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Coordinated CareSome Utilization Management provisions require that you contact GHI before receiving treatment,admission to a hospital and/or other health care services.You can reach GHI’s Utilization Management Department at 1-212-615-4662 or 1-800-223-9870outside New York City.Precertification. Your program may require you or your provider to obtain precertification ofcertain services in order to be eligible for maximum benefits and to avoid penalties. Precertificationis the evaluation of proposed treatments or services for medical necessity before theyare rendered and includes precertification of hospital and medical services. Requests for servicesthat require precertification are known as pre-service claims. When utilizing a Network Providerfor covered services, the Network Provider will initiate the precertification process on your behalf.The following sections outline how to obtain precertification from GHI. In general, you and/or your provider need to initiate the precertification process by calling GHI before services arerendered. GHI will notify you and your provider of its decision on a non-urgent precertificationrequest within three (3) business days. GHI will notify you in writing and by telephone.If GHI requires more information to make a decision, GHI will request such information from youand your provider. GHI will give you at least 45 days to supply the information. If you supply allof the requested information to GHI within the time that GHI gives you to supply it, GHI willnotify you of its decision within three (3) business days. Otherwise, GHI will notify you of itsdecision within fifteen (15) days of its receipt of partial information or within 15 days of the endof the time period GHI gives you to supply the information.If you fail to follow GHI’s precertification procedure(s) when required by your program, GHI willinform you of the proper precertification procedure within five (5) days (or within 24 hours in thecase of a request for approval of urgent care claim) of receipt of the request by a GHI person orunit customarily responsible for handling benefit matters.Certain procedures, treatments, and admissions require that you obtain advance approval fromGHI in order to receive full benefits. The specific services that require precertification underyour program are identified in your Certificate of Insurance and Certificate Attachments.For hospital admissions, you, a family member, or your physician should contact GHI’sCoordinated Care Program for precertification:• At least 10 days prior to the date of admission of elective procedures, or as soon asreasonably possible.• Within two business days of an emergency admission, or as soon as reasonably possible.To precertify most care, contact GHI’s Coordinated Care Department at 1-212-615-4662 or1-800-223-9870 outside New York City.Back to Tableof ContentsDownloadClaim FormsRegister at ​ghi.comDirectory of HealthCare Providers22