GHP Family Provider Manual

GEISINGER HEALTH PLAN FAMILY
1
HealthChoices Provider Manual
Revised as of January 2024
The Geisinger Health Plan Family (GHP Family) HealthChoices Provider Manual (Manual), as may be amended
from time to time, is incorporated by reference to the Agreement. The Manual is designed for use by, and
applicable to, all GHP Family Participating Providers. The Manual supports all applicable federal and state laws,
Department of Human Services (DHS) regulations and policies as promulgated through Medical Assistance
Bulletins and the specifications of the HealthChoices RFP and HealthChoices Agreement.
Table of Contents
ABOUT GEISINGER HEALTH PLAN FAMILY .......................................................................................... 5
CONTACT INFORMATION ....................................................................................................................... 6
ADDITIONAL GHP FAMILY CONTACT INFORMATION ........................................................................... 6
DHS CONTACT INFORMATION ............................................................................................................... 7
BEHAVIORAL HEALTH CONTACT INFORMATION ................................................................................. 8
COUNTY BEHAVIORAL HEALTH CRISIS INTERVENTION CONTACT INFORMATION ....................... 14
MEDICAL ASSISTANCE TRANSPORTATION PROGRAM (MATP) COUNTY CONTACT
INFORMATION ....................................................................................................................................... 22
PROVIDER RESPONSIBILITIES ............................................................................................................ 23
GENERAL PROVISIONS ........................................................................................................................ 23
PRIMARY CARE PROVIDERS (PCPs) ................................................................................................... 26
MEMBER ASSIGNMENT TO PCP .......................................................................................................... 26
CHANGING PCPS .................................................................................................................................. 27
SPECIALTY CARE PROVIDERS (SCP) ................................................................................................. 27
SCP AS PCP ........................................................................................................................................... 28
APPOINTMENT STANDARDS ................................................................................................................ 28
PCP WAIT TIMES ................................................................................................................................... 30
APPOINTMENT NOTIFICATION AND FOLLOW-UP .............................................................................. 30
EARLY PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT (EPSDT) ........................................ 30
SCHOOL-BASED HEALTH SERVICES .................................................................................................. 31
SUSPECTED CHILD ABUSE OR NEGLECT .......................................................................................... 31
REPORTABLE CONDITIONS ................................................................................................................. 32
INFECTION CONTROL MEASURES ...................................................................................................... 32
RETURN COMMUNICATION.................................................................................................................. 32
PCP PRACTICE ACCEPTANCE STATUS AND MEMBER LIMITATIONS .............................................. 32
REFERRALS ........................................................................................................................................... 33
DIRECT ACCESS AND SELF-REFERRAL ............................................................................................. 33
SUBSTANCE ABUSE AND BEHAVIORAL HEALTH............................................................................... 34
MEDICAL MANAGEMENT & PRIOR AUTHORIZATIONS ...................................................................... 34
MEDICAL MANAGEMENT PLAN ............................................................................................................ 34
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MEDICAL MANAGEMENT STATEMENT................................................................................................ 34
QUALITY MANAGEMENT PLAN ............................................................................................................ 34
POPULATION MANAGEMENT PROGRAMS ......................................................................................... 35
DISEASE MANAGEMENT PROGRAM DEVELOPMENT ....................................................................... 37
PRACTITIONER PROGRAM CONTENT ................................................................................................ 37
ENROLLMENT AND PATIENT PARTICIPATION ................................................................................... 38
RISK STRATIFICATION.......................................................................................................................... 38
INTERVENTIONS ................................................................................................................................... 38
PRACTITIONER DECISION SUPPORT.................................................................................................. 38
EVALUATION OF PROGRAM EFFECTIVENESS .................................................................................. 39
PRACTITIONER’S RIGHTS .................................................................................................................... 39
PRIOR AUTHORIZATION (PRECERTIFICATION) ................................................................................. 40
INPATIENT SERVICES........................................................................................................................... 42
OUTPATIENT SERVICES ....................................................................................................................... 45
OUTPATIENT RADIOLOGY AND IMAGING ........................................................................................... 49
SPECIALTY PHARMACY PROGRAM .................................................................................................... 51
OUTPATIENT PRESCRIPTION DRUGS ................................................................................................ 51
PHARMACY PRIOR AUTHORIZATION AND NONFORMULARY/NONPREFERRED EXCEPTION
PROCESS .............................................................................................................................................. 52
Requesting Prior Authorization ................................................................................................................ 52
MATERNAL HEALTH PROGRAM (INCLUDING HEALTHY BEGINNINGS PLUS) ................................. 54
EARLY IDENTIFICATION ....................................................................................................................... 55
QUALITY IMPROVEMENT AND REGULATORY REQUIREMENTS ...................................................... 55
SERVICE DESCRIPTION ....................................................................................................................... 55
MEMBER HEALTH EDUCATION ............................................................................................................ 56
PROVIDER RELATIONS ........................................................................................................................ 57
COMMUNITY OUTREACH ..................................................................................................................... 57
MEMBER INCENTIVES .......................................................................................................................... 57
REPORTING ........................................................................................................................................... 57
AUDIT CHECKS...................................................................................................................................... 59
MEMBER RESTRICTION PROGRAM .................................................................................................... 59
PROGRAM EXCEPTION PROCESS ...................................................................................................... 61
SPECIAL NEEDS UNIT........................................................................................................................... 61
COVERED SERVICES............................................................................................................................ 62
COVERED MEDICATIONS WITH NO COPAY ....................................................................................... 68
DENTAL SERVICES ............................................................................................................................... 68
FAMILY PLANNING SERVICES ............................................................................................................. 70
PA VACCINES FOR CHILDREN (VFC) PROGRAM ............................................................................... 72
ADVANCE DIRECTIVES ......................................................................................................................... 78
REIMBURSEMENT & CLAIMS SUBMISSION REIMBURSEMENT/FEE-FOR-SERVICE PAYMENT ..... 79
BILLING INSTRUCTIONS ....................................................................................................................... 79
CMS 1500 REQUIRED FIELDS .............................................................................................................. 84
ENCOUNTER DATA SUBMISSION ........................................................................................................ 86
EXPLANATION OF PAYMENT (EOP) .................................................................................................... 86
CLAIMS RESUBMISSION ....................................................................................................................... 87
GHP FAMILY PAY-FOR-QUALITY PROGRAM ...................................................................................... 87
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MEMBER RIGHTS & RESPONSIBILITIES ............................................................................................. 87
CONFIDENTIALITY & PRIVACY OF GHP FAMILY MEMBER MEDICAL RECORDS & PROTECTED
HEALTH INFORMATION (PHI) ............................................................................................................... 88
MEMBER COMPLAINTS, GRIEVANCES AND DHS FAIR HEARINGS .................................................. 88
PROVIDER APPEALS AND DISPUTES ............................................................................................... 106
REGULATORY COMPLIANCE ............................................................................................................. 107
MAINSTREAMING ................................................................................................................................ 108
HIPAA AND CONFIDENTIALITY........................................................................................................... 109
HIPAA NOTICE OF PRIVACY PRACTICES ......................................................................................... 109
CONFIDENTIALITY REQUIREMENTS ................................................................................................. 109
MEMBER PRIVACY RIGHTS................................................................................................................ 110
PRIVACY PROCESS REQUIREMENTS ............................................................................................... 110
LIMITATIONS ........................................................................................................................................ 111
FRAUD AND ABUSE ............................................................................................................................ 111
GHP FAMILY COMPLIANCE PROGRAM ............................................................................................. 111
DEFINING FRAUD, WASTE, AND ABUSE ........................................................................................... 112
REPORTING FRAUD AND ABUSE ...................................................................................................... 112
EXAMPLES OF RISKS FOR FRAUD, WASTE AND ABUSE ................................................................ 113
PROVIDER SCREENING OF EMPLOYEES AND CONTRACTORS FOR EXCLUSION FROM
PARTICIPATION IN FEDERAL HEALTH CARE PROGRAMS .............................................................. 115
OVERVIEW ........................................................................................................................................... 115
PROCEDURE ....................................................................................................................................... 116
PROVIDER SELF-AUDIT PROTOCOL ................................................................................................. 117
GLOSSARY .......................................................................................................................................... 118
4
ABOUT GEISINGER HEALTH PLAN FAMILY
Geisinger Health Plan Family (GHP Family) is a Geisinger Health Plan Medicaid managed care plan serving the
entire state of Pennsylvania for the HealthChoices managed care program offered to Medical Assistance
recipients by the Commonwealth of Pennsylvania Department of Human Services.
Geisinger Health Plan is recognized as a national leader among managed care organizations and, through GHP
Family, brings a physician-led, patient-centered approach to health care delivery for the Medical Assistance
enrollees of Pennsylvania. A model for healthcare reform, with documented success in innovative patient
management programs and performance-based provider reimbursement, Geisinger Health Plan consistently ranks
among America’s top health plans.
This manual pertains to the participation with GHP Family and the HealthChoices Physical
Health Program in the Northwest, Northeast, Southeast, Lehigh/Capital, and Southwest Zone.
These 5 zones include all 67 counties in the state of Pennsylvania.
This manual is intended to be used as an extension of the Participating Provider Agreement and a reference guide
for Participating Providers and their office staff. While this manual contains basic information about the
Commonwealth of Pennsylvania Department of Human Services (DHS) and the Centers for Medicare and
Medicaid Services (CMS), providers are required to fully understand and apply DHS and CMS requirements when
administering covered services. Please refer to https://www.dhs.pa.gov/ and https://www.cms.gov//.
5
CONTACT INFORMATION
All paper Claims should be submitted to:
Claims Department
Geisinger Health Plan
PO Box 160
Glen Burnie, MD 21060
Visit GHP Family Provider Web portal at https://www.ghpfamily.com or visit GHP at https://www.navinet.net/ to
utilize the following online tools:
• Member eligibility and authorizations

• View Claims
• EDI enrollment
• Prior authorization list, medical policies, and clinical guidelines
• Pay-for-Quality data
• Provider and formulary searches
ADDITIONAL GHP FAMILY CONTACT INFORMATION
Department Phone Number [Fax Number] Hours of Operation
(800) 883-6355 or
Monday - Friday
Case Management (570) 271-8763
8:00 a.m. - 4:30 p.m.
Fax: (570) 271-7860
Monday, Tuesday, Thursday

and Friday, 7 a.m. – 7 p.m.;
Customer Care (855) 227-1302
Wednesday, 7 a.m. – 8 p.m.
Saturday, 8 a.m. – 2 p.m.
Customer Care -
24 Hours/Day,
Interactive Voice Response (855) 227-1302
7 Days/Week
(IVR) System
(800) 883-6355 or
Durable Medical Equipment (570) 271-8763 Monday - Friday
Network 8:30 a.m. - 4:30 p.m.
Fax: (570) 271-7860
24 Hours/Day,
Fraud and Abuse Hotline (800) 292-1627
7 Days/Week
(877) 466-3001 or
Home Health & Hospice Monday - Friday
(570) 271-5506
Network 8:30 a.m. - 4:30 p.m.
Fax: (570) 271-5507
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(800) 544-3907 or
Monday – Friday
Medical Management (570) 271-6497
8:00 a.m. - 5:00 p.m.
Fax: (570) 271-5534
(800) 270-9981 or
Outpatient Rehabilitation Monday – Friday
(570) 271-5301
Therapy Network 8:30 a.m. - 5:00 p.m.
Fax: (570) 271-5302
(855) 552-6028 or
Monday – Friday
Pharmacy (570) 214-3554
8:00 a.m. - 5:00 p.m.
Fax: (570) 271-5610
(800) 876-5357 or
Monday – Friday
Provider Account Manager [email protected]
8:00 a.m. - 5:00 p.m.
Monday – Friday
Special Needs Unit (855) 214-8100
8:30 a.m. - 5:00 p.m.
Monday – Friday
(800) 447-2833 or 8:30 a.m. – 4:30 p.m.
TDD for the Hearing
Impaired
711 for PA Relay services PA Relay Services available
24 Hours/Day, 7 Days/Week
DHS CONTACT INFORMATION
Name Phone Number Hours of Operation
DHS HelpLine:
Department of Human Services 24 Hours/Day, 7 Days/Week
(800) 692-7462
DHS ChildLine:
Department of Human Services (800) 932- 0313 24 Hours/Day, 7 Days/Week
TDD: (866) 872-1677

Department of Human
Services
Monday – Friday
OMAP - HealthChoices Program (800) 798-2339
8:30 a.m. - 4:30 p.m.
Complaints, Grievance, and Fair
Hearings
Eligibility Verification
(800) 766-5EVS (5387) 24 Hours/Day, 7 Days/Week
System (EVS)
7
Medical Assistance Provider
(866) 379-8477 Monday – Friday
Compliance Hotline (Formerly
9:00 a.m. - 3:30 p.m.
Fraud and Abuse Hotline)
Monday - Friday
Provider Inquiry Hotline (800) 537-8862 Prompt 4
8:00 a.m. - 4:30 p.m.
Medical Assistance Provider

Monday-Friday
Enrollment Applications (800) 537-8862 Prompt 1 8:30 a.m. - 12:00 noon and
InProcess (Inpatient and
1:00 p.m. – 3:30 p.m.
Outpatient Providers)
Medical Assistance Provider Monday - Friday

(800) 537-8862 Prompt 1
Enrollment Changes 8:00 a.m. - 4:30 p.m.
Outpatient Providers Practitioner Monday - Friday

(800) 537-8862 Prompt 1
Unit 8:00 a.m. - 4:30 p.m.
Monday – Friday
Pharmacy Hotline (800) 558-4477 Prompt 1
8:00 a.m. - 4:30 p.m.
BEHAVIORAL HEALTH CONTACT INFORMATION

For referrals to a Behavioral Health Provider, please use the information below which is current as of the published
date of this manual.
Behavioral Health Services County Phone Numbers and Websites

Behavioral Health
County Contact Information
Provider
1-866-738-9849
Community Care
TTY: 711; Request 1-833-545-9191
Adams Behavioral Health
Spanish line: 1-866-229-3187
Organization
www.ccbh.com
1-800-553-7499
Community Care
TTY: 711; Request 1-833-545-9191
Allegheny Behavioral Health
Spanish line: 1-866-229-3187
Organization
www.ccbh.com
1-888-204-5581
Carelon Behavioral
Armstrong TTY: 711
Health
https://www.carelonbehavioralhealth.com/
1-888-204-5581
Carelon Behavioral
Beaver TTY: 711
Health
8
1-800-553-7499
Community Care
TTY: 711; Request 1-833-545-9191
Bedford Behavioral Health
Spanish line: 1-866-229-3187
Organization
https://www.ccbh.com
1-800-553-7499
Community Care
TTY: 711; Request 1-833-545-9191
Berks Behavioral Health
Spanish line: 1-866-229-3187
Organization
1-800-553-7499
Community Care
TTY: 711; Request 1-833-545-9191
Blair Behavioral Health
Spanish line: 1-866-229-3187
Organization
1-800-553-7499
Community Care
TTY: 711; Request 1-833-545-9191
Bradford Behavioral Health
Spanish line: 1-866-229-3187
Organization
Magellan Behavioral 1-877-769-9784
Bucks Health (MBH) of Pa. TTY: 711
https://www.magellanofpa.com
1-888-204-5581
Carelon Behavioral
Butler TTY: 711
Health
Magellan Behavioral 1-877-769-9784
Cambria Health (MBH) of Pa. TTY: 711
1-800-553-7499
Community Care
TTY: 711; Request 1-833-545-9191
Cameron Behavioral Health
Spanish line: 1-866-229-3187
Organization
1-800-553-7499
Community Care
TTY: 711; Request 1-833-545-9191
Behavioral Health
Carbon Spanish line: 1-866-229-3187
Organization
1-800-553-7499
Community Care
TTY: 711; Request 1-833-545-9191
Centre Behavioral Health
Spanish line: 1-866-229-3187
Organization
1-800-553-7499
Community Care
TTY: 711; Request 1-833-545-9191
Chester Behavioral Health
Spanish line: 1-866-229-3187
Organization
1-800-553-7499
Community Care
TTY: 711; Request 1-833-545-9191
Clarion Behavioral Health
Spanish line: 1-866-229-3187
Organization
9
1-800-553-7499
Community Care
TTY: 711; Request 1-833-545-9191
Clearfield Behavioral Health
Spanish line: 1-866-229-3187
Organization
1-800-553-7499
Community Care
TTY: 711; Request 1-833-545-9191
Clinton Behavioral Health
Spanish line: 1-866-229-3187
Organization
1-800-553-7499
Community Care
TTY: 711; Request 1-833-545-9191
Columbia Behavioral Health
Spanish line: 1-866-229-3187
Organization
1-888-204-5581
Carelon Behavioral
Crawford TTY: 711
Health
1-888-722-8646
TTY: 1-800-654-5984
Cumberland PerformCare
or PA Relay 711
https://pa.performcare.org/
1-888-722-8646
TTY: 1-800-654-5984
Dauphin PerformCare
or PA Relay 711
1-877-769-9784
Magellan Behavioral
Delaware TTY: 711
Health (MBH) of Pa.
http://www.magellanofpa.com
1-800-553-7499
Community Care
TTY: 711; Request 1-833-545-9191
Elk Behavioral Health
Spanish line: 1-866-229-3187
Organization
1-800-553-7499
Community Care
TTY: 711; Request 1-833-545-9191
Erie Behavioral Health
Spanish line: 1-866-229-3187
Organization
1-888-204-5581
Carelon Behavioral
Fayette TTY: 711
Health
1-800-553-7499
Community Care
TTY: 711; Request 1-833-545-9191
Forest Behavioral Health
Spanish line: 1-866-229-3187
Organization
1-866-773-7917
TTY: 1-800-654-5984
Franklin PerformCare
or PA Relay 711
10
1-866-773-7917
PerformCare TTY: 1-800-654-5984
Fulton
or PA Relay 711
1-800-553-7499
Community Care
TTY: 711; Request 1-833-545-9191
Greene Behavioral Health
Spanish line: 1-866-229-3187
Organization
1-800-553-7499
Community Care
TTY: 711; Request 1-833-545-9191
Huntingdon Behavioral Health
Spanish line: 1-866-229-3187
Organization
1-888-204-5581
Carelon Behavioral
Indiana TTY: 711
Health
1-800-553-7499
Community Care
TTY: 711; Request 1-833-545-9191
Jefferson Behavioral Health
Spanish line: 1-866-229-3187
Organization
1-800-553-7499
Community Care
TTY: 711; Request 1-833-545-9191
Juniata Behavioral Health
Spanish line: 1-866-229-3187
Organization
1-800-553-7499
Community Care
TTY: 711; Request 1-833-545-9191
Lackawanna Behavioral Health
Spanish line: 1-866-229-3187
Organization
1-888-722-8646
TTY: 1-800-654-5984
Lancaster PerformCare
or PA Relay 711
1-888-204-5581
Carelon Behavioral
Lawrence TTY: 711
Health
1-888-722-8646
TTY: 1-800-654-5984
Lebanon PerformCare
or PA Relay 711
1-877-769-9784
Magellan Behavioral
Lehigh TTY: 711
Health (MBH) of Pa.
1-800-553-7499
Community Care
TTY: 711; Request 1-833-545-9191
Luzerne Behavioral Health
Spanish line: 1-866-229-3187
Organization
11
1-800-553-7499
Community Care
TTY: 711; Request 1-833-545-9191
Lycoming Behavioral Health
Spanish line: 1-866-229-3187
Organization
1-800-553-7499
Community Care
TTY: 711; Request 1-833-545-9191
McKean Behavioral Health
Spanish line: 1-866-229-3187
Organization
1-888-204-5581
Carelon Behavioral
Mercer TTY: 711
Health
1-800-553-7499
Community Care
TTY: 711; Request 1-833-545-9191
Mifflin Behavioral Health
Spanish line: 1-866-229-3187
Organization
1-800-553-7499
Community Care
TTY: 711; Request 1-833-545-9191
Monroe Behavioral Health
Spanish line: 1-866-229-3187
Organization
1-877-769-9784
Magellan Behavioral
Montgomery TTY: 711
Health (MBH) of Pa.
1-800-553-7499
Community Care
TTY: 711; Request 1-833-545-9191
Montour Behavioral Health
Spanish line: 1-866-229-3187
Organization
1-877-769-9784
Magellan Behavioral
Northampton TTY: 711
Health (MBH) of Pa.
1-800-553-7499
Community Care
TTY: 711; Request 1-833-545-9191
Northumberland Behavioral Health
Spanish line: 1-866-229-3187
Organization
1-888-722-8646
TTY: 1-800-654-5984
Perry PerformCare
or PA Relay 711
1-888-545-2600
Community Behavioral
Philadelphia TTY: 1-888-436-7482
Health
https://www.cbhphilly.org/
1-800-553-7499
Community Care
TTY: 711; Request 1-833-545-9191
Pike Behavioral Health
Spanish line: 1-866-229-3187
Organization
12
1-800-553-7499
Community Care
TTY: 711; Request 1-833-545-9191
Potter Behavioral Health
Spanish line: 1-866-229-3187
Organization
1-800-553-7499
Community Care
TTY: 711; Request 1-833-545-9191
Schuylkill Behavioral Health
Spanish line: 1-866-229-3187
Organization
1-800-553-7499
Community Care
TTY: 711; Request 1-833-545-9191
Snyder Behavioral Health
Spanish line: 1-866-229-3187
Organization
1-800-553-7499
Community Care
TTY: 711; Request 1-833-545-9191
Somerset Behavioral Health
Spanish line: 1-866-229-3187
Organization
1-800-553-7499
Community Care
TTY: 711; Request 1-833-545-9191
Sullivan Behavioral Health
Spanish line: 1-866-229-3187
Organization
1-800-553-7499
Community Care
TTY: 711; Request 1-833-545-9191
Susquehanna Behavioral Health
Spanish line: 1-866-229-3187
Organization
1-800-553-7499
Community Care
TTY: 711; Request 1-833-545-9191
Tioga Behavioral Health
Spanish line: 1-866-229-3187
Organization
1-800-553-7499
Community Care
TTY: 711; Request 1-833-545-9191
Union Behavioral Health
Spanish line: 1-866-229-3187
Organization
1-888-204-5581
Carelon Behavioral
Venango TTY: 711
Health
1-800-553-7499
Community Care
TTY: 711; Request 1-833-545-9191
Warren Behavioral Health
Spanish line: 1-866-229-3187
Organization
1-888-204-5581
Carelon Behavioral
Washington TTY: 711
Health
1-800-553-7499
Community Care
TTY: 711; Request 1-833-545-9191
Wayne Behavioral Health
Spanish line: 1-866-229-3187
Organization
13
1-888-204-5581
Carelon Behavioral
Westmoreland TTY: 711
Health
1-800-553-7499
Community Care
TTY: 711; Request 1-833-545-9191
Wyoming Behavioral Health
Spanish line: 1-866-229-3187
Organization
1-800-553-7499
Community Care
TTY: 711; Request 1-833-545-9191
York Behavioral Health
Spanish line: 1-866-229-3187
Organization
COUNTY BEHAVIORAL HEALTH CRISIS INTERVENTION CONTACT INFORMATION

