utilize any other delivery method that would provide the Member with direct access to the PCP ordesignated covering PCP with medical direction or care during PCPs non-business hours.Participating Provider’s specialty services immediately following an emergency department discharge or an inpatienthospital discharge, whether in or outside the mandatory post-operative period, excluding direct access services, requirean Outpatient Referral Form issued by the Member’s PCP.All out-of-Network services immediately following an emergency department discharge or an inpatient hospitaldischarge, require precertification.Orthotic and Prosthetic ServiceWhen an orthotic or prosthetic has been determined to be Medically Necessary, the prescribing Participating Providershould verify benefit and eligibility with the applicable Customer Service Team and then issue a written prescription inthe Member’s name for the applicable device. Written prescriptions issued by a Participating Provider for the orthoticor prosthetic device should be kept on file in the Member’s medical record.An Outpatient Referral Form is not required for an orthotic or prosthetic when ordered by a Member’s PCP; or an SCPacting upon a valid referral issued by a Member’s PCP, specifying request for “Evaluate and Treat.”Orthotic or prosthetic Participating Providers can be found online at www.ghpfamily.com.Behavioral Health and Substance Abuse ServicesGHP Family encourages all health care providers to be cognizant of the impact that behavioral health problems mayhave on physical health, to treat the Member accordingly and to refer to, and coordinate with, a behavioral healthspecialist when necessary. Providers are encouraged to be holistic in their approach and to promote the integration ofbehavioral health and physical health services in their Member’s care. All contact with behavioral health providersneeds to be conducted in accordance with state and federal privacy policies in effect at the time.Coordination of care with behavioral health providers is strongly encouraged and especially important for Memberswho present with physical health problems in addition to:• Chronic history of depression, anxiety or substance abuse/dependence.• Multiple psychotropic medications.50