In the event of a life-threatening emergency, please dial 9-1-1.
National Suicide Prevention Hotline (800) 273-TALK (8255)
Crisis Intervention Services Phone Numbers
County Contact Information
York/Adams MH/IDD Program

Website: https://www.yorkcountypa.gov/492/Mental-Health
Adams
Phone: 717-771-9618
Wellspan Crisis Services: 717-851-5320
Allegheny County Department of Human Services

Website: https://connect.alleghenycounty.us/get-help-now/
Allegheny
Phone: 412-350-4456
Crisis Services: 1-888-796-8226 (888-7-YOU CAN)
Armstrong/Indiana Behavioral & Developmental Health Program
Website: https://www.aibdhp.org/
Armstrong
Phone: 724-548-3451
Crisis Services: 1-877-333-2470
Beaver County Behavioral Health
Website: https://www.beavercountypa.gov/departments/behavioral-health
Beaver
Phone: 724-891-2827
Crisis Services: 1-800-400-6180 and 724-371-8060
Bedford-Somerset Developmental & Behavioral Health Services (DBHS)
Website: https://www.dbhs.co
Bedford
Phone: 814-623-5166 or 877-814-5166
Crisis Services: 1-866-611-6467 or text 988
14
Berks County MH/DD
Website: https://www.countyofberks.com/departments/mental-health-
Berks
developmental-disabilities
Crisis Services: 610-379-2007
Blair County MH/BH/ID Programs
Website: https://www.blairco.org/departments/social-services
Blair
Phone: 814-693-3023
Crisis Services: 814-889-2141 Choose option 1
Bradford/Sullivan Mental Health Services
Website: https://www.bradfordcountypa.org/index.php/human-services/mental-
Bradford health-services
Phone: 1-800-588-1828 or 570-265-1760
Crisis Intervention: 1-877-724-7142
Bucks County Dept. Of Mental Health/Developmental Programs

Bucks Website: https://www.buckscounty.gov/315/Behavioral-Health
Butler County MH/EI/ID Program
Website: https://www.butlercountypa.gov/289/Human-Services
Butler
Phone: 724-284-5114
Behavioral Health / Intellectual Disabilities / Early Intervention
Website: https://www.cambriacountypa.gov/behavioral-health/
Cambria
Phone: 814-535-8531 Ebensburg Satellite Office: 814-472-4400
Cameron/Elk Counties Behavioral & Development Programs
Website: https://www.cemhmr.org
Cameron
Phone: 814-772-8016
Carbon-Monroe-Pike Mental Health & Developmental Services
Website: www.cmpmhds.org/
Carbon
Phone: 570-992-0879
Centre County MH/ID/EI
Website: https://centrecountypa.gov/329/MHIDEI---Drug-Alcohol
Centre
Phone: 814-355-6786 and 814-355-6744
Chester County Mental Health/Intellectual & Developmental Disabilities
Chester Website: www.chesco.org/615/Mental-HealthIntellectual-Dev-Disabiliti
Crisis Center: 610-280-3270
15
Clarion County MH/DD
Website:
https://www.co.clarion.pa.us/government/departments/human_services__mhddei
Clarion
.php
Phone: 814-226-7223
Community Connections of Clearfield/Jefferson Counties
Clearfield Website: www.ccc-j.com
Crisis Hotline: 1-800-341-5040
Lycoming-Clinton Joinder Programs
Website: www.joinder.org
Clinton
Phone: 570-748-2262
Crisis Intervention Services: 1-844-707-3224
CMSU Behavioral Health & Developmental Services
Website: www.cmsu.org
Columbia
Phone: 570-275-4962
Crawford County Human Services
Website: https://www.crawfordcountypa.net/cchs/Pages/home.aspx
Crawford
Phone: 814-724-8380 or toll free at 1-877-334-8793
Crisis Services: 814-724-2732 or 1-888-275-7009
Cumberland/Perry MH/IDD
Website: https://www.cumberlandcountypa.gov/2493/Crisis-Intervention
Crisis Services:
• Camp Hill area: 717-763-2222
Cumberland
• Carlisle area: 717-243-6005
• All other areas: 1-866-350-HELP
Dauphin County Mental Health/Intellectual Disabilities Program

Website: https://www.dauphincounty.gov/government/human-services/mental-
Dauphin
health-autism-developmental-programs
Crisis Intervention Services: 717-232-7511 or 1-888-596-4447
Delaware County BH/ID
Delaware Website: https://delcopa.gov/health/mentalhealth.html
Crisis Connections Team: 1-855-889-7827
Cameron/Elk Counties Behavioral & Development Programs
Website: www.cemhmr.org
Elk
Phone: 814-772-8016
16
Erie County MH/ID
Website: https://eriecountypa.gov/departments/human-services/mental-health/
Erie
Phone: 814-528-0600
Crisis Services: 814-456-2014 or 1-800-300-9558
Fayette County Behavioral Health Administration
Website: www.fcbha.org
Fayette
Phone: 724-430-1370
Forest/Warren Human Services
Website: www.wc-hs.org
Forest
Phone: 1-855-284-2494 or TTY 724-631-5600
Crisis Line: 1-844-757-3224 or text 63288
Franklin/Fulton MH/IDD/EI
Website: www.franklincountypa.gov/index.php?section=human-services_mental-
Franklin health
Phone: 1-800-841-3593
Franklin/Fulton MH/ID/EI
Website: www.franklincountypa.gov/index.php?section=human-services_mental-
Fulton health
Phone: 1-800-841-3593
Greene County Human Services
Greene Website: https://www.co.greene.pa.us/
Phone: 724-852-5276
Juniata Valley Behavioral & Developmental Services
Website: http://www.jvbds.org/
Phone: 1-833-888-1804
Huntingdon
CCR Crisis Text Line: 63288
Crisis Chat Link: https://ccrinfo.org
Armstrong/Indiana Behavioral & Developmental Health Program
Website: www.aibdhp.org
Indiana
Phone: 724-349-3350
Community Connections of Clearfield/Jefferson Counties
Jefferson Website: www.ccc-j.com
Crisis Hotline: 1-800-341-5040
17
Phone: 717-242-6467 or 1-833-888-1804
Juniata
Lackawanna Susquehanna BHIDEI Programs
Website: www.lsbhidei.org
Lackawanna
Phone: 570-346-5741
Lancaster County Behavioral Health and Developmental Services
Website: https://www.lancastercountybhds.org/
Lancaster Crisis Intervention: 717-394-2631
Text Line: 988
Chat Line: 988lifeline.org
Lawrence County Mental Health - Developmental Services
Website: https://lawrencecountypa.gov/departments/mhds
Lawrence
Phone: 724-510-3317
Crisis Intervention Services: 724-652-9000
Lebanon County MH/ID/EI
Website: https://lebanoncountypa.gov/departments/mhidei
Lebanon
Phone: 717-274-3415
Crisis Services: 717-274-3363 or dial 988
Lehigh County Human Services
Website: www.lehighcounty.org/Departments/Human-Services/Mental-Health
Phone: 610-782-3200
Lehigh
National Suicide Prevention Lifeline: 1-800-273-8255
National Crisis Text Line: Text HOME to 741741
Luzerne-Wyoming Counties Mental Health & Developmental Services
Website: https://www.luzernecounty.org/466/Mental-Health-Developmental-
Luzerne Services
Phone: 1-800-816-1880
Lycoming-Clinton Joinder Programs
Website: www.joinder.org
Lycoming
Phone: 570-326-7895
Crisis Intervention Services: 844-707-3224
18
McKean County Mental Health Services
Website:
https://www.mckeancountypa.gov/departments/human_services/mental_health_s
McKean
ervices/index.php
Phone: 814-887-3350
Mental Health Crisis Hotline: 1-800-459-6568 or 814-362-4623
Mercer County MH/DS
Website: www.mercercountybhc.org/
Mercer
Phone: 724-662-2230

Phone: 1-833-888-1804
Mifflin
Monroe
Phone: 570-992-0879
Montgomery County MH/DD/EI Program Office
Website: https://www.montgomerycountypa.gov/150/Mental-HealthDev-
Montgomery DisabilitiesEarly-Inter
Phone: 610-278-3642
Crisis Services: 1-855-634-HOPE (4673)
Montour
Phone: 570-275-5422
Northampton County MH/EI/Dev. Prog. Div.
Website: www.northamptoncounty.org/HS/MENHEALTH/Pages/default.aspx
Northampton
Phone: 610-829-4800
Crisis Services: 610-829-4801 or 610-652-9060
Northumberland County BH/ID Services

Website: https://www.norrycopa.net/index.php/bhids/
Northumberland
Phone: 570-495-2040
Cumberland/Perry MH/IDD
Website: www.ccpa.net/118/Mental-Health-Intellectual-Develop-Dis
Perry
Phone: 1-866-240-6320
19
Philadelphia Dept of BH and Intellectual disAbility Services
Website: www.dbhids.org
Philadelphia Phone: 1-888-545-2600
Crisis Services: 215-686-4420 or Dial 988
Pike
Phone: 570-992-0879
Potter County Human Services
Website: www.pottercountyhumansvcs.org
Potter
Phone: 1-800-800-2560 or 814-544-7315
Crisis Services: 1-866-957-3224 or text 63288
Schuylkill County Administrative Offices Of MH/DS/D&A
Website:
https://schuylkillcountypa.gov/departments/human_services/mental_health_devel
Schuylkill
opment_services.php
Phone: 570-621- 2890
Crisis Services: 1-877-9WE-HELP or 1-877-993-4357
Snyder
Phone: 570-275-5422
Bedford-Somerset Developmental & Behavioral Health Services (DBHS)
Website: www.dbhs.co
Somerset
Phone: 814-443-4891 or 877-814-4891
Crisis Services: 1-866-611-6467 or dial 988
Bradford/Sullivan Mental Health Services
Website: www.bradfordcountypa.org/index.php/human-services/mental-health-
Sullivan services
Phone: 1-800-588-1828 or 570-265-1760
Crisis Intervention: 1-877-724-7142
Lackawanna Susquehanna BHIDEI Programs
Website: www.lsbhidei.org
Susquehanna
Phone: 570-346-5741
Tioga County Dept. Of Human Services
Website: https://www.tiogacountypa.us/departments/human-services
Tioga
Phone: 570-724-5766
20
Union Phone: 570-275-5422
Venango County Mental Health & Developmental Services
Website: https://co.venango.pa.us/366/Care-Management
Venango
Phone: 814-432-9111
Forest/Warren Human Services
Website: www.wc-hs.org
Warren
Phone: 1-855-284-2494 or TTY 724-631-5600
Crisis Line: 1-844-757-3224 or text 63288
Washington County BH/DS
Website: https://washingtoncountyhumanservices.com/agencies/behavioral-
health-developmental-services
Phone: 724-228-6832
Washington
Mental Health Crisis: 1-877-225-3567
Suicide Prevention: 1-800-273-8255
Domestic Violence: 724-223-9190
Drug and Alcohol Crisis: 1-800-GET-HELP
Wayne County Behavioral & Developmental Programs

Website: https://waynecountypa.gov/155/Behavioral-and-Developmental-
Programs
Wayne Phone: 1-866-558-0735 or 570-253-9200
Text: 63288
Chat Online: https://www.ccrinfo.org/
Westmoreland County Behavioral Health & Developmental Programs

Website: www.co.westmoreland.pa.us/841/Behavioral-Health-Developmental-
Westmoreland Services
Phone: 1-800-353-6467
Luzerne-Wyoming Counties Mental Health and Developmental Services

Website: https://www.luzernecounty.org/466/Mental-Health-Developmental-
Wyoming Services
Phone: 1-800-816-1880
York/Adams MH/IDD Program
Website: https://yorkcountypa.gov/492/Mental-Health
York
Phone: 717-771-9618
Wellspan Crisis Services: 717-851-5320
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MEDICAL ASSISTANCE TRANSPORTATION PROGRAM (MATP) COUNTY CONTACT
INFORMATION
The Medical Assistance Transportation Program, also known as MATP, provides non-emergency transportation to
medical appointments for Medical Assistance Members who do not have transportation available to them. The
individual’s county of residence will provide the type of transportation that is the least expensive while still meeting
their needs.
Medical Assistance Transportation Program (MATP) County Phone Numbers

County Local Number Toll-Free
Adams 717-846-RIDE (7433) 1-800-632-9063

Allegheny 412-350-4476 1-888-547-6287
Armstrong 724-548-3408 1-800-468-7771
Beaver 724-375-2895 1-800-262-0343
Bedford 814-623-9129 1-800-323-9997
Berks 610-921-2361 1-800-383-2278
Blair 814-695-3500 1-800-458-5552
Bradford 570-888-7330 1-800-242-3484
Bucks 215-794-5554 1-888-795-0740
Butler 724-431-3663 1-866-638-0598
Cambria 814-535-4630 1-888-647-4814
Cameron 1-866-282-4968 Same as local number
Carbon 570-669-6380 Same as local number
Centre 814-355-6807 Same as local number
Chester 484-696-3854 1-877-873-8415
Clarion 814-226-7012 Same as local number
Clearfield 814-765-1551 1-800-822-2610
Clinton 570-323-7575 1-800-206-3006
Columbia 717-846-RIDE (7433) 1-800-632-9063
Crawford 814-333-7090 1-800-210-6226
Cumberland 717-846-RIDE (7433) 1-800-632-9063
Dauphin 717-232-9880 1-800-309-8905
Delaware 610-490-3960 1-866-450-3766
Elk 1-866-282-4968 Same as local number
Erie 814-456-2299 Same as local number
Fayette 724-628-7433 1-800-321-7433
Forest 814-927-8266 1-800-222-1706
Franklin 717-846-RIDE (7433) 1-800-632-9063
Fulton 717-485-6767 1-888-329-2376
Greene 724-627-6778 1-877-360-7433
Huntingdon 814-641-6408 1-800-817-3383
Indiana 724-463-3235 1-888-526-6060
Jefferson 814-938-3302 1-877-411-0585
Juniata 717-242-2277 1-800-348-2277
Lackawanna 570-963-6482 Same as local number
Lancaster 717-291-1243 1-800-892-1122
Lawrence 724-658-7258 1-888-252-5104
Lebanon 717-273-9328 Same as local number
22
Lehigh 610-253-8333 1-888-253-8333
Luzerne 570-288-8420 1-800-679-4135
Lycoming 570-323-7575 1-800-222-2468
McKean 1-866-282-4968 Same as local number
Mercer 724-662-6222 Same as local number
Mifflin 717-242-2277 1-800-348-2277
Monroe 570-839-6282 ext 434 1-888-955-6282
Montgomery 215-542-7433 Same as local number
Montour 717-846-RIDE (7433) 1-800-632-9063
Northampton 610-253-8333 1-888-253-8333
Northumberland 717-846-RIDE (7433) 1-800-632-9063
Perry 717-846-RIDE (7433) 1-800-632-9063
Philadelphia 1-877-835-7412 Same as local number
Pike 570-296-3408 1-866-681-4947
Potter 814-544-7315 1-800-800-2560
Schuylkill 570-628-1425 1-800-656-0700
Snyder 717-846-RIDE (7433) 1-800-632-9063
Somerset 814-701-3691 1-800-452-0241
Sullivan 570-888-7330 1-800-242-3484
Susquehanna 570-278-6140 1-866-278-9332
Tioga 570-888-7330 1-800-242-3484
Union 717-846-RIDE (7433) 1-800-632-9063
Venango 814-432-9767 1-877-836-4699
Warren 814-723-1874 Same as local number
Washington 724-223-8747 1-800-331-5058
Wayne 570-253-4280 1-800-662-0780
Westmoreland 724-832-2706 1-800-242-2706
Wyoming 570-278-6140 1-866-278-9332
York 717-846-RIDE (7433) 1-800-632-9063
PROVIDER RESPONSIBILITIES
GENERAL PROVISIONS
Participating Provider and GHP Family agree to abide by the following General Provisions:
Assignment. The Agreement or any part, articles or sections thereof may not be assigned during the term of the
Agreement by any of the parties without the prior written consent of the other party(s), except (i) as may otherwise
be provided for in the Agreement and (ii) each party may at any time assign its rights and obligations under the
Agreement to any corporation controlled by, in control of or under common control of the assigning party provided,
however, it provides the non-assigning party(s) with thirty (30) days prior written notice of said assignment.
Compliance. The parties agree to comply with all applicable federal and state laws and rules including, but not
limited to (i) Title VII of the Civil Rights Act of 1964; (ii) The Age Discrimination Act of 1975; (iii) The Rehabilitation
Act of 1973; (iv) The Americans With Disabilities Act; (v) other laws applicable to recipients of Federal funds; (vi)
Medicare laws, regulations and Centers for Medicare and Medicaid Services (“CMS”) instructions; (vii) Patients’ bill
of Rights in accordance with OPM; (viii) the Genetic Information Nondiscrimination Act of 2008; (ix) Health
Insurance Portability and Accountability Act of 1996 (HIPAA); and all other applicable laws and rules. Furthermore,
Participating Provider hereby warrants and represents that it shall comply and shall be responsible for requiring
any party that it may subcontract with to furnish services to Members to comply with GHP Family’s policies and
23
procedures and all other terms and conditions of the Agreement. Additionally, it is hereby disclosed that payments
made by GHP Family to related entities, contractors and subcontractors are, in whole or in part, from federal funds
received by the GHP Family through its contracts with the Centers for Medicare and Medicaid Services.
Entire Agreement/Amendments/Multiple Originals. The Agreement, together with any attachments,

exhibits, or applicable Provider Manual(s), as amended from time to time, set forth the entire Agreement between
the parties with respect to the subject matter. Any prior purchase orders, agreements, promises, negotiations, or
representations, whether oral or written, not expressly set forth in the Agreement, are of no force or effect. The
Agreement shall be executed in multiple originals, one for Participating Provider and the other for GHP Family.
The parties agree that the Agreement shall be automatically amended to comply with applicable federal and state
laws and regulations; otherwise, the Agreement may not be amended except in writing, signed by the parties.
Exhibits. All exhibits within the Agreement are incorporated by reference and made part of the Agreement as if
they were fully set forth in the text of the Agreement.
Governing Law. The Agreement shall be deemed to have been made and shall be construed and interpreted in
accordance with the laws of the Commonwealth of Pennsylvania, and the parties hereto agree to the jurisdiction of
the Commonwealth of Pennsylvania.
Indemnification. Participating Provider and GHP Family agree to protect, indemnify and hold harmless the other
party(s) from and against any and all loss, damage, cost and expense (including attorneys’ fees) which may be
suffered or incurred under the Agreement as a result of the negligent or intentional acts of the indemnifying party,
its employees, agents, consultants or subcontractors. Said indemnity is in addition to any other rights that the
indemnified party may have against the indemnifying party and will survive the termination of the Agreement.
Insurance. The parties agree to maintain, at its own cost and expense, insurance coverage as necessary and
reasonable to insure itself and its employees and agents in connection with the performance of its duties and
responsibilities under the Agreement. Upon request, the parties agree to provide one another with a Certificate of
Insurance evidencing said insurance coverage. Participating Provider shall notify GHP Family within ten (10) days
of the cancellation or material alteration of such coverage.
Notices. All notices and communications hereunder shall be in writing and deemed given, when personally
delivered to or upon receipt when deposited with the United States Postal Service, certified or registered mail,
return receipt requested, postage prepaid; a nationally recognized overnight courier, with all fees prepaid; or e-
mail addressed as set forth on the first page of the Agreement or to such other person and/or address as the party
to receive may designate by notice to the other.
Notification of Incidents. The parties agree to notify the other party (s) within twenty-four (24) hours after the
discovery of any incidents, occurrences, claims or other causes of action involving the Agreement. Upon receipt of
discovery by any party of any incident, occurrence, claims (either asserted or potential), notice of lawsuit or lawsuit
involving the Agreement, said party agrees to immediately notify the other party(s). The parties hereto agree to
provide complete access, as may be provided by law, to records and other relevant information as may be
necessary or desirable to resolve such matters. This Section shall survive the termination of the Agreement.
Other Parties. The Agreement is solely between the parties hereto and is not intended to be enforceable by any
other party or to create any express or implied rights hereunder of any nature whatsoever in any other party.
Partial Invalidity/Interpretation. If any term or provision of the Agreement is determined to be invalid or

unenforceable, the remainder of the Agreement will not be affected thereby. The section headings in the
Agreement are solely for reference purposes. Participating Provider acknowledges that portions of the Agreement
24
are subject to review by Governmental Agencies and/or their designated representatives, as applicable, and if
such Governmental Agencies and/or their designated representatives require any material change to the terms
and conditions of the Agreement, Participating Provider agrees to renegotiate the affected terms and conditions
upon being notified of such required change by GHP Family.
Promotional Materials. Participating Provider consents to GHP Family’s use of its name, address and the names
and professional designations of its healthcare professionals in traditional membership and marketing materials.
The parties hereto agree not to use the name of or any trademark, service mark or design registered to the other
parties or their affiliates or any other party in any additional publicity, promotional or advertising material, unless
review and written approval of the intended use shall first be obtained from the releasing party(s) prior to the
release of any such material. Said approval shall not be unreasonably withheld by any of the parties.
Notwithstanding anything to the contrary in the preceding sentences, GHP Family shall have the right to publish
Participating Provider’s summary rating as part of GHP Family’s Physician Quality Summary Program without
obtaining the consent by Participating Provider prior to the release of such rating.
Relationship Among Parties. The parties hereto expressly acknowledge and agree that: (i) GHP Family’s duties
and responsibilities under the Agreement apply solely to GHP Family Members; (ii) in its capacity as third-party
administrator, Company’s duties and responsibilities under the Agreement apply to Members of an Employer-
Sponsored Program; and (iii) with the exception of (ii) of this Section, Company’s duties and responsibilities under
the Agreement apply to Company Members. Each party hereto shall be considered independent entities with
respect to each other. None of the provisions of the Agreement are intended to create nor shall be deemed or
construed to create any relationship between the parties other than that of independent entities contracting with
each other solely for the purpose of effecting the provisions of the Agreement. Neither the parties nor any of their
respective agents or employees shall be construed to be the agent, employee, joint Employer or representative of
the other. The parties shall not have any express or implied rights or authority to assume or create any obligation
or responsibility on behalf of or in the name of the other, except as may be otherwise set forth in the Agreement.
Release of Information. The provisions of the Agreement are confidential and protected from disclosure to any
other party unless: (i) otherwise provided for in the Agreement; (ii) disclosure is required by GHP Family, an
Employer or Participating Provider to meet any federal, state or local rule, law or regulation; or (iii) any party hereto
engages a third party for purposes such as quality assurance or auditing.
Unforeseen Circumstances. In the event either party’s operations are substantially interrupted by war, fire,
insurrection, the elements, earthquakes, acts of God or, without limiting the foregoing, any other cause beyond the
control of the affected party (including the GHP Family no longer meeting all material requirements imposed on
GHP Family by Federal or State law resulting in a significant impact on the GHP Family’s operations), the affected
party shall be relieved of its obligations only as to those affected portions of this Agreement for the duration of
such interruption. In the event that the performance of the affected party hereunder is substantially interrupted
pursuant to such event, the other party shall have the right to terminate this Agreement upon ten (10) days’ prior
written notice to the affected party.
Waiver. Failure of a party to complain of any act or omission on the part of another party shall not be deemed to
be a waiver. No waiver by a party of a breach of the Agreement will be deemed a waiver of any subsequent
breach. Acceptance of partial payment will be deemed a part payment on account and will not constitute an accord
and satisfaction.
25
PRIMARY CARE PROVIDERS (PCPs)
A Primary Care Provider (PCP) is a specific physician, physician group or a Certified Registered Nurse Practitioner
(CRNP) operating under the scope of his/her licensure, and who is responsible for supervising, prescribing, and
providing primary care services; locating, coordinating and monitoring other medical care and rehabilitative
services and maintaining continuity of care on behalf of the Member. Additional PCP responsibilities include, but
are not limited to:
• Providing primary and preventive care and acting as the Member’s advocate, providing, recommending, and
arranging for care.
• Documenting all care rendered in a complete and accurate encounter record that meets or exceeds the DHS
data specifications.
• Maintaining continuity of each Member’s health care.

• Communicating effectively with the Member by using sign language interpreters for those who are deaf or hard
of hearing and oral interpreters for those individuals with LEP when needed by the Member. Services must be
free of charge to the Member.
• PCPs are responsible for initiating and coordinating referrals of Members for Medically Necessary services
beyond the scope of their contract of practice. PCPs must monitor the progress of the referred Members’ care.
• Maintaining a current medical record for the Member, including documentation, of all the services provided to
the Member by the PCP, as well as any specialty or referral services.
• Arranging for Medically Necessary Behavioral Health Services for Members by appropriate referrals to a
HealthChoices Behavioral Health – Managed Care Organization (BH-MCO) in accordance with the
specifications of the provider agreement.
MEMBER ASSIGNMENT TO PCP

Upon enrollment, Members may choose a PCP for themselves and any other eligible family Members. Any
Member who does not select a PCP within fourteen (14) Business Days of enrollment will automatically be
assigned to a PCP.
If the Member is dissatisfied with the auto-selection assignment or wishes to change their PCP for any other
reason, the Member may choose an alternative PCP at any time by calling Customer Care. GHP Family will
promptly grant the request and process the PCP change in a timely manner.
GHP Family manages each PCP’s panel to automatically stop accepting new Members after the limit of 1,000
Members has been reached. Upon contracting with GHP Family, if the PCP/PCP Site employs Certified
Registered Nurse Practitioners/Physician Assistants, then the Provider/Provider Site will be permitted to add an
additional 1,000 Members to the practice’s panel. Other exceptions to the 1,000 Member panel policy will be
considered on a case-by-case basis. Please contact your GHP Family Provider Account Manager for more
information.
Assignment of Newborns
Newborns are immediately enrolled in the program and all Medically Necessary services are provided to
newborns. GHP Family makes every effort to identify what PCP/pediatrician the mother chooses to use for the
26
newborn prior to the birth, so that the provider chosen by the parent can be assigned to the newborn on the date of
birth.
Hospitals need to notify the Member’s County Assistance Office (CAO) as soon as the Member gives birth to
ensure that the newborn will be appropriately enrolled in Medical Assistance and in GHP Family. Payment for
deliveries will be delayed to the extent that accurate enrollment can be confirmed.
CHANGING PCPS
If a Member is dissatisfied with the auto-selection assignment or wishes to change their PCP for any other reason,
the Member may choose an alternative PCP at any time by calling the Customer Care number on the back of their
GHP Family identification card. GHP Family will promptly grant the request and process the PCP change in a
timely manner. Members will receive a new ID card indicating the new PCP’s name.
GHP Family maintains policies and procedures allowing Members to select or be assigned to a new PCP
whenever requested by the recipient when a PCP is terminated from the Network or when a PCP change is
required as part of the resolution to a Grievance or Complaint proceeding.
In cases where a PCP has been terminated for reasons other than cause, GHP Family informs Members assigned
to that PCP within thirty (30) days prior to the effective date of the PCPs termination to allow them to select another
PCP prior to the PCP’s termination effective date. In cases where a Member fails to select a new PCP, the Member
is reassigned to another compatible PCP prior to their previous PCP’s termination date, informing the Member of
the change in writing.
Please Note: Upon notification from DHS that a Participating Provider is suspended or terminated from
participation in the Medicaid or Medicare Programs, GHP family will immediately act to terminate the provider from
participation. Terminations for loss of licensure and criminal convictions must coincide with the MA effective date
of the action.
SPECIALTY CARE PROVIDERS (SCP)

The PCP is responsible for initiating, coordinating and documenting orders to Specialty Care Providers (SCPs)
within the GHP Family Network. Members may request a second opinion from providers within the Network. If
there is not a second provider with the same specialty in the Network, Members may request a second opinion
from a provider out of Network at no charge to the Member.
SCPs must coordinate with the PCP when Members need an order to see another provider. Upon request, such
records must be shared with the appropriate providers and forwarded at no cost to the Member or other providers.
SCPs are responsible for obtaining orders from physicians and bringing Members into compliance with medical
treatment plans.
Members with a disease or condition that is life threatening, degenerative, or disabling may request a medical
evaluation. If evaluation standards are met, Members will receive one of the below:
• A standing order to a SCP for treatment of their disease or condition. If a Member needs ongoing care from a
SCP, GHP Family will authorize, if Medically Necessary, a standing order to the SCP with clinical expertise in
treating the Member’s disease or condition. In these cases, GHP Family may limit the number of visits or the
period during which such visits are authorized and may require the SCP to provide the PCP with regular
updates on the specialty care provided, as well as all necessary medical information.
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• A designated SCP to provide and coordinate both primary and specialty care for the Member. The SCP
treating the Member’s disease or condition will serve as the Member’s PCP, coordinating care and making
referrals to other SCPs, as needed.
Please refer to Medical Management & Prior Authorizations section of Manual for more information.
SCP AS PCP
A Member may select a SCP to act as PCP if she/he has a disease or condition that is life threatening,
degenerative, or disabling. The SCP as a PCP must agree to provide or arrange for all primary care, consistent
with GHP Family preventive care guidelines, including routine preventive care, and to provide those specialty
health care services consistent with the Member's special need in accordance with GHP Family’s standards and
within the scope of the specialty training and clinical expertise. To accommodate the full spectrum of care, the
SCP as a PCP also must have admitting privileges at a hospital in GHP Family’s Network.
PCPs are responsible for initiating and coordinating referrals of Members for Medically Necessary services beyond
the scope of their contract of practice. PCPs and SCPs must monitor the progress of the referred Members’ care
and SCPs must see that Members are returned to the PCP’s care as soon as medically appropriate.
SCP’s can contact the GHP Family Special Needs Unit at 855-214-8100
APPOINTMENT STANDARDS
GHP Family works with providers to outreach to HealthChoices Members concerning appointments for
Medically Necessary care, preventive care and scheduled screenings and examinations. Contracted GHP Family
providers are responsible to adhere to the appointment availability standards for Members. Providers must monitor
the adequacy of their appointment processes and reduce unnecessary emergency room visits.
Appointment
Member Provider Type Appointment Standard(s)
Type
Emergency Recipients must be seen
Medical All PCP immediately or referred to an
Condition emergency facility.
Urgent Medical PCP

All Appointments within 24 hours
Condition
Emergency
Medical All SCP Appointments immediately
Condition
Urgent Medical SCP
All Appointments within 24 hours
Condition
Appointments must be
Routine All PCP scheduled within 10 Business
Days.
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Dermatology
Dentist
Orthopedic Surgery
Otolaryngology
Pediatric:
• Allergy &
Immunology
• Endocrinology
• Gastroenterology Appointments must be
• General Surgery
Specialty All scheduled within 15 Business
• Hematology Days.
• Infectious Disease
• Nephrology
• Neurology
• Oncology
• Pulmonology
• Rehab
• Rheumatology
• Urology
• Dentistry
Specialty All All Other Specialty scheduled within 10 Business
Days.
Health
All PCP scheduled within three (3) weeks
Assessment
of enrollment.
scheduled within seven (7) days
HIV/AIDs
Initial of enrollment unless the
Recipients PCP or SCP
Appointment Member is already in an active
care with a PCP or SCP.
scheduled within 45 days of
SSI
enrollment unless the Member is
Recipients
PCP or SCP already in an active care with a
PCP or specialist.
Initial Prenatal
Pregnant OB/GYN or Certified
Care
Recipients Nurse Midwife
Appointment
Appointments must be scheduled
First within 10 Business Days of the
Trimester Member identified as being
pregnant.
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Second
within five (5) Business Days of
Trimester
Member being identified.
within four (4) Business Days of
Third
Member identified as being
Trimester
pregnant.
High Risk within 24 hours of identification of
Pregnancy high risk or immediately if an
emergency exist.
scheduled within 45 days of
EPSDT Under age enrollment unless the child is
PCP
Screens 21 already under the care of a PCP
and current with screens.
GHP Family’s appointment availability standards reflect minimum requirements. GHP Family routinely monitors
providers for compliance with these standards. Noncompliance may result in the initiation of a corrective action
plan or further corrective actions.
PCP WAIT TIMES

Waiting time standards for PCPs require that Members, on average, should not wait at a PCP office for more than
thirty (30) minutes for an appointment for routine care. On rare exceptions, if a physician encounters an
unanticipated urgent visit or is treating a Member with a difficult medical need, the waiting time may be expanded
to one (1) hour. GHP Family monitors compliance with appointment and waiting time standards and works with
providers to ensure that these standards are met.
APPOINTMENT NOTIFICATION AND FOLLOW-UP

GHP Family requires that PCP’s, Dentists, and Specialists conduct affirmative outreach whenever a Member
misses an appointment and to document this in the medical record. Such an effort shall be deemed to be
reasonable if it includes three (3) attempts to contact the Member. Such attempts may include, but are not limited
to written attempts, telephone calls, and home visits. At least one (1) such attempt must be a follow up telephone
call. Communications with the Member should take the language and literacy capabilities of Members into
consideration.
EARLY PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT (EPSDT)

Early Periodic Screening, Diagnosis, and Treatment (EPSDT) services are federally mandated services intended
to provide preventive health care to children and young adults (under the age of 21 years) at periodic intervals
which are based on the recommendations of the American Academy of Pediatrics (AAP), and the Centers for
Disease Control and Prevention (CDC). All PCPs who provide services to Members under age twenty-one (21) are
required to provide comprehensive health care, screening, and preventive services. GHP Family requires Network
PCPs to provide all EPSDT services in compliance with federal and state regulations and periodicity schedules.
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EPSDT screens for any new Member under the age of twenty-one (21) must be scheduled within forty-five (45)
days from the effective date of Enrollment unless the child is already under the care of a PCP and the child is
current with screens and immunizations. Members with suspected developmental delays under the age of five (5)
are required to be referred by their PCP through CONNECT (800) 692-7288 for referral for local Early Intervention
Program services.
GHP Family will distribute quarterly lists to each PCP that identify Members who have not had an encounter during
the first six (6) months of enrollment or Members who have not complied with EPSDT periodicity and immunization
schedules for children. PCPs shall be responsible to contact all Members who have not had an Encounter during
the previous twelve (12) months or within the MA appointment time frames. These EPSDT Member lists are also
available upon request from GHP Family.
Please reference the most recent periodicity guidelines published on the Pennsylvania DHS Web site at:
https://www.dhs.pa.gov/.
SCHOOL-BASED HEALTH SERVICES

School-based health services can play a pivotal role in ensuring children receive the health care they need. PCPs
are required, with the assistance of GHP Family, to coordinate and/or integrate into the PCP's records any health
care services provided by school-based health services. GHP Family‘s Special Needs Unit can assist PCPs with
the coordination of services among the PCP, parents or guardians, and other providers.
SUSPECTED CHILD ABUSE OR NEGLECT

When the County Children and Youth Agency system notifies GHP Family or a Participating Provider suspects a
potential case of child neglect and/or abuse of a HealthChoices Member, GHP Family works with the agency and
the Participating Providers to ensure that the Member receives timely physical examinations for the abuse or
neglect in accordance with the Child Protective Services Law, 23 Pa. C.S. 6301 et seq. and DHS regulations. If a
Participating Provider determines that a mental health assessment is needed, the Participating Provider must
inform the Member or the County Children Youth Agency representative of how to access mental health services
and coordinate access to these services, when necessary. GHP Family’s Special Needs Unit can assist providers
as necessary to connect with local county agencies to remain compliant with mandatory reporting requirements.
In addition to conducting physical examinations, providers must proactively report suspected abuse and/or neglect
of HealthChoices Members. Participating Providers can report abuse to the DHS’s ChildLine at: (800) 932-0313;
TDD: 866-872-1677. ChildLine accepts calls from the public and professional sources 24 hours/day, 7 days/week.
The ChildLine provides information, counseling, and referral services for families and children to ensure the safety
and well-being of the children of Pennsylvania.
Professionals who have reasonable cause to suspect that a child has been abused are required to file a report.
The individual may remain anonymous. Each call to ChildLine is answered by a trained intake specialist who will
interview the caller to determine the most appropriate course of action. Actions include forwarding a report to a
county agency for investigation as child abuse or general protective services, forwarding a report directly to law
enforcement officials or refer the caller to local social services (such as counseling, financial aid, and legal
services).
For additional information on how to assist children and families, please visit the Child Welfare Services section of
the DHS’s Website https://www.dhs.pa.gov/.
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REPORTABLE CONDITIONS
In accordance with 28 Pennsylvania Code 27.1 Providers must comply with mandatory reporting requirements for
Members with identified communicable diseases. A complete listing of responsibilities and disciplinary actions for
failure to comply with said requirements by the Pennsylvania licensing boards can be found at:
https://www.pacodeandbulletin.gov/Display/pacode?file=/secure/pacode/data/028/chapter27/chap27toc.html&d=re
duce. A quick summary of the provider responsibilities includes requirements to:
• Report an outbreak within 24 hours in accordance with § 27.4 (relating to reporting cases).
• Report a suspect public health emergency or an unusual occurrence of a disease, infection or
condition not listed as reportable in Subchapter B (relating to reporting of diseases, infections, 24
and conditions) or defined as an outbreak, within 24 hours, and in accordance with § 27.4.
• Report any unusual or group expression of illness which the Department designates as a public health
emergency within 24 hours, and in accordance with § 27.4.
GHP Family will conduct random chart audits on an annual basis to verify compliance with this requirement. For
assistance in contacting the designated local county/municipal health department, please contact the Special
Needs Unit.
INFECTION CONTROL MEASURES

GHP Family wants to ensure providers exercise approved and effective infection control practices. The Guide to
Infection Control Prevention for Outpatient Settings: Minimum Expectations for Safe Care, produced by the
Centers for Disease Prevention can be found at: https://www.cdc.gov/Infectioncontrol/index.html
RETURN COMMUNICATION
Specialty Providers are responsible for providing the Member’s PCP with information pertaining to the Member’s
recent episode of care or treatment after each visit or as often as necessary according to federal and/or state laws.
PCPs should accurately file written correspondence in the Member’s medical record and review such material to
assure coordination of the Member’s care.
GHP Family provides the “Obstetrical Needs Assessment Form" (ONAF) and the "Retinal Evaluation/Examination
Form” to applicable Participating Providers. Contact your Provider Account Manager for a supply of these forms.
PCP PRACTICE ACCEPTANCE STATUS AND MEMBER LIMITATIONS

In the event a PCP determines it is necessary to limit their clinical practice to new Health Plan membership
because of the PCP practice member capacity, the following conditions are required:
• Advanced written notification of a minimum of thirty (30) Business Days prior to effective date of the limitation.
• PCP acknowledges that they will continue to accept all current Health Plan membership and will continue to
provide Medical Services to assigned Member(s), regardless of a pre-existing physician-patient relationship.
• PCP acknowledges that changing to “accepting existing patients only” status represents that they will continue
to accept all patients who may change to Health Plan coverage and the change will not be published in written
Member and/ or provider material until next acceptable printing.
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• PCP must concurrently establish a limited membership acceptance status with all other managed care plans
with which PCP participates.
REFERRALS
Primary care providers (PCPs) —no longer need to submit referrals for GHP Family patients to see a specialist.
Specialty care providers (SCPs) —no longer need to check for a valid referral from GHP Family patient’s PCP to
care for your patient.
It’s important to remember that prior authorization requirements for certain specialty or out-of-network services
remain in effect. Check our prior authorization lists at: https://www.geisinger.org/-
/media/OneGeisinger/Files/PDFs/Provider/PriorAuthList.pdf?la=en, to see which services and medications need to
be approved for coverage.
We value the PCP-centered care model, so we’ll always ask our GHP Family members to keep their PCP
informed about specialty services they receive elsewhere.
DIRECT ACCESS AND SELF-REFERRAL

The following services do not require a referral from the PCP:
• Vision
• Dental care
• Obstetrical and Gynecological (OB/GYN) services
• Chiropractic services may be accessed in accordance with the process set forth in Medical Assistance Bulletin
15-07-01
• Physical therapy services may be accessed in accordance with the amended Physical Therapy Act (63 P.S.
1301 et seq.)
Please Note: To be self-referred, the Member must obtain these self-referred services from GHP Family’s
Network.
Family Planning Services do not require Prior Authorization or referral. Members may access Family Planning
Services from any qualified provider. Family Planning Services include, but are not limited to:
• Health Education
• Counseling necessary to make an informed choice about contraceptive methods
• Pregnancy testing and breast and cervical cancer screening services
• Contraceptive supplies such as oral birth control pills, diaphragms, foams, creams, jellies, condoms (male and
female), Norplant, injectables, intrauterine devices, and other family planning procedures
• Diagnostic screens, biopsies, cauterizations, cultures, and assessments
• Members have direct access to OB/GYN services and have the right to select their own OB/GYN provider; this
includes nurse midwives participating in GHP Family’s Network. They can obtain maternity and gynecological
care without prior approval from a PCP. This includes:
o Selecting a provider to give an annual well-woman gynecological visit

o Primary and preventive gynecology care
o PAP smear and referrals for diagnostic testing related to maternity and gynecological care, and
Medically Necessary follow-up care
33
o Perinatal and Postpartum maternity care
In situations where a new pregnant Member is already receiving care from an out-of-Network OB-GYN SCP at the
time of enrollment, the Member may continue to receive services from that SCP throughout the pregnancy and
postpartum care related to the delivery.
SUBSTANCE ABUSE AND BEHAVIORAL HEALTH

Many behavioral health disorders such as depression, anxiety and substance abuse often occur in Members who
present for medical care. PCPs and all non-behavioral health practitioners are encouraged to recommend
behavioral health services to Members when deemed appropriate. Substance abuse and behavioral health
services are available to all GHP Family Members through the Member’s local county mental health office or that
office’s sub-contracted provider. PCP must inform the Member or the County Children and Youth Agency
representative how to access these mental health services and coordinate access to these services, when
necessary. To refer GHP Family Members for these services, please reference the behavioral health contact
information table in the Contact Information section of this manual for county, provider, and contact details.
Members may also self-refer.
MEDICAL MANAGEMENT & PRIOR AUTHORIZATIONS
MEDICAL MANAGEMENT PLAN

The Medical Management Plan defines and clarifies the structure and function of the Medical Management
Department. This document provides a definition of authority and accountability for medical management activities
within the organization, articulates the scope and content of the Medical Management program, identifies the roles
and responsibilities of individuals involved, and outlines the program evaluation process.
A copy of the complete MM Plan can be requested from GHP Family's Medical Management Department.
MEDICAL MANAGEMENT STATEMENT

Participating Providers are reminded that utilization criteria is available upon request. Participating Providers may
request a copy of the applicable criteria as part of the utilization decision phone conversation, by fax or U.S. mail,
or through discussion with the respective Medical Director. Criteria can be requested in writing from the Medical
Management Department at:
Medical Management Department

100 N. Academy Ave.
Danville, Pa 17822-3220.
Phone: (800) 544-3907 or (570) 271-6497; Mon. through Fri., 8 a.m. to 5 p.m.
Fax: (570) 271-5534
QUALITY MANAGEMENT PLAN

The Geisinger Health System’s mission is to enhance the quality of life through an integrated health service
organization based on balanced patient care, education, research, and community service. GHP Family supports
the overall mission of Geisinger Health System. The GHP Family Quality Management (QM) Plan provides the
structure and processes for continuously monitoring, analyzing, and improving the clinical care and services
provided under GHP Family products to further that mission.
34
The scope of the QM Plan is comprehensive in nature, allowing for improvement, and is consistent with the DHS’s
goals related to access, availability, and quality of care.
A copy of the complete QM Plan can be requested from your Provider Account Manager.
POPULATION MANAGEMENT PROGRAMS

GHP Family’s Case Management Department offers Population Management Programs for Members across the
healthcare continuum including Case Management and Disease Management programs to assist Members with
chronic conditions.
GHP Family’s Case Management Department engages patients as part of a collaborative process that assesses,
plans, implements, coordinates, monitors, and evaluates the options and services required to meet an individual’s
health needs, using communication and available resources to promote quality and cost-effective outcomes.
Providers may contact GHP Family Special Needs Unit at 855-214-8100.
GHP’s Family Case Management Department is responsible for the delivery of Case Management/Disease
Management programs to Insured Individuals. GHP Family provides the following services and programs:
Case Management
Case Managers work in collaboration with the PCP to manage patients with complex co-morbid conditions. The
Case Manager completes a comprehensive assessment and prioritizes the patient’s needs that allow the provider,
Member and/or Member representative, and Case Manager to develop a patient centric plan of care and self-
management action plan. Post discharge transitions of care are integral to this patient centered model and include
medication reconciliation, confirmation that services are in place (i.e., home health and durable medical
equipment), and that there is adequate social support in place. Case Managers facilitate a five (5) to seven (7) day
follow-up appointment with the PCP as this is essential to the continuity of care.
For advanced illness, case managers will facilitate palliative care, home health and hospice referrals and the
Physician Orders for Life-Sustaining Treatment (POLST) form, if appropriate. Contact your Provider Account
Manager for a supply of this form. Advanced directives are facilitated for all Members and are discussed further in
the Advanced Directives section of this manual.
Heart failure and COPD are progressive conditions that are managed by case managers in collaboration with the
PCP/SCP.
Heart Failure
An ongoing combination of education and management that provides patient education and activation, teaching
Members the importance of medications, symptom monitoring that includes daily weights and exacerbation
management. Diuretic protocols may be implemented as part of the treatment plan that can be initiated by the
Member or family, if determined appropriate by the provider. Diet and life-style habits are also part of the education
process to improve the management of heart failure. Overall effort is to manage the condition and improve the
Member’s quality of life.
Chronic Obstructive Pulmonary Disease (COPD)

The Chronic Obstructive Pulmonary Disease (COPD) Program helps Members with COPD to better manage the
condition through the inclusion of pulmonary function testing, education, medication management and symptom
35
monitoring including COPD Rescue Kits, if appropriate, in the treatment plan. Information about tobacco cessation
and life-style modification is provided by a Case Manager.
Complement the Care provided by the PCP and/or SCP

Case Managers/Health Managers work with Members and the PCP/SCP to assist Members in the community with
chronic health/social problems. The Case Managers/Health Managers also provides monitoring and education to
help Members better manage the following health conditions: The following programs are available for all
Members:
Adult and Pediatric Asthma

Education is a key factor in the Asthma Care Program. Nurse Case Managers/ Respiratory Therapists work with
Members and their families to help them understand and manage asthma triggers and symptoms and adhere to
treatment plans. Case Managers/Health Managers work with Members to educate them about medications, proper
use of inhalers, spacers, nebulizers, and peak flow monitoring. The Case Manager/Health Manager collaborates
with the PCP/SCP to develop an individualized Asthma Action Plan with the Member.
Chronic Kidney Disease (CKD)

The purpose of the CKD program is to improve the coordination of appropriate services with a PCP or nephrologist
for Members with kidney disease. Case Managers/Health Managers provide education about the importance of
proper nutrition, medications, blood pressure control, and other important health care information.
Diabetes
Members in the Diabetes Care Program work with a Case Manager/Health Manager who provides education
including pathophysiology, medications, dietary management, exercise and other selfcare strategies that will assist
Members in taking control of their diabetes. The Case Managers/Health Managers coordinate services for
Members that facilitate standards of care and Healthcare Effectiveness Data and Information Set ( HEDIS® )
measures to ensure quality.
Coronary Artery Disease (CAD)

Managing risk factors and promoting proper medication management is the focus of the CAD program for
Members with heart disease. Cholesterol and blood pressure management are key aspects of the program. Case
Managers/Health Managers also provide education about diet and exercise strategies, and work with providers to
coordinate recommended therapies.
Hypertension
Case Managers/Health Managers assist Members in learning what they can do to control blood pressure and
reduce the risk of developing other health problems that can result from poorly controlled blood pressure.
Education and optimizing a treatment plan are key to “moving a Member to Goal”.
Osteoporosis
This program provides education to women and men at risk for osteoporosis, as well as those who have already
been diagnosed. Case Managers/Health Managers outline steps to prevent osteoporosis and to reduce the risk of
complications. Case Managers/Health Managers work with providers to facilitate Dexa Scans and appropriate
therapy with patients, as appropriate.
Tobacco Cessation (teen and adult)

In the Tobacco Cessation Program, professional support is provided by Case Managers/Health
Managers/Wellness Coaches through phone, group, web-based, or individual coaching. The program goal is to
help break the addiction to tobacco products such as cigarettes, pipes, and smokeless tobacco, and help
Members quit.
36
Well on Your Weigh (weight management)
Designed for both adults and children, the program focuses on developing a healthy lifestyle rather than dieting.
Members work with Case Managers/Health Managers/Wellness Coaches to set manageable goals, eat healthy
and stay active to control their weight long term.
To refer a Member to a Case Management/Disease Management Program, or to learn more about a specific Case
Management/Disease Management Program, Participating Providers should visit GHP Family’s Provider
Information Center at www.ghpfamily.com or contact the Case Management Department at (570) 271-8763 or toll
free (800) 883-6355, Monday through Friday from 8:00 a.m. to 4:30 p.m.
DISEASE MANAGEMENT PROGRAM DEVELOPMENT

Case Management conducts an analysis of the disease under consideration prior to the development of a Case
Management/Disease Management program. The following criteria are evaluated:
• Disease prevalence
• Disease complexity
• Potential for reducing complications, improving quality of life
• Current cost of managing the disease
• Existence of an evidence-based clinical guideline to assist practitioners in the management of the disease
• Value to the Participating Provider, Member and GHP Family if the program is implemented
Case Management leadership determines the need for a specific Case Management/Disease Management
program based upon the criteria listed above and submits a proposal to GHP Family’s Medical Management
Administrative Committee and Quality Improvement Committee for review and approval. Actively practicing
practitioners are participating Members of Case Management/Disease Management teams and assist in the
development, implementation, and monitoring of new and established Case Management/Disease Management
programs.
PRACTITIONER PROGRAM CONTENT

The design of all Case Management/Disease Management programs includes but is not limited to: evidence-
based clinical guidelines, Member identification, passive or active enrollment, stratification, interventions based on
stratification level, practitioner decision support and evaluation of program effectiveness.
Evidence-based clinical guidelines are a core component of all Disease Management programs. Board certified
SCPs and/or PCPs are involved in the review and approval of evidenced-based guidelines.
Clinical guidelines are reviewed every two years or when the appropriate guideline team, GHP Family’s Guideline
Committee and the Quality Improvement Committee make recommendations. Identified primary and SCPs are
involved in the development and review of new Case Management/Disease Management programs.
GHP Family’s Case Management Department and the accompanying teams are responsible for program content
that is consistent with current clinical practice guidelines.
Evidence-based guidelines are posted online at www.ghpfamily.com, and announcements are made in the
monthly provider update, to inform practitioners of their availability. Printed copies or electronic PDF files are
available upon request for practitioners who do not have Internet access by contacting GHP Family’s Case
Management department at (570) 271-8763 or toll free (800) 883-6355, Monday through Friday from 8:00 a.m. to
5:00 p.m.
37
Identification of Members who benefit from Case Management/Disease Management programs is accomplished
through Claims analysis using standard clinical specifications from criteria such as the HEDIS®. Member
identification is also facilitated by direct referrals from primary and SCPs, the Member and/or family, and from
various GHP Family departments including Medical Management, Customer Care, Appeals, and Quality
Improvement.
ENROLLMENT AND PATIENT PARTICIPATION

All Members with a disease-specific diagnosis are identified by Claims analysis and/or HEDIS® criteria and mailed
a disease-specific informational newsletter. Members are informed of their enrollment in the program and can “opt
out” by contacting GHP Family’s Case Management Department.
All enrollees receive disease-specific informational newsletters each year to increase their knowledge of disease
self-management. Each newsletter also encourages the Members to become “active” participants in the disease
management program(s).
A Member becomes actively enrolled in the appropriate disease management program when the Member contacts
GHP Family’s Case Management Department directly, is referred by a Health Care Provider or a GHP Family
department, or accepts an invitation extended by GHP Family’s Case Management Department (through disease-
specific Member newsletters or direct Member invitation by letter or phone as the result of Claims analysis
information).
A Case Manager/Health Manager reviews the referral information and contacts the Member to either schedule an
office appointment with the Proven Health Navigator Health/Case Manager or to arrange to routinely communicate
with the Member telephonically. After the Member’s verbal and/or written consent for participation is obtained, the
Member is actively enrolled in the appropriate program.
RISK STRATIFICATION
Case Managers/Health Managers stratify active Members based on clinical criteria according to low, moderate, or
high risk. For example, Members enrolled in the Congestive Heart Failure program are stratified according to the
American College of Cardiology (ACC). Members with diabetes are stratified using glycosylated hemoglobin (A1c)
control and the presence of risk factors.
INTERVENTIONS
The degree of intervention is based on the Member’s risk stratification. For example, a Member classified as low
risk receives a minimum of one (1) program informational newsletter each year, self-management education, a
plan of care, and one or more follow-up office or phone appointments. A Member with a high- risk stratification
receives these interventions in addition to more frequent office/phone visits and referrals for necessary specialty or
case management services.
PRACTITIONER DECISION SUPPORT

The Case Management/Disease Management decision support model includes evidence-based clinical guidelines
(previously described), Case Managers/Health Managers, the plan of care, and the Practitioner Quality Feedback
Report. The program is designed for actively practicing PCPs.
38
Case Managers/Health Managers are key to providing collaborative “real time” decision support to PCPs. The
Case Manager/Health Manager follow internally developed education Care Paths (Algorithms) that complement
the clinical guidelines. The education Care Paths (Algorithms) provide a framework for self- management
education, the recommended laboratory/diagnostic studies, and targeted clinical goals.
The plan of care includes information regarding the Member’s self-management of their condition, barriers, special
considerations or exceptions, review of medical test results, management of co- morbidities, collaborative goal-
setting and problem-solving, medication review, plans for follow-up, and preventive health monitoring. The plan of
care is reviewed and discussed by the PCP and/or SCP and the Case Manager/Health Manager in person, by
phone, or through an electronic medical record messaging process.
Additional decision support information is mailed to Participating Providers annually from the Case Management
administrative staff in the form of a letter accompanied by the Practitioner Quality Feedback Report.
The involvement of the practitioner is integral in the design of program content for all Case Management/Disease
programs. Practitioner participation ensures program content is appropriate for the actively practicing PCP. All
PCPs are surveyed annually to elicit feedback regarding the program(s).
EVALUATION OF PROGRAM EFFECTIVENESS

Program effectiveness is measured by conducting a pre-and post-analysis of pertinent clinical measures, annual
Member/practitioner program satisfaction surveys and pre- and post-comparisons of services utilized by Members
in the programs.
PRACTITIONER’S RIGHTS
Practitioners who care for Members have the right to:
• Obtain information regarding Case Management/Disease Management programs and services in conjunction
with GHP Family as outlined herein; and
• Obtain information regarding the qualifications of the Case Management staff; and
• Obtain information regarding how the Case Management staff facilitates interventions via treatment plans for
individual Members; and
• Know how to contact the Case Managers/Health Managers responsible for managing and communicating with
their patients; and
• Request the support of the Case Manager/Health Manager to make decisions interactively with Members
regarding their health care; and
• Receive courteous and respectful treatment from Case Management staff at all times; and
• File a Complaint when dissatisfied with any component of the Case Management/Health Management
programs by contacting the Case Management Department at (570) 271-8763, toll free at (800) 883- 6355, or
the Customer Care team at the number listed on your patient’s insurance card.
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PRIOR AUTHORIZATION (PRECERTIFICATION)
Precertification is GHP Family’s response to information presented relating to a request for specified health care
services.
Precertification does not guarantee a Member’s coverage or GHP Family payment.
A Member’s coverage is pursuant to the terms and conditions of coverage set forth in a Member’s applicable
benefit document.
A Member is not financially responsible for a Participating Provider’s failure to (i) obtain precertification, or (ii)
provide required and accurate information to GHP Family. Copayments are the financial responsibility of the
Member, when applicable.
A complete list of services requiring Prior Authorization is available online https://www.geisinger.org/health-

plan/providers/forms-and-resources-for-providers
PRECERTIFICATION DETERMINATION AND COMMUNICATION PROCESS

Precertification of services may be required and will be performed by GHP Family Medical Management staff, or
through delegated vendor relationships. Delegated vendors may review services such as, but not be limited to,
radiology and dental services.
Precertification staff, which includes appropriate practitioner reviewers, utilizes nationally recognized medical
guidelines as well as internally developed medical benefit policies, individual assessment of the Member, and
other resources to guide precertification, Concurrent Review, and Retrospective Review processes in accordance
with the Member’s eligibility and benefits.
Upon submission of required information, the precertification staff will provide the Member, the Member’s PCP,
and the prescribing provider with notification of the determination of coverage as expeditiously as the Member’s
health condition requires; or, at least orally, within two (2) Business Days of receiving the request, unless
additional information is needed. If no additional information is needed, GHP Family will mail written notice of the
decision to the Member, the Member’s PCP, and the prescribing provider within two (2) Business Days after the
decision is made.
If additional information is needed to decide, GHP Family will request such information from the appropriate
provider within forty-eight (48) hours of receiving the request and allow fourteen (14) days for the provider to
submit the additional information. If GHP Family requests additional information, GHP Family will notify the
Member on the date the additional information is requested, using the Request for Additional Information Letter
template supplied by the Department. If the requested information is provided within fourteen (14) days, GHP
Family will make the decision to approve or deny the service, and notify the Member orally, within two (2) Business
Days of receipt of the additional information. GHP Family will mail written notice of the decision to the Member, the
Member’s PCP, and the prescribing provider within two (2) Business Days after the decision is made. If the
requested information is not received within fourteen (14) days, the decision to approve or deny the service will be
made based upon the available information and the Member will be notified orally within two (2) Business Days
after the additional information was to have been received. GHP Family will mail a written notice of the decision to
the Member, the Member’s PCP, and the prescribing provider within two (2) Business Days after the decision is
made. In all cases, the decision to approve or deny a covered service or item will be made and the Member must
receive written notification of the decision no later than twenty-one (21) days from the date GHP Family receives
the request, or the service or item is automatically approved.
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When Precertification results in a denial of services, as defined in this manual’s Glossary, GHP Family will issue a
written notice of denial to the Member, and copy the Participating Provider, using the appropriate notice which
includes the Member’s appeal rights. In addition, the notice will be available in accessible formats for individuals
with visual impairments and for persons with limited English proficiency.
CONCURRENT REVIEW DETERMINATION AND COMMUNICATION PROCESS

As it relates to urgent Concurrent Review approvals, GHP Family has a process with Participating Providers that,
once approval has been given it remains in effect until GHP Family notifies the provider otherwise. This means
that as Concurrent Review of care is ongoing and the case continues to meet criteria for approval, GHP Family
does not provide repeated notices of approval.
When Concurrent Review results in a denial of services, as defined in this manual’s Glossary, GHP Family will
issue a written notice of denial to the Member, and copy the Participating Provider, using the appropriate notice
which includes the Member’s appeal rights. In addition, the notice will be available in accessible formats for
individuals with visual impairments and for persons with limited English proficiency.
Participating Providers are verbally notified of any pending medical review denial(s) and are offered the
opportunity to discuss pending adverse decision(s) directly with an appropriate practitioner reviewer making the
initial determination, or reviewer available at a time convenient for the Participating Provider. The Participating
Provider’s request to discuss the pending determination is required to occur within one (1) Business Day of GHP
Family’s pending verbal denial notification to meet stringent regulatory timelines for the generation of denial
notices. The Participating Provider can supply additional supportive information for discussion.
Please note: The Member only bears potential copay liability for a given service. Depending on whether the
Member exercises their appeal rights and the timeframe in which the Member does so, the Member may bear
potential payment for a given service only if the Member decides to receive a service after having been informed
before receiving the service that the Member will be liable to pay for the service.
Contact Medical Management at (800) 544-3907 or (570) 271-6497, Monday through Friday 8:00 a.m. to 4:30 p.m.
or fax (570) 271-5534. Medical Management’s IVR system is available 24 hours/day, 7 days/week.
AUTHORIZATION REQUIRED FOR PAYMENT

Any service, with or without an authorization, rendered by a Participating Provider and determined to be clinically
inappropriate by the Medical Director will be paid at an appropriate alternate level of care or payment will be
denied completely. Medical Director determinations are in accordance with individual Member’s needs,
characteristics of the local delivery system, applicable medical criteria and clinical expertise. At the time of a claim
payment denial, the Participating Provider is verbally notified of the option to speak with a Medical Director
regarding such payment denial. The Provider Appeal process is also available to Participating Providers for claims
payment issues.
MEDICAL BENEFIT POLICIES

A medical policy is the written description of GHP Family’s position concerning the use or application of a biologic,
device, pharmaceutical, or procedure, based on any or all of the following: Regulatory guidelines, clinical practice
guidelines, nationally accepted standards, and the findings and conclusions drawn from a complete Technology
Assessment (TA). Additionally, a medical policy is an informational resource that establishes the Medical
Necessity criteria for the biologic, device, pharmaceutical, or procedure. It also functions as an informational
resource by describing any special requirements for Claims processing.
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New and revised medical benefit policies, which include services deemed to require precertification, are
communicated online in the Clinical Policies section https://www.geisinger.org/health-plan/providers/ghp-clinical-
policies and in the provider update newsletter. The provider update is accessible on the GHP plan central page on
https://www.navinet.net. A hard copy may be obtained from your Provider Account Manager. A minimum of thirty
(30) days advance notice is provided regarding those services, which have been added to the GHP precertification
list. The precertification list can be found at https://www.geisinger.org/-
/media/OneGeisinger/Files/PDFs/Provider/PriorAuthList.pdf.
Participating Providers with questions about the above medical policies can contact the Medical Management
Department at the number listed below:
Phone: (800) 544-3907 or (570) 271-6497; Monday through Friday 8:00 a.m. to 4:30 p.m.
Fax: (570) 271-5534
VERIFICATION OF ELIGIBILITY AND BENEFIT LIMIT

Prior to coordinating health care services, a Member’s eligibility and benefits should always be verified through:
• DHS Eligibility Verification System (EVS) at (800) 766-5EVS (5387),

• https://www.navinet.net, or
• GHP Family Customer Care Team at (855) 227-1302
Except in an Emergency or as otherwise permitted in accordance with the terms and conditions of coverage set
forth in a Member’s benefit document, all healthcare services for a Member must be provided by and rendered in a
Participating Provider or must be approved in advance by the GHP Family Medical Director.
INPATIENT SERVICES
Requests for precertification of inpatient services (including planned hospital, inpatient rehabilitation, and skilled
level of care admissions) are the responsibility of the admitting Participating Provider.
REQUESTING PRECERTIFICATION
Providers will be able to request precertification for inpatient services through
https://coherehealth.com/provider/resources/ for all GHP Family patients. Cohere offers evidence-based care
suggestions, but Geisinger Health Plan Medical Management will still review requests and retain ultimate authority
over medical necessity determinations.
Check GHP Family’s precertification list frequently at https://www.geisinger.org/-

/media/OneGeisinger/Files/PDFs/Provider/PriorAuthList.pdf?la=en to know which services require authorization
submission through Cohere.
Visit the Cohere Learning Center at https://coherehealth.zendesk.com/hc/en-us/articles/10169953922327-Out-of-

Network-Exceptions for detailed user guides. Registration with Cohere is required to access the learning center.
Register with Cohere at https://coherehealth.com/provider/register/.
Cohere uses a team of nurses and doctors to make sure guidance during the request process is medically
appropriate and meets clinical guidelines. Here’s what happens when precertification is requested online through
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Cohere:
1. Cohere’s consultative request process guides the user through each step, providing patient-specific
suggestions that can expedite approval.
2. Requests are immediately relayed to Geisinger Health Plan Medical Management for review. Geisinger Health
Plan Medical Management will make a determination in accordance with the Precertification Determination and
Communication Process outlined above.
3. Upon approval, the authorization number populates in the portal.
When a request has received a final determination (approved, partially approved, or denied) Cohere will send the
submitter an email notification with the status of the authorization.
Using Cohere’s online portal is the most direct way to manage authorization requests. However, prior authorization
can also be requested using print and fax forms at https://www.navinet.net or https://www.geisinger.org/health-
plan/providers/forms-and-resources-for-providers.
INPATIENT ADMISSIONS EXCLUDED FROM PRECERTIFICATION:
• Emergency and/or Urgent Care inpatient admissions, which may be an (i) admission from an emergency room
that results in a direct admission, (ii) a direct admission from an ambulatory surgery center or (iii) an admission
directly from a physician’s office.
• An inpatient admission to a hospital provider where GHP Family is secondary to another payer who requires
precertification and authorization has been obtained from the primary carrier. However, notification for
Concurrent Review is required.
• A full-term pregnancy with intent to deliver, either vaginal or cesarean section. Please note: Inpatient hospital
admissions unrelated to the course of pregnancy may require precertification.
• A transfer from one hospital Participating Provider to another hospital Participating Provider where the first
inpatient admission was precertified and/or followed by GHP Family Concurrent Review and has been
determined appropriate for an acute inpatient level of care.
• Retrieval of a Member from a non-participating facility to a Participating Facility through GHP Family’s out- of-
Network retrieval process. Transfer may only occur at such time when the Member’s condition has stabilized,
and the Member can be transported safely to a Participating Facility without suffering detrimental
consequences or aggravating the Member’s condition.
• Observation services furnished by a hospital provider in an outpatient setting that include the use of a bed and
periodic monitoring by a hospital provider’s nursing or other staff and does not exceed a maximum of twenty-
three (23) hours in duration.
PLANNED INPATIENT ADMISSION

GHP will only require prior authorization for planned hospital admissions under the following circumstances:
• If any provider involved in a GHP patient’s care is considered a non-participating provider with that patient’s
plan
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• If the procedure being performed is an outpatient procedure, but the provider requests an acute inpatient level
of care
• If a GHP patient is being admitted to an acute inpatient rehabilitation or skilled nursing facility
• If the procedure being performed is a non-covered service under the GHP patient’s plan
• If the procedure being performed is a covered service designated as requiring prior authorization on GHP’s
prior authorization list
If any of the exceptions listed above hold true, prior authorization is required no less than two (2) business days
prior to the planned date of admission.
OBSERVATION SERVICES
Precertification is required for observation services expected to exceed twenty-three (23) hours.
NEWBORN NOTIFICATION
Information required from hospital providers to give notice of new births:
• Mother’s information
o Mother’s name, Member ID number, date of birth and contact information
o Facility name
o Reviewer’s name and contact information
o Date of admission
o Date of Discharge
o Diagnosis (vaginal or c-section delivery)
o Attending physician
• Baby’s information:
o Mother’s name and Member ID number
o Baby’s name, sex, and date of birth
o Baby’s weight and Apgar score
o Discharge/NICU/Detained
o Attending physician
o Baby’s primary care physician (if known)
Please note: GHP Family Medical Management staff is available to assist with discharge planning, especially for
complex or hard-to-place Members.
SNF SERVICES REQUIRING COORDINATION
• Hospice Election: The SNF or hospital provider is required to notify GHP Family’s Home Health/Hospice
Management Department at (877) 466-3001 immediately upon a Member’s decision to invoke their hospice
benefit. Notification should also be made to GHP Family’s Medical Management Department at (800) 544-
3907.
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• Personal Care Facility: GHP Family does not consider a Personal Care Facility (PCF) an institutionalized
facility, regardless of a PCF’s affiliation with a SNF or hospital provider. A PCF is considered an alternative to
home living. Excluding Emergency Services and Direct Access Services, Members residing in a PCF require
an Outpatient Referral Form issued by the Member’s PCP for Specialty consultative, evaluation and
management and surgical services.
• Infusion Therapy Services: Participating Providers are encouraged to refer to their Agreement for specific
information regarding the reimbursement inclusions/exclusions for infusion therapy services. Questions
regarding infusion therapy services should be reviewed during the Concurrent Review process with the
Medical Management Department.
• Mental Health and Substance Abuse Services: Participating Providers may assist Members in obtaining
authorization and coordinating mental health and substance abuse services. Refer to the reverse side of the
Member’s Identification Card for the applicable mental health and substance abuse vendor’s name and
telephone number or contact the applicable Customer Care Team for further assistance.
• Laboratory/Pathology Services: All laboratory/pathology specimens for Members admitted to a SNF/hospital

under any level of care must be forwarded to a Participating Provider for analysis.
• Home Phlebotomy Services: Home phlebotomy services for Members residing in a PCF who meet
homebound criteria must be coordinated through the Home Health/Hospice Management Department. Please
refer to the portion of this section titled “Home Health and Home Phlebotomy Services” for specific information.
• Radiology Services: All radiology and mobile radiology services, excluding routine chest x-rays, for Members
admitted to a SNF must be coordinated with a radiology Participating Provider. A complete listing of radiology
Participating Providers can be located at www.ghpfamily.com m.
NOTIFICATION OF A NON-SKILLED ADMISSION

Prior to a non-skilled admission and again upon discharge of a Member, SNF or hospital provider accepting the
admission is required to notify the Medical Management Department. Failure to notify GHP Family of a non-skilled
admission or discharge may reflect non-compliant behavior and result in GHP Family administrative action.
OUTPATIENT SERVICES
Requests for precertification of outpatient services (including, but not limited to home health and hospice,
outpatient rehab, Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS), therapy and non-
emergent ambulance) are the responsibility of the Participating Provider.
REQUESTING PRECERTIFICATION
Request precertification for inpatient services through https://coherehealth.com/provider/resources/ for all GHP
Family patients. Cohere uses a collaborative online authorization process that offers evidence-based care
suggestions, but Geisinger Health Plan Medical Management will still review requests and retain ultimate authority
over medical necessity determinations.
Check GHP Family’s precertification list frequently https://www.geisinger.org/-

/media/OneGeisinger/Files/PDFs/Provider/PriorAuthList.pdf?la=en to know which services require authorization
submission through Cohere.
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Visit the Cohere Learning Center at https://coherehealth.zendesk.com/hc/en-us/articles/10169953922327-Out-of-
Network-Exceptions for detailed user guides. Registration with Cohere is required to access the learning center.
Register with Cohere at https://coherehealth.com/provider/register/.
Cohere uses a team of nurses and doctors to make sure guidance during the request process is medically
appropriate and meets clinical guidelines. Here’s what happens when precertification is requested online through
Cohere:
1. Cohere’s real-time consultative request process efficiently guides the user through each step, providing
patient-specific suggestions that can expedite approval.
2. Requests are immediately relayed to Geisinger Health Plan Medical Management for review. Geisinger Health
Plan Medical Management will make a determination in accordance with the Precertification Determination and
Communication Process outlined above.
3. Upon approval, the authorization number populates in the portal.
When a request has received a final determination (approved, partially approved, or denied) Cohere will send the
submitter an email notification with authorization status.
Using Cohere’s online portal is the most direct way to manage authorization requests. However, prior authorization
can also be requested using print and fax forms at https://www.navinet.net or https://www.geisinger.org/health-
Call Cohere at (855) 460-8026 with registration, login and technical issues with the portal. Questions related to
determinations, appeals, peer-to-peer and member information should be directed to Geisinger Health Plan at
(800) 876-5357.
Ordering DME through Tomorrow Health

GHP is working with home medical equipment company Tomorrow Health to provide patients with easier, more
convenient, and more affordable access to home medical equipment. Through this program, providers and
patients will enjoy a superior DMEPOS experience:
• Free, fast home-delivery for your patients
• More on-time starts of care for your patients
• Single point of contact for all GHP DMEPOS orders
• Hands-on support from a team of expert Care Advocates
All GHP DMEPOS orders should be placed through Tomorrow Health. Tomorrow Health will either service orders
directly or route orders to a DMEPOS provider in the Geisinger network that best suits the patient’s needs. Vision
services should not be placed through the Tomorrow Health platform. For a full list of HCPCS codes the program
covers visit https://home.tomorrowhealth.com/providers
How to place orders

Ordering providers can place orders on behalf of patients using one of the following methods:
• Online form – Complete the HIPAA-compliant order form at https://home.tomorrowhealth.com/providers.
• Phone – Place orders through an expert Care Advocate at 844-402-4344.
• Fax – Access order forms at www.tomorrowhealth.com/referral and follow the instructions to submit via fax.
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Supply closets and onsite consignment
Providers who wish to keep their existing supply closet relationships will be able to. However, for the equipment or
supplies to be reimbursed by Geisinger Health Plan, referring or ordering providers will need to submit copies of
the corresponding prescriptions to Tomorrow Health by fax or online within one (1) business day of dispensing the
item(s).
DME Prior authorizations

After the referring/ordering provider sends an order to Tomorrow Health, Tomorrow Health will ensure all
information required for requesting prior authorization is collected and complete before sending the order to a
DMEPOS provider. Once the DMEPOS provider receives and accepts an order from Tomorrow Health, that
DMEPOS provider will still request authorization (if needed) through Cohere.
Contact Tomorrow Health

For general inquiries not related to a specific patient or order, please contact Tomorrow Health:
Ordering Providers: [email protected]
DME Providers: [email protected]
Requesting a Non-Emergent Ambulance

Prior authorization is required through Cohere for non-emergent ambulance transportation (NEAT) — including
transports from the emergency department (ED) to skilled nursing facilities (SNF), inpatient rehabilitation, other
ambulatory care facilities or the patient’s home.
Register with Cohere at http://www.coherehealth.com/register.
View GHP Family’s ambulance transport service medical benefit policy MP017 at https://www.geisinger.org/-
/media/OneGeisinger/Files/Policy-PDFs/MP/1-50/MP017-Ambulance-Transport-
Service.pdf?sc_lang=en&hash=38341DC562687E36ACF2B996AB64AAF9 for detailed coverage criteria.
Changes to NEAT dispatch process

• Alliance Logistic Solutions will no longer coordinate dispatch for GHP members as of June 30, 2023. After
June 30, 2023, discharge personnel and ordering providers can coordinate directly with medical transport
providers.
• Reference the member’s prior authorization number supplied by Cohere when coordinating transport.
• Make every effort to use participating ambulance providers when ordering NEAT for GHP members. Find in-
network ambulance providers on our provider search page at https://www.geisinger.org/healthsparq. Simply
enter your location, search Places by Type and start typing “ambulance”. Results will include ambulance
provider contact and plan acceptance information.
• If using a participating ambulance provider is unreasonable because of availability or distance, alternate
arrangements can be made in the best interest of the member. You can note the reasons for using an out-of-
network ambulance provider during the Cohere prior authorization request process.
• Keep in mind that options other than ambulance may be more appropriate depending on the nature of the
member’s transportation needs (e.g., wheelchair van).
• Member cost-sharing may apply according to member benefits.
Contact us
• Contact your Account Manager at 800-876-5357 or [email protected].
• Contact our Medical Management team at 800-544-3907.
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Coordinating shift care/private duty nursing services
When a GHP Family member requires shift care/private duty nursing services, providers and home health
agencies should work with GHP Medical Management to ensure a request for review of any new or additional
services is completed within one business day of completion of the admission assessment. Each request is
reviewed by GHP Medical Management on an individual basis of need. Reference medical benefit policy MP287 at
https://www.geisinger.org/-/media/onegeisinger/files/policy%20pdfs/mp/251-300/mp287%20shift%20care for more
information and guidelines for medical necessity.
There are several options for requesting authorization and coordinating services so that members in need
experience no disruption when obtaining or continuing these services.
For new members already receiving shift care/private duty nursing services:
• Agencies caring for the member should submit the Shift Care Notification Form within five (5) days of any
changes in the status of a member receiving shift care services. Fax form to 570-271-5507. The Shift Care
Notification Form can be found at https://www.geisinger.org/health-plan/providers/forms-and-resources-for-
providers.
• Other providers who become aware of any disruption to shift care/private duty nursing services for new
members should contact GHP Medical Management immediately to help coordinate services.
• Agencies who can’t accommodate continuing services or discharged member from services due to staffing
issues should call GHP Medical Management immediately to help coordinate services. When notified, GHP
Medical Management will work with GHP care coordinators to find available covered services for the member.
For members in need of shift care/private duty nursing services for the first time (new to shift care):
• Prescribing providers referring members for initial shift care/private duty nursing services should use the
Private Duty Nursing/Shift Care Form to relay patient and provider information to GHP Medical Management.
Fax form to 570-271-5507. The Shift Care Notification Form can be found at https://www.geisinger.org/health-
• Prescribing providers do not need an agency to request shift care/private duty nursing services for a
member. A referring provider should request authorization and coordination of shift care/private duty nursing
services directly from GHP Medical Management. There are two ways to request authorization/coordination
directly from GHP Medical Management:
o Request services through Cohere at https://coherehealth.com/provider/resources/.
o Request services by submitting the Private Duty Nursing/Shift Care Form. Fax form to 570-271-5507. The
Shift Care Notification Form can be found at https://www.geisinger.org/health-plan/providers/forms-and-
resources-for-providers.
• Agencies who can’t accommodate new patients or have discharged members due to staffing issues should call
GHP Medical Management immediately to help coordinate services. When notified, GHP Medical Management
will work with GHP care coordinators to find available covered services for the member.
• When a home health agency has been identified as the agency that will staff a new case when initial authorization
is received, that agency may assist with the development of the authorization request, and GHP may correspond
with that agency for purposes of obtaining all necessary information to support the request, but the requesting
prescribing provider must be the one to initiate the authorization request.
• For reauthorization requests, the request may be submitted by either the prescribing provider or the home health
agency of record that currently staffs the case.
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Outpatient cardiology, MSK and interventional pain management services
Prior authorization for MSK, cardiology and pain management services has transitioned from HealthHelp to
Cohere as of October 1, 2023. Cardiology, MSK and pain management services that require authorization can be
requested through Cohere. Authorization for radiology continues through HealthHelp.
OUTPATIENT RADIOLOGY AND IMAGING

GHP Family works with HealthHelp to establish a consultative authorization process to improve quality, reduce the
cost of care and ensure members receive clinically appropriate and medically necessary services. The HealthHelp
authorization process will involve:
• Collecting relevant clinical information from the ordering/treating physician’s office;

• Reviewing this information alongside the latest evidence-based medical criteria for certain procedures;
• If necessary, providing expert peer consultation on treatment and/or test appropriateness and patient safety. If
a requested service does not meet evidence-based guidelines, HealthHelp will facilitate a physician-to-
physician conversation with the requesting provider to consider alternatives.
Services that will require authorization

All requests for the tests and procedures listed below need to go through HealthHelp, except services rendered in
an emergency or inpatient setting.
• CT
• CTA
• MRI
• MRA
• PET
A complete list of associated procedure codes requiring authorization can be found at

https://www.geisinger.org/health-plan/providers/radiology-authorization.
How to request authorization

Ordering physicians can request an authorization for services using one of the following methods:
• Web: Complete your request through the online tool at www.healthhelp.com/Geisinger.
• Fax: Complete the HealthHelp procedure review request form and fax to 877-391-7294. For an expedited
request, fax to 877-391-7295.
• Phone: Call HealthHelp at 877-391-7293.
The most efficient method for obtaining an authorization number is through the web. Contact HealthHelp program
support at 800-546-7092 if you need assistance setting up web access.
What you need to initiate your prior authorization request

The following information is required for all authorization requests and should be available in the patient’s chart:
• Member name and ID number
• Ordering provider name
• Ordering provider telephone and fax numbers
• Member diagnosis or clinical indication
• Test being ordered (CPT code)
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• Reason for test
• Member symptoms and duration
• Prior related diagnostic tests
Ordering providers:
• Laboratory studies
• Member medications and duration
• Prior treatments
• Summary of clinical findings
• Member risk factors (primarily applies to imaging requests related to cancer indications including screening)
How to confirm authorization

Ordering providers should confirm authorization before scheduling services. Ordering providers can confirm
authorization for radiology services using one of the following methods:
Web: When you submit your request through the web, your authorization will be available immediately online to
print.
Fax: When you submit your request via fax, a faxed copy of the authorization will be sent to the ordering provider’s
office fax number you provided on the form.
Phone: When you submit your request by phone, a HealthHelp client service representative will provide a verbal
authorization over the phone. A confirmation will also be faxed to the ordering provider office fax number provided.
HealthHelp representatives are available Monday–Friday, from 8 a.m. to 6 p.m. Eastern Standard Time.
After-hours requests may be submitted by fax or via web portal.
Urgent authorization requests

HealthHelp no longer processes any Expedited Requests for Medicaid members.
To submit a Medicaid Expedited request, it must be physician ordered and meet the following criteria as per DHS.
Urgent Care Services — Services furnished to an individual who requires services to be furnished within twenty-
four (24) hours in order to avoid the likely onset of an Emergency Medical Condition.
Urgent Medical Condition — An illness, injury or severe condition which under reasonable standards of medical
practice, should be diagnosed and treated within a twenty-four (24) hour period and if left untreated, could rapidly
become a crisis or Emergency Medical Condition. The term also includes services that are necessary to avoid a
delay in hospital discharge or hospitalization.
If the service you are requesting meets the above criteria, submit your Expedited Request by fax to GHP Family at
570-214-0211.
Additional resources
HealthHelp will host webinars to familiarize Geisinger Health Plan network providers with the authorization
process. The webinars will give a system demonstration with user experience insight on how to appropriately enter
procedure requests, along with additional program information — such as the Geisinger procedure code list,
support tools and HealthHelp contact information.
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Visit For Providers section of Geisinger Health Plan’s website at http://geisinger.org/health-
plan/providers/radiology-authorization to register for one of the webinars. Additional educational materials and
program implementation information — including a list of all procedure codes requiring authorization through
HealthHelp — will be available:
• On the For Providers section of Geisinger Health Plan’s website at http://geisinger.org/health-
plan/providers/radiology-authorization
• Through the Geisinger plan central page on https://www.navinet.net
• On HealthHelp’s website at http://www.healthhelp.com/Geisinger
For questions or information regarding general prior authorization policy and procedures, contact a Geisinger
Health Plan Medical Management representative at 800-544-3907.
SPECIALTY PHARMACY PROGRAM

Certain prescription and injectable drugs are covered only through GHP Family’s Specialty Network. For more
detail and a complete list of drugs and pharmacies available through this program, refer to www.ghpfamily.com or
call 855-552-6028. Medication requests are the responsibility of the prescribing Participating Provider. Unless
noted on the list, the use of the Specialty Pharmacy Program is not mandatory if the physician elects to buy the
medication and bill GHP Family for the cost or if GHP Family is the secondary payer.
Please note: Prior authorization may be required for certain drugs. Please refer to the section titled “Pharmacy
Prior Authorization and Nonformulary/Nonpreferred Exception Process” within this Manual for further information.
Specialty Pharmacy Program Process

To initiate the program, the Participating Prescriber can directly e-scribe or fax the prescription to any of the
specialty pharmacies in GHP Family’s Specialty network. For a full list of specialty medications and participating
pharmacies please visit: https://www.geisinger.org/health-plan/providers/pharmacy-forms
For more information, please call 855-552-6028.
OUTPATIENT PRESCRIPTION DRUGS

GHP Family, like other MCOs in Pennsylvania, follow the Statewide Preferred Drug List (PDL) which is developed
by the Department of Human Services Pharmacy and Therapeutics Committee.
For those Medications not covered by the Statewide PDL, GHP Family utilizes a Formulary for purposes of
Member care through the rational selection and use of medications, and to ensure quality, cost-effective
prescribing. The Formulary is developed with the input of practicing physicians and pharmacists. Medications in
each therapeutic class have been reviewed for efficacy, safety, and cost. Maintenance of the Formulary is a
dynamic process; the Pharmacy and Therapeutics Committee continually review new medications as well as
information related to medications currently included in the Formulary.
GHP Family: The GHP Family benefit includes coverage only for prescription and over-the-counter (OTC) drugs
listed in the Formulary or Statewide PDL. Formulary and PDL exceptions may be granted on a case-by-case
basis.
• Tier 1–Includes Generics. Prior authorization may be necessary.

• Tier 2–Includes Brand name drugs. Prior authorization may be necessary.
51
The most current Statewide PDL can be found at https://papdl.com/preferred-drug-list and the GHP Family
Formulary is available online at www.ghpfamily.com.
Maintenance Medications – members are eligible to receive a ninety (90) day supply of maintenance
medications, excluding those that are considered specialty medications or are controlled substances. For
questions about which medications are considered maintenance medications please check online at:
https://www.geisinger.org/health-plan/providers or call GHP Family Pharmacy services at (855) 522-6082 or (570)
214-3554. Members are able to receive the 90-day supply of medications from a participating retail pharmacy or a
participating mail order pharmacy and will be charged the same copay as a one-month supply.
Non-Formulary/Non-Preferred medications: The Formulary and Statewide PDL are designed to meet most
therapeutic needs of the population served by GHP Family. Occasionally, because of allergy, therapeutic failure,
or a specific diagnostic-related need, Formulary/Preferred medications may not meet the special needs of an
individual Member. In these special instances, the prescribing physician may make requests to the GHP Family
Pharmacy Department for nonformulary, nonpreferred, or restricted medications through the exception process.
The prescribing physician will receive written documentation and/or a verbal response from the GHP Family
Pharmacy Department regarding the request. Under the GHP Family plan, non-Formulary/non-Preferred
medications requiring an exception will be available at the appropriate copayment tier (Tier 1 – generic; Tier 2 –
brand).
Formulary addition requests: Requests for changes or additions to the Formulary can be made by written
request to the GHP Family Pharmacy Department at the address listed below. Any additions or deletions to the
Formulary may be found in the monthly provider update.
Geisinger Health Plan Pharmacy Department

100 North Academy Avenue
Danville, PA 17822-2410
Phone: (855) 552-6028; (570) 214-3554
Fax: (570) 300-2122
PHARMACY PRIOR AUTHORIZATION AND NONFORMULARY/NONPREFERRED

EXCEPTION PROCESS
GHP Family’s Pharmacy Department maintains a process by which Health Care Providers can:
• Request Prior Authorization for medications designated in the Formulary/PDL as requiring such. Drugs that
require Prior Authorization are designated with a “PA” indicator.
• Request an exception for specific drugs, drugs used for an off-label purpose, and biologicals and medication(s)
not included in the current drug Formulary/PDL.
Requesting Prior Authorization
Prior authorization forms can be found at: www.ghpfamily.com.
Health Care Providers can initiate such requests by contacting the Pharmacy Department by telephone, fax or
written request at the following:
52
Geisinger Health Plan Pharmacy Department
Phone: (855) 552-6028 or (570) 214-3554 Monday – Friday 8:00 a.m. - 5:00 p.m.
Fax: (570) 300-2122
Information required to process the request includes:

• Caller’s name and telephone number.
• Member’s GHP Family identification number and if applicable medical record number.
• Prescribing Health Care Provider’s name and telephone number.
• The medication requested, directions, and number of refills.
• Supporting clinical rationale, which may include, but is not limited to, relevant pages from the medical record,
laboratory studies, prior medication treatment history and other documentation, as determined by GHP Family
to be relevant.
Prior authorization requests will be addressed within twenty-four (24) hours of the request being made. If a claim
denies at point of sale because a prior authorization is required, the pharmacist will dispense either a five (5) day
supply for new medications or a fifteen (15) day supply for ongoing treatment. This does not apply if the
pharmacist determines that taking the medication would put the Member at risk.
Exception Determination Process

Formulary/PDL exception requests will be evaluated, and a determination of coverage made utilizing all the
following criteria:
• Member’s eligibility to receive requested services (enrollment in the plan, prescription drug coverage).
• Utilization of the requested agent for a clinically proven treatment indication or diagnosis.
• Therapeutic failure, intolerance, or contraindication to use of Formulary/PDL agent and/or agents designated
as therapeutically equivalent.
• Appropriateness of the non-formulary/non-preferred agent compared with available formulary/preferred agents,
including but not limited to:
o Safety
o Efficacy
o Therapeutic advantage as demonstrated by head-to-head clinical trials
o Meets DHS criteria for drug or drug class PDL exception
o Meets GHP Family criteria for drug or drug class Formulary exception
All requests for prior authorization of a medication will be addressed within twenty-four (24) hours of the request
being made.
A GHP Family Pharmacist will perform the initial review of the necessary information and assemble documents
necessary to recommend a course of action. A licensed physician shall make the final decision in those instances
where an exception decision results in a denial based on Medical Necessity and appropriateness.
Based on the determination of coverage made, one (1) of the following will occur:
53
If the exception is approved:
• An electronic override will be entered into the pharmacy Claims adjudication system. The Member (or
Member’s authorized representative) and provider will be notified of the determination of coverage within
twenty-four (24) hours of the request being made.
o At the time of notification, GHP Family will indicate the coverage provided in the amount disclosed by GHP
Family for the service requested.
• A written confirmation of the approval will be sent to the provider and Member within 24 hours of the request
being made.
• If the request for a Formulary/PDL exception is denied, resulting in an adverse benefit determination, the
following will occur:
o GHP Family will mail the appropriate denial notice with information on appeal rights and process to the
Member (or Member’s authorized representative) and copy the Provider, within twenty-four (24) hours of
the request.
o The Member and provider will be verbally notified of the adverse determination within twenty- four (24)
hours of the request. This verbal notification will include instruction on how to initiate a Complaint or
Grievance.
o The prescribing Health Care Provider will be offered the opportunity to discuss the determination of
coverage with a GHP Family Pharmacist or Medical Director.
The written denial notice and verbal explanation shall include:

• The specific reason for the determination;
• The basis and clinical rationale utilized in rendering the determination of coverage, if applicable;
• Any internal policy or criterion applied, if applicable, and;
• Instructions regarding initiation of the Complaint or Grievance.
Formulary changes are printed in the monthly provider update, available on the GHP plan central page on
https://www.navinet.net. A minimum of thirty (30) days advance notice is provided to Participating Providers
regarding Formulary changes, except when the Formulary change is due to the approval or withdrawal of a
medication by the Food and Drug Administration. The most current Statewide PDL can be found at
https://papdl.com/preferred-drug-list.
MATERNAL HEALTH PROGRAM (INCLUDING HEALTHY BEGINNINGS PLUS)

Pregnant Member’s coverage includes all Medically Necessary ultrasonography. GHP Family’s program entitled
“Right from the Start” is designed to serve the GHP Family Member throughout her pregnancy, from early
identification, through the prenatal experience and postpartum follow-up. GHP Family’s comprehensive approach
to assist Members through this life changing event engages many areas of health plan employees, provider
offices, and most importantly the Member and caregivers.
GHP Family collaborates with various Community-Based Organizations to provide Home Visiting Programs that
are available to all first-time parents and parents/caregivers of children who have been identified as having
additional risk factors which may include social, clinical, racial, economic, or environmental factors. The Home
Visiting Programs are also available to any infant and the infant’s parent/caregiver who requests Home Visiting
54
services. Services are available from the prenatal period and at a minimum through the child’s first 18 months of
life.
The Home Visiting Programs are innovative, expansive, inclusive programs which provide individualized,
strengths-based, and family-focused services. These programs are designed to provide support to
parents/caregivers, children, and families to ensure that all needs are addressed, and families are active partners
in their care.
EARLY IDENTIFICATION
The process begins with early identification of the pregnancy. GHP Family will attempt to identify Members who
are pregnant through a variety of processes including:
• Data extractions including, but not limited to, enrollment files, Chronic Conditions and Specialist Visits reports,
positive laboratory testing results, and/or prescriptions filled for prenatal vitamins.
• New Member Calls conducted by the dedicated GHP Family Customer Care Team which asks if the Member
or anyone in the household who also has GHP Family is pregnant.
• Direct referrals from Case Managers, providers, or other health plan representatives.
• Claims information indicating pregnancy.
• OBNA Form Completion received either via fax or secure electronic submission through the provider portal.
A master list of any identified Member who is pregnant will be reviewed by the QI Department. Any Member
identified as “high risk” will be referred to the Women’s Health and EPSDT Coordinator (or designee) for case
management intervention. Following this assessment, any case not deemed “high risk” will be forwarded
electronically to the QI Specialist assigned for HEDIS® preventative calls.
QUALITY IMPROVEMENT AND REGULATORY REQUIREMENTS

The GHP Family has a strong commitment to quality metrics to improve the overall health of the membership. As
such, the Quality Improvement Department is charged with conducting scheduled outbound calls to improve
Member compliance with measures including:
• Weeks of pregnancy at time of enrollment and live birth
• Timeliness of physician visit (Measure: percentage of live births that had a prenatal visit within the first
trimester or 42 days of plan enrollment)
• Timeliness of postpartum visit (Measure: Postpartum visit within 7-84 days of delivery)
• Cesarean Section for low-risk, first birth women
• Percentage of live births less than 2,500 grams
• Completion of Prenatal Depression Screening and treatment for those who screen positive
• Prenatal screening for smoking and treatment discussion during a prenatal visit
• Screening home environment for smoke
SERVICE DESCRIPTION
Member Assistance with Appointment Scheduling

GHP Family will help the Member obtain a provider visit as needed within twenty-four (24) hours to ten (10) days
of notification of the pregnancy as required by the Department, depending on the risk level and trimester. See the
table in the Appointment Standards section of this manual. GHP Family assists the Member in completing a
minimum number of prenatal visits and in completing a follow up visit within 7-84 days postpartum.
55
Network Access
GHP Family Members have direct access to a Women’s Health provider. In the event the Member is transferring
from another health plan and the current provider is not in-network, GHP Family will cover maternity care through
the course of the pregnancy and postpartum care with the non-participating provider.
High Risk Management

Members are screened for high-risk management by Quality Improvement Specialists and referred to Women’s
Health case management nurses with seasoned experience in high-risk fetal maternal health care as appropriate.
Regionally based case management staff will coordinate services with perinatology specialty sites throughout the
GHP Family service area. Services include telephonic outreach to ensure timely and continuous provider follow-
up, assistance with overcoming barriers to care such as transportation or access to appointments or providing
resources to assist with weight management and smoking cessation during pregnancy.
Coordination with Healthy Beginnings Plus

GHP Family encourages expectant mothers to participate with participating Healthy Beginnings Plus providers
throughout all 67 Pennsylvania counties. Healthy Beginnings Plus is a program that provides education and
assistance to female Members with a goal of a healthy prenatal experience and compliant postpartum follow-up.
Behavioral Health Coordination

The Special Needs Unit (SNU) can assist Members to connect with the assigned Behavioral Health Managed Care
Organization (BH MCO) in the Member's county of residence. The BH MCO can assist with concerns during
pregnancy including depression or other mental illness conditions.
Physical Health Managed Care Organizations (PH-MCOs) Integrated Care Plan (ICP) Program
The purpose of this program is to capture and monitor the case management activities of the PH/BH-MCOs
population of members diagnosed with serious persistent mental illness (SPMI). Geisinger Health Plan Care
Management staff will be reaching out to providers to discuss an Integrated Care Plan (ICP) that has components
of physical health and behavioral health for GHP members with SPMI.
Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Management

Post-delivery, GHP Family is committed to facilitate timely access and compliance with recommended visits and
vaccination schedules for children under the age of 21. Through a series of telephonic outreach, GHP Family
Quality Improvement (QI) nursing staff will review Members at key milestones for well child visits and scheduled
immunizations. In the event Members are non-compliant with EPSDT visits, GHP Family will make every attempt
to reach the Member/caregiver to facilitate compliance.
MEMBER HEALTH EDUCATION

GHP Family has a robust education strategy to outreach to Members upon identification of pregnancy. Topics
include importance of scheduling and keeping prenatal appointments, healthy nutrition, and transportation
coordination.
Messaging may be accomplished through mailing print materials, reminder phone calls or cell phone texting
depending on the risk stratification of pregnant condition and trimester.
56
PROVIDER RELATIONS
Education
GHP Family respects the value and contribution of the providers taking care of expectant Members.
Communication with the obstetrics provider is emphasized from the first identification of pregnant status. The
Obstetrical Needs Assessment (ONAF) Form should be completed with pregnancy determination. Completion and
submission of the form is part of the GHP Family Provider Pay for Performance Program. The process for
submission of this form is discussed in the Maternal Health Program section of this manual.
Communication
GHP Family uses a variety of methods to keep providers up to date with current information to the management of
pregnant members including a web-based provider manual, operational bulletins, and visits by Provider Network
Staff.
COMMUNITY OUTREACH
GHP Family will make efforts to engage local community agencies, school systems, and providers to provide
education and assistance in the care of our Members. Venues for health education include area high schools,
family planning agencies such as Planned Parenthood, or other organizations dedicated to the care of women.
GHP Family will outreach with community agencies specifically in the top four counties designated for teen
pregnancy in the sixty-seven-county service area.
MEMBER INCENTIVES
GHP Family offers Member incentives to encourage compliance with keeping prenatal and postpartum
appointments, preventative dental visits, and well visits. Incentives will be offered to:
• Members who completed one prenatal visit in the first trimester and one prenatal visit in the second trimester.
Two visits must be completed to be eligible for an incentive.
• Members who experience a live birth and keep their postpartum visit between 7-84 days.
• Members ages 6 - 9 and ages 19 - 20 who have had at least one preventative dental visit in the measurement
year.
• Members who have had 5 well visits by their 15-month birthday.
• Members 3 - 4 years of age, 11-13 years of age and 17-21 years of age who have completed one well visit
with their primary care physician.
Incentives may include gift cards or items for mom and/or baby. Compliance will be determined through claims
data. No additional reporting is required of the provider.
REPORTING
GHP Family recognizes the responsibility to comply with the Department of Human Services’ reporting
requirements specific to the care of women who are pregnant. The following table is a general summary for
required reports, including report name, description, frequency, and responsible party.
57
Requirements for Medicaid Maternity/Pregnancy Reporting
Measure Responsible
Summary of Measure Frequency
Title Party
Percentage of
live births Live births <2,500 grams as a Clinical
Monthly
weighing less percent of total live births Informatics
than 2,500 grams
Screened for depression during

prenatal visit
Positive depression screen
Positive depression screen who
Perinatal
received further evaluation or referral Clinical
Depression Monthly
Screened for depression during Informatics
Screening (Pre
postpartum visit
and postnatal)
Positive depression screen
Positive depression screen who
received further evaluation or referral
Screened for smoking during one of

first two visits
Prenatal Screened for smoking during one of
Screening for first two visits and currently smoke,
Smoking and given counseling/advice or referral
Treatment Screened for smoking during one of
Clinical
Discussion during first two visits and quit during Monthly
Informatics
a Prenatal Visit pregnancy
(Smoking and Screened for environmental tobacco
environmental smoke during one of first two visits 5.
smoke) Screened for environmental tobacco
smoke during one of first two visits,
given counseling/advice or referral
Cesarean Rate
for Nulliparous C-section rates for low-risk first birth Clinical
Monthly
Singleton women Informatics
Vertex
58
Percentage of live births that
received a prenatal care visit within
first trimester or within 42 days of
Prenatal and Clinical
enrollment Monthly
Postpartum Care Informatics
Percentage of live births that
received a postpartum visit between
7 and 84 days after delivery
Percentage of deliveries which had

the expected number of prenatal
Frequency of visits: <21% of expected visits
Clinical
Ongoing Prenatal 21%- 40% of expected visits Monthly
Informatics
Care 41%- 60% of expected visits
61%- 80% of expected visits
>=81% of expected visits
Weeks of
Percentage of women who delivered
Pregnancy at Clinical
a live birth, by the weeks of Monthly
Time of Informatics
pregnancy at time of enrollment
Enrollment
Provides counts of second and third
trimester live maternity outcomes;
Maternity Clinical
broken out by recipient group for Annually
Outcome Counts Informatics
Cesarean Section (C-section) and
Vaginal live births;
Provides maternity utilization

information (discharges, days, and
Annual Maternity Clinical
average length of stay) for both Annually
Utilization Informatics
Cesarean Section (C-section) and
Vaginal live births.
Provides newborn utilization

Annual Newborn information (discharges, days, and Clinical
Annually
Utilization average length of stay) for both well Informatics
newborns and complex newborns.
AUDIT CHECKS
The GHP Family Women’s Health Coordinator (or designee) will audit the Members identified with a Live Birth
diagnosis against those screened and contacted through the Maternal Health Program on an annual basis. Any
discoveries to better understand the variances between Members not identified during pregnancy and those with
live birth will be assessed to improve processes for early identification of pregnancy for future implementation.
MEMBER RESTRICTION PROGRAM

DHS’s Bureau of Program Integrity manages a centralized Member Restriction Program for all managed care and
Fee- For-Service delivery systems. GHP Family maintains a Member Restriction Program that interfaces with the
centralized program and cooperates with DHS. The program identifies, restricts, and monitors Members who have
been determined to be abusing and/or misusing Medical Assistance services or who may be defrauding the
59
HealthChoices Program. With the approval of DHS, Members may be restricted to receiving services from a
single, designated provider for a period of five years.
GHP Family’s Special Investigations Unit monitors and evaluates the utilization of Members who are referred to
the Member Restriction Program. Providers will receive notification of Members who are restricted, and restrictions
are enforced through the Claims payment system.
GHP Family may not pay for a service rendered by any provider other than the one to whom the Member is
restricted, unless the services are furnished in response to an emergency or a Medical Assistance Member
Referral Form (MA 45) is completed and submitted with the Claim. The MA 45 must be obtained from the
practitioner to whom the Member is restricted. If a Member is restricted to a provider with your provider type, the
EVS will notify you if the Member is locked into you or another provider. The EVS will also indicate all type(s) or
provider(s) to which the Member is restricted. Valid emergency services are excluded from the lock-in process.
GHP Family obtains approval from DHS prior to implementing a restriction, including approval of written policies
and procedures and correspondence to restricted Members.
GHP Family will:

• Refer to DHS’s Bureau of Program Integrity (BPI) those Members identified as over utilizing or mis-utilizing
health care services.
• Evaluate the degree of Abuse including review of pharmacy and medical Claims history, diagnoses and other
documentation, as applicable.
• Propose whether the Member should be restricted to obtaining services from a single, designated provider for
a period of five years.
• Forward case information and supporting documentation to BPI for review to determine appropriateness of
restriction and to approve the action.
• Upon BPI approval, GHP Family will send notification via certified mail to Member of proposed restriction,
including reason for restriction, effective date and length of restriction, name of designated provider(s) and
option to change Provider, and instructions for requesting a hearing, with a copy to BPI.
• Send notification of Member’s restriction to the designated provider(s) and the County Assistance Office.
• Enforce the restrictions through appropriate notifications and edits in the Claims payment system.
• Prepare and present case at a DHS Fair Hearing to support restriction action.
• Monitor subsequent utilization to ensure compliance.
• Change the selected provider per the Member’s or provider’s request within thirty (30) days from the date of
the request, with prompt notification to BPI through the Intranet provider change process.
• Continue a Member restriction from the previous delivery system as a Member enrolls in the managed care
organization, with written notification to BPI.
• Review the Member’s services prior to the end of the five-year period of restriction to determine if the
restriction should be removed or maintained, with notification of the results of the review to BPI, Member,
provider(s) and County Assistance Office.
• Perform necessary administrative activities to maintain accurate records.
• Educate Members and providers to the restriction program, including explanations in handbooks and printed
materials.
Members have the right to appeal a restriction by requesting a DHS Fair Hearing. Members may not file a
Complaint or Grievance with GHP Family regarding the restriction action. A request for a DHS Fair Hearing must
be in writing, signed by the Member and sent to:
60
Department of Human Services
Office of Medical Assistance Programs of Bureau of Program Integrity
Division of Program and Provider Compliance: Member Restriction Section
P.O. Box 2675
Harrisburg, Pennsylvania 17105-2675
PROGRAM EXCEPTION PROCESS

Participating Providers may request coverage for items or services that are included under the Member’s benefit
package but are not currently listed on the Medical Assistance Program Fee Schedule. Participating Providers
may also request an exception for services or items that exceed limits on the fee schedule if the limits are not
based in statute or regulation. These exceptions should be requested in advance of providing services. To request
program exceptions, Participating Providers must follow the GHP Family Prior Authorization process.
SPECIAL NEEDS UNIT

The Special Needs Unit is a dedicated resource for the unique needs of the GHP Family Member. A member with
Special Needs is based upon a non-categorical or generic definition of Special Needs. This definition of special
need will be based on a non-categorical or generic perspective that identifies key attributes of ongoing physical,
developmental, emotional, behavioral conditions, or life circumstances which may serve as a barrier to the
member’s access to care or services. The Special Needs Unit works collaboratively to provide a unified Case
Management service through its Proven Health Navigator Case and Health Management program and
collaborative agreements with behavioral health managed care organizations and community agencies. Examples
of factors in the determination of a Member with a Special Need(s) include, but are not limited to, the following:
• Require care and/or services of a type or amount that is beyond what is typically required;
• Require extensive rehabilitative, habilitative, or other therapeutic interventions to maintain or improve the level
of functioning for the individual;
• May require that primary care be managed by a SCP, due to the nature of the condition;
• May incur higher morbidity without intervention and coordination in the care of the individual;
• Require care and/or services that necessitate coordination and communication among Network providers
and/or out-of-Network providers;
• Require care and/or services that necessitate coordination and collaboration with public and private community
services organizations;
• Require coordination of care and/or services between the acute inpatient setting and other facilities and
Community Providers;
• Result in the Member requiring assistance to schedule or make arrangements for appointments or services,
including arranging for transportation to and from appointments;
• Result in the need for language, communication, or mobility accommodations; or
• Result in the need for a Member to be accompanied or assisted while seeking or receiving care by an
individual who may act on the Member's behalf.
• Require assistance in discharge planning from an inpatient or long-term care or pediatric residential setting to
ensure the member will receive services in the least restrictive environment possible.
• Children who are in the custody of Office of Children, Youth and Families (OCYF) or known to have an open
case with OCYF.
• Any condition, event or life circumstance that as a result inhibits a member’s access to any necessary service
or support needed to address their medical condition or maintain their current level of functioning.
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The Special Needs Unit can be used as a resource for Providers, Members and Caregivers to assist with
management of Members with special needs. The Special Needs Unit can be reached at (855) 214-8100.
COVERED SERVICES
Members are entitled to certain covered services under the Medical Assistance Program of the Commonwealth of
Pennsylvania. Member benefits can be verified online through the GHP plan central page, at
https://www.navinet.net or by calling Customer Care. Covered services for Members are represented in the GHP
Family Benefit Grid below.
Copays are excluded for services provided to:
• Individuals under 21 years of age;
• Services to pregnant women, including through the postpartum period;
• Services provided to patients in long term care facilities (including ICF/ID and ICF/ORC);
• Services or items provided to a terminally ill individual who is receiving hospice care;
• Services provided to individuals residing in a personal care home or domiciliary care home;
• Services provided to women in the Breast and Cervical Cancer Prevention and Treatment (BCCPT) coverage
group; and
• Services provided to individuals of any age eligible under Titles IV-B and IV-E Foster Care and Adoption
Assistance.
This is not a full list. Please call GHP Family Customer Care for more information on any of the services below,
copayment information, prior authorization information or benefit limit information.
Service Children Adults

Limit No No
Primary Care Co-payment $0 $0
Provider Prior Authorization Prior Auth: No Prior Auth: No
/ Referral Referral: No Referral No
Limit No No
Co-payment $0 $0
Specialist
Prior Authorization Prior Auth: No Prior Auth: No
Limit No No
Certified
Co-payment $0 $0
Registered Nurse
Practitioner
Federally Limit No No
Qualified Health Co-payment $0 $0
Center / Rural Prior Authorization Prior Auth: No Prior Auth: No
Health Center / Referral Referral: No Referral No
Limit No No
Outpatient Non- Co-payment $0 $0
Hospital Clinic Prior Authorization Prior Auth: Yes Prior Auth: Yes
62
Limit No No
Outpatient Co-payment $0 $0
Hospital Clinic Prior Authorization Prior Auth: Yes Prior Auth: Yes
Limit No No
Co-payment $0 $0
Podiatrist Services
Limit No No
Radiology services Radiology services
received at a received at a
Chiropractor chiropractic office chiropractic office
Services are not covered. are not covered.
Co-payment $0 $0
Limit No No
Optometrist Co-payment $0 $0
Services Prior Authorization Prior Auth: No Prior Auth: No
Limit Respite care may Respite care may
not exceed a total of not exceed a total
5 days in a 60-day of 5 days in a 60-
certification period. day certification
Hospice Care
period.
Co-payment $0 $0
Limit See Dental Care See Dental Care
Services Services
Co-payment $0 $0
Dental Care Prior Authorization Prior Auth: Yes Prior Auth: Yes
Services / Referral Referral: No Referral No
Some procedures Some procedures
require prior require prior
authorization authorization
Limit No No
Radiology (ex. X- Co-payment $0 $1
rays, MRIs, CTs) Prior Authorization Prior Auth: No Prior Auth: No
Limit No No
Co-payment $0 $3
Outpatient Prior Auth: Yes Prior Auth: Yes
Hospital Short Referral: No Referral: No
Prior Authorization
Procedure Unit Some procedures Some procedures
/ Referral
63
Limit No No
Co-payment $0 $3
Outpatient Prior Authorization Prior Auth: Yes Prior Auth: Yes
Ambulatory / Referral Referral: No Referral: No
Surgical Center Some procedures Some procedures
Limit Covered if you live Covered if you live
in a nursing home in a nursing home
or need or need
specialized non- specialized non-
emergency emergency
transportation transportation
OR OR
Contact your Contact your
Non-Emergency county MATP county MATP
Medical Transport provider provider
Co-payment Contact your Contact your
county MATP county MATP
provider provider
Prior Authorization Prior Auth: Yes Prior Auth: Yes
/ Referral Referral: No Referral: No
Covered Services Covered Services
Limit No No
Co-payment $0 $0
Family Planning
Services
Sterilization Sterilization
procedures require procedures require
prior authorization prior authorization
Limit No Adult initial training
for home dialysis
is limited to 24
sessions per
calendar year.
Back up visits to
Renal Dialysis the facility limited
to no more than 75
per calendar per
year.
Co-payment $0 $0
64
Limit No No
Emergency Co-payment $0 $0
Limit No No
Urgent Care Co-payment $0 $0
Limit No No
Co-payment $0 $0
Ambulance / Referral Referral: No Referral: No
Services Non-emergent Non-emergent
ambulance ambulance
services require services require
prior authorization prior authorization
Limit No No
Co-payment $0 $3 per day/$21
max per admission
Inpatient Hospital
Some admissions Some admissions
Limit No No
Co-payment $0 $3 per day/$21
Inpatient Rehab max per admission
Hospital Prior Authorization Prior Auth: Yes Prior Auth: Yes
Limit No No
Co-payment $0 $0
Maternity Care
65
Limit No No
Co-payment See Pharmacy $1 Generic
Copay $3 Brand
See Pharmacy
Copay
Some medications Some medications
Prescription Drugs
authorizations. authorizations.
Refer to the Refer to the
https://papdl.com/pr https://papdl.com/p
eferred-drug-list referred-drug-list
or or
www.ghpfamily.com www.ghpfamily.co
m
Limit No No
Enteral/Parenteral
Co-payment $0 $0
Nutritional
Supplements
Limit MCO responsibility MCO responsibility
until CHC takes until CHC takes
Nursing Facility over over
Services Co-payment $0 $0
Limit No First 28 days
Home Health Care unlimited; then 15
including Nursing, days per month
Aide, and Therapy Co-payment $0 $0
Services Prior Authorization Prior Auth: Yes Prior Auth: Yes
Limit There may be There may be
limits on some limits on some
DME DME
Co-payment $0 $2
Durable Medical
Equipment
Some DME Some DME
requires a prior requires a prior
auth auth
66
Limit No No
Flat foot diagnosis Flat foot diagnosis
is not covered is not covered
Co-payment $0 $2 (if copay
Prosthetics and applies)
Orthotics Prior Authorization Prior Auth: Yes Prior Auth: Yes
Some services Some services
Limit No limits, but after 4 4 standard lenses
standard lenses per per calendar year.
year, additional
lenses in that year
Eyeglass Lenses must be prior
authorized.
Co-payment $0 $0
Limit No limits, but after 2 2 standard frames
standard frames per per calendar year.
year, additional
frames in that year
Eyeglass Frames must be prior
authorized
Co-payment $0 $0
Limit No limits, but after 4 4 lenses per
lenses per year, calendar year.
additional lenses in
that year must be
Contact Lenses
prior authorized.
Co-payment $0 $0
Limit Covered when Covered when
medically medically
Contact Lens necessary necessary
Fitting Co-payment $0 $0
67
Limit No No
Co-payment $0 $0
Medical Supplies
Some medical Some medical
supplies may supplies may
Limit No No
Therapy (Physical,
Co-payment $0 $0
Occupational,
Speech) Prior Authorization Prior Auth: Yes Prior Auth: Yes
Limit No No
Co-payment $0 $0
Laboratory / Referral Referral: No Referral: No
Some laboratory Some laboratory
tests require prior tests require prior
Limit No No
Tobacco Co-payment $0 $0
Cessation Prior Authorization Prior Auth: No Prior Auth: No
COVERED MEDICATIONS WITH NO COPAY

All Member categories, except General Assistance Members 21 to 65 years of age, do not have a copay for the
following groups of medications:
• Antihypertensives (high blood pressure)
• Antidiabetics (high blood sugar)
• Anticonvulsants (seizure)
• Cardiovascular preparations (heart disease)
• Antipsychotics (except those that are controlled substance antianxiety drugs)
• Antineoplastics (cancer drugs)
• Antiglaucoma drugs
• Anti-Parkinson’s drugs
• HIV/AIDS drugs
• Naloxone
DENTAL SERVICES
Dental services are covered for children under the age of 21. Additional services will be covered when
medically necessary:
Service Limits Copayments Prior Auth

Exams / Check ups 1 every 180 days $0 No
Cleanings 1 every 180 days $0 No
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Fillings No limits $0 No
Fluoride Varnish 6 per calendar year for $0 No
children under 21
Fluoride Topical Application 1 every 180 days $0 No

Bitewings No limits $0 No
Intraoral, complete series 1 per 5 years $0 No
Panoramic Film 1 per 5 years $0 No
Sealants No Limit $0 No
Anesthesia No Limit $0 Yes
Bony Impacted Teeth No Limit $0 Yes
Braces No Limit $0 Yes
Crowns No Limit $0 Yes
Dentures No Limit $0 Yes
Extractions No Limit $0 Yes
Periodontal Services No Limit $0 Yes
Root Canals No Limit $0 Yes
Dental Services for Adults 21 years of age and older:
Service Limits Copayments Prior Auth

Exams / Check ups 1 every 180 days $0 No
Cleanings 1 every 180 days $0 No
Fillings No limits $0 No
Flouride Varnish Not Covered
Flouride Topical Application Not Covered
Bitewings No limits $0 No
Intraoral, complete series 1 per 5 years $0 No
Panoramic Film 1 per 5 years $0 No
Dental Surgical Procedures When medically $0 Yes
necessary
Anesthesia Covered when $0 Yes
performed in a hospital
short procedure unit,
ambulatory surgical
center
Crowns Only covered by a BLE $0 Yes
Dentures One partial/full upper $0 Yes
and one partial/full
lower in a lifetime
Extractions When medically $0 Yes
necessary
Periodontal Services Only covered by a BLE $0 Yes
69
Root Canals Only covered by a BLE $0 Yes
FAMILY PLANNING SERVICES

Members can choose any provider for family planning services. Covered Family Planning Services include, but are
not limited to:
• Medically Necessary abortions only as allowed in MA Bulletin 1141-95-01

• Contraceptive implants/injections
• Education/counseling
o In-office visit with PCP or PCP Obstetrician
o Tubal ligation/Hysterectomies/other sterilizations for both male and female are covered for all Members
over age 20.
Required family planning services forms

When a Participating Provider performs certain family planning services, a federally required form must
accompany a Claim for payment, regardless of its mode of transmission (electronically or hardcopy on the CMS-
1500 Claim form). The Sterilization Patient Consent Form (MA 31), Patient Acknowledgement for Hysterectomy
(MA 30), and the Physicians Certification for an Abortion (MA 3) are forms that are required by the Federal
Government. Payment for sterilizations, abortions, and hysterectomies will only be made if the appropriate form(s)
are completed and accurate, and the procedures were performed within any time frames specified within the
regulations. Appropriate consent form must be received at least thirty (30) days prior to the procedure but not more
than 180 days prior to the procedure. Consent forms are available online at Department’s website:
https://www.dhs.pa.gov/docs/Publications/Pages/Medical-Assistance-Provider-Forms.aspx.
Procedures That May Be Included with a Family Planning Clinic Comprehensive Visit, a Problem Visit or a
Routine Revisit:
• Insertion, implantable contraceptive capsules
• Implantation of contraceptives, including device (e.g., Norplant) (once every five years) (females only)
• Removal, Implantable contraceptive capsules
• Removal with reinsertion, Implantable contraceptive capsules (e.g., Norplant) (once per five years) (females
only)
• Destruction of vaginal lesion(s); simple, any method (females only)
• Biopsy of vaginal mucosa; simple (separate procedure) (females only)
• Biopsy of vaginal mucosa; extensive, requiring suture (including cysts) (females only)
• Colposcopy (vaginoscopy); separate procedure (females only)
• Colposcopy (vaginoscopy); with biopsy(s) of the cervix and/or endocervical curettage
• Colposcopy (vaginoscopy); with loop electrosurgical excision(s) of the cervix (LEEP) (females only)
• Intensive colposcopic examination with biopsy and or excision of lesion(s) (females only)
• Biopsy, single or multiple or local excision of lesion, with or without fulguration (separate procedure) (females
only)
70
• Cauterization of cervix; electro or thermal (females only)
• Cauterization of cervix; cryocautery, initial or repeat (females only)
• Cauterization of cervix; laser ablation (females only)
• Endometrial and/or endocervical sampling (biopsy), without cervical dilation, any method (separate procedure)
(females only)
• Alpha-fetoprotein; serum (females only)
• Nuclear molecular diagnostics; nucleic acid probe, each
• Nuclear molecular diagnosis; nucleic acid probe, each
• Nuclear molecular diagnostics; nucleic acid probe, with amplification; e.g., polymerase chain reaction (PCR),
each Fluorescent antibody; screen, each antibody Immunoassay for infectious agent antibody; quantitative, not
elsewhere specified
• Antibody; HIV-1
• Antibody; HIV-2
• Treponema Pallidum, confirmatory test (e.g., FTA-abs)
• Culture, chlamydia
• Cytopathology, any other source; preparation, screening, and interpretation
• Progestasert I.U.D. (females only)
• Depo-Provera injection (once per 60 days) (females only)
• ParaGuard I.U.D. (females only)
• Hemoglobin electrophoresis (e.g., A2, S, C)
• Microbial Identification, Nucleic Acid Probes, each probe used
• Microbial Identification, Nucleic Acid probes, each probe used; with amplification (PCR)
Procedures That May Be Included with a Family Planning Clinic Problem Visit:
• Gonadotropin, chorionic, (hCG); quantitative
• Gonadotropin, chorionic, (hCG); qualitative
• Syphilis test; qualitative (e.g., VDRL, RPR, ART) Culture, bacterial, definitive; any other source Culture,
bacterial, any source; anaerobic (isolation)
• Culture, bacterial, any source; definitive identification, each anaerobic organism, including gas chromatography
• Culture, bacterial, urine; quantitative, colony county
• Dark field examination, any source (e.g., penile, vaginal, oral, skin); without collection
• Smear, primary source, with interpretation; routine stain for bacteria, fungi, or cell types
• Smear, primary source, with interpretation; special stain for inclusion bodies or intracellular parasites (e.g.,
malaria, kala azar, herpes)
71
• Smear, primary source, with interpretation; wet mount with simple stain for bacteria, fungi, ova, and/or
parasites
• Smear, primary source, with interpretation; wet and dry mount, for ova and parasites Cytopathology, smears,
cervical or vaginal, the Bethesda System (TBS), up to three smears; screening by technician under physician
supervision
• Level IV – Surgical pathology, gross and microscopic examination
• Antibiotics for Sexually Transmitted Diseases (course of treatment for 10 days) (two units may be dispensed
per visit)
• Medication for Vaginal Infection (course of treatment for 10 days) (two units may be dispensed per visit
• Breast cancer screen (females only)
• Mammography, bilateral (females only)
• Genetic Risk Assessment
PA VACCINES FOR CHILDREN (VFC) PROGRAM

The Vaccines for Children (VFC) program was created as part of the Federal Omnibus Budget Reconciliation Act
(OBRA), Section 1928 of the Social Security Act, in August 1993. The purpose of this program is to improve
immunization levels across the U.S. by providing vaccines, at no cost, to enrollment public and private providers.
The program is regulated by the Centers for Disease Control and Prevention (CDC) and the National Center of
Immunizations and Respiratory Disease (NCIRD).
In October 1994, Pennsylvania began its VFC program under the administration of the Department of Health
(DOH), Division of Immunization. VFC vaccines are purchased through CDC contracts by the DOH and are
supplied to VFC enrolled providers at no cost.
VFC ELIGIBILITY
Children, birth through 18 years of age (to their 19th birthday), are eligible for VFC vaccines if they meet at least
one of the following criteria:
• Are enrolled in Medicaid (including Medicaid managed care plans)
• Have no health insurance
• American Indian or Alaska Native (regardless of insurance coverage)
• Underinsured: A child who has health insurance, but the coverage does not include vaccines; a child whose
insurance covers only selected vaccines (VFC eligible for non- covered vaccines only). Underinsured children
are eligible to receive VFC vaccine only through a federally qualified health center (FQHC), rural health clinic
(RHC) or a state health center (SHC) under an approved deputization agreement.
Children with health insurance that covers vaccines and who fail to meet one of the previously mentioned criteria
are not eligible through the VFC program, even when the insurance requires a deductible. There are no income
restrictions imposed by the VFC program if the child meets all other enrollment criteria.
INSURED CHILDREN
Children whose health insurance covers the cost of vaccinations are not eligible for VFC vaccines, even when a
claim for the cost of the vaccine and its administration would be denied for payment by the insurance carrier
because the plan’s deductible (high deductible plan) had not been met.
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VFC Eligibility Scenario:
VFC
Child is insured and… Insurance Status
Eligible
Has not yet met plan’s deductible Insured No
Plan covers all ACIP

recommended
Insured No
vaccines but excludes certain
products/combination vaccines
Plan covers only a portion of the

vaccine cost and does not have Insured No
Medicaid as secondary insurance
Has Medicaid as secondary

Medicaid eligible Yes
insurance
Plan covers only a portion of the

vaccine Medicaid eligible Yes
cost and has Medicaid as
secondary insurance
Has not yet met plan’s deductible

and has Medicaid as secondary Medicaid eligible Yes
insurance
Has exceeded plan’s annually

Underinsured - must obtain vaccine
allowed number of provider visits
through FQHC, RHC, or deputized Yes
or insurance doesn’t cover
SHC
vaccines
Cannot access health insurance

Uninsured Yes
due to being incarcerated
A Medicaid eligible child is eligible for PA VFC vaccines regardless if they have a primary health care
coverage/insurance plan.
For complete eligibility requirements please visit

https://www.health.pa.gov/topics/programs/immunizations/Pages/VFC.aspx.
73
NEW PROVIDER ENROLLMENT
• Complete and submit the Pa. Vaccines for Children Program Provider Agreement (Pa. VFC PPA) by fax to
717-214-7223. Upon receipt of the completed Pa. VFC PPA, the provider identification number (PIN) will be
assigned to your facility.
• A copy of the VFC Provider Handbook will be mailed to your facility. This should be reviewed by the
physician(s), office manager, primary and backup VFC contacts prior to the enrollment/training site visit.
• Prepare your office and staff for a site visit to go over the administrative requirements of the program and to
ensure proper storage and handling of vaccines when received.
• An immunization nurse from your district will contact you to schedule an enrollment/training site visit to review
all aspects of the VFC program, to ensure that the vaccine storage units and thermometers meet the
requirements of the CDC and to answer any questions staff may have. This visit takes approximately two
hours.
• After completion of the enrollment/training visit, the immunization nurse will notify the PA DOH that your facility
has been approved to order and receive VFC vaccines.
• VFC staff will notify the PA Statewide Immunization Information System (PA-SIIS) to provide the primary and
back-up VFC coordinators with unique usernames and passwords referred to as “logon credentials.” This will
allow staff to order vaccines online, update facility address and list vaccine shipping hours.
• View the video “Keys to Storing and Handling Your Vaccine Supply” and printing credentials from the CDC
website. This is required for all new enrollments and reactivations. The video is found at:
https://www.youtube.com/watch?v=0atwOngjVQY.
PROVIDER REQUIREMENTS
• Administer VFC program vaccines to VFC-eligible children;
• Retain all VFC documentation including patient eligibility screening records for a minimum of three years;
• Make immunization records available to the PA DOH, upon request and during CDC required site visits;
• Comply with the appropriate immunization schedule, dosage and contraindications established by the CDC’s
Advisory Committee on Immunization Practices (ACIP);
• Document and retain parent/guardian/individual refusal/rationale for not having client immunized;
• Provide current vaccine information statements (VIS), maintain records in accordance with the National
Childhood Vaccine Injury Act and provide, according to federal law, all vaccine providers must give patients, or
their parents or legal representatives, the appropriate VIS whenever a vaccination is given;
• Not to impose a charge for the cost of the vaccine to any eligible patient;
• Not to deny administration of a vaccine to a child due to the inability of the child’s parent/guardian/individual of
record to pay an administrative fee;
• Comply with VFC program procedures and requirements; and
• Adhere to all federal and state requirements.
For complete provider requirements including provider annual enrollment and PA VFC compliance site visits
please visit https://www.health.pa.gov/topics/programs/immunizations/Pages/VFC.aspx.
PROVIDER RESPONSIBILITIES
• Notify PA DOH regarding:
o Change in facility name
o Change in facility address
o Change in facility telephone or fax number
o Change in primary VFC contact
74
o Change in back-up VFC contact
o Change in medical director/primary physician
• Staff training
o Provide internal training on proper vaccine storage and handling guidelines.
o Provide internal training on vaccine administration protocols to each new employee at time of employment
orientation and review annually.
o Document these trainings and those who attended as required.
• Developing and maintaining written procedures

o Emergency handling procedures
o Vaccine management plan
o Vaccine disaster recovery plan
• Twice-daily temperature documentation

o Time when temperature was checked
o Initials of staff checking unit temperature
o Current, min, and max temperature
o Corrective action documentation on the temperature log (if needed)
• Vaccine storage and handling

o CDC/PA DOH requirements/recommendations
o Equipment (refrigerators/freezers)
o Thermometers/digital data loggers
o Maintenance of cold chain
WITHDRAWING FROM THE VFC PROGRAM

To assure a smooth transition of services, the following steps must be taken should a facility choose to discontinue
participating in the Pa. VFC Program.
• Notify the Pa. VFC program 30 days in advance at (1-888-646-6864) if the office plans to disenroll.
• Submit a complete inventory of all Pa. VFC vaccines on-site to include brand, lot number, expiration date and
number of doses.
• Submit three months of temperature logs.
• Refer VFC-eligible children to another VFC Provider. If necessary, contact the PA DOH for help finding another
VFC provider.
FRAUD WASTE AND ABUSE

The Pa. VFC Program recognizes that a vast majority of VFC providers abide by their legal and professional duties
and provide critical health care services to VFC patients every day. The Pa. VFC Program is committed to
safeguarding federally funded vaccines by targeting fraud perpetrators and saving taxpayer dollars while reducing
the burden on legitimate providers.
The comprehensive program to prevent and detect fraud, waste and abuse consists of:
• Procedures for the identification of potential fraud, waste and abuse in the Pa. VFC Program;
• A process to conduct a timely, reasonable inquiry into potential violations of federal and state criminal, civil and
administrative laws, rules and regulations; and
75
• A process to refer potential violations of applicable federal and state criminal, civil and administrative laws,
rules, and regulations to law enforcement for further investigation within a reasonable period.
VACCINE MANAGEMENT
• Post a vaccine expiration list on the refrigerator and freezer.
• Check and rotate inventory on a weekly basis.
• Administer shorter-dated vaccines first.
• Notify immunization nurses to assist in relocating vaccines expiring in 90 to 120 days to avoid waste.
• Deplete current single antigen vaccine inventory prior to switching to a combination antigen vaccine.
VACCINES AVAILABLE THROUGH THE PA VFC PROGRAM:

• Diphtheria, Tetanus and Acellular Pertussis (DtaP)
• Haemophilus Influenza Type b (Hib)
• Hepatitis A (Pediatric)
• Hepatitis B (Pediatric)
• Human Papillomavirus (HPV)
• Influenza
• Measles, Mumps and Rubella (MMR)
• Meningococcal Conjugate (MCV4)
• Meningococcal B
• Pneumococcal Conjugate 13 (PCV13)
• Pneumococcal Polysaccharide (PPSV23)
• Polio (IPV)
• Rotavirus
• Tetanus and Diphtheria (Td)
• Tetanus, Diphtheria and Acellular Pertussis (Tdap)
• Varicella
• Several Combination Vaccines
In addition, the following non-VFC vaccines are available by request for department approved public providers,
including state health centers, county and municipal health departments, federally qualified health centers, rural
health clinics and other public providers as approved by the PA DOH:
• Hepatitis A (adult)
• Hepatitis B (adult)
• Human papillomavirus (HPV – adult)
• Measles, mumps and rubella (MMR – adult)
• Meningococcal conjugate (MCV4 – adult)
• Meningococcal B (adult)
• Pneumococcal conjugate 13 (PCV13 – adult)
• Pneumococcal polysaccharide (PPSV23 – adult)
• Tetanus and diphtheria (Td – adult)
• Tetanus, diphtheria and acellular pertussis (Tdap – adult)
• Varicella (adult)
For complete vaccine management instructions please refer to

76
NOTE: As new vaccines or combination vaccines are approved by the FDA, they will be made available by the
CDC.
Vaccine Ordering
Vaccine orders are placed online using PA-SIIS or by faxing a PA Department of Health Supplied Vaccine Order,
Inventory, and Accountability form to 717-441-3800 or call 1-888-646-6864.
• Order monthly: first thru 15th.
• Order only one month’s supply of vaccine
• Order by number of doses, not packages
• Order according to type of facility (private provider ‒ order only pediatric vaccines; public providers – pediatric
and adult)
For complete ordering vaccines instructions and shipping information please refer to the
Returning Vaccines
All vaccines, including flu, deemed “returnable non-viable” should be returned within six months following
expiration date. However, vaccines that have expired more than six months previously will still be accepted. When
requesting a shipping label for the return of vaccines, please allow one to five business days to receive notification.
Complete the vaccine return and accountability form for returning all vaccines.
Vaccines may be returned when:
• They are expired and unopened.
• They are stored or handled improperly (must complete incident report)
• A storage unit failure occurs (must complete incident report)
• A power outage occurs (must complete incident report)
For complete returning vaccines instructions please refer to

Vaccine Storage and Handling

Any new providers enrolling in the VFC program will be required to use standalone refrigerators and standalone
freezers for vaccine storage. PA DOH-approved household combination units are no longer permitted for new
enrollment and/or replacement unit purchases.
PA DOH-supplied vaccine must be stored in one of the following:
• Standalone storage units (medical/pharmaceutical grade is highly recommended);

• Medical/pharmaceutical grade combination units; or
• Household combination unit (refrigerator portion only, must have separate standalone freezer).
For complete storage and handling instructions please refer to

Contact Information
Pennsylvania Department of Health (PA DOH) Division of Immunizations
625 Forster St., Room 1026
77
Harrisburg, PA 17120
Toll Free: 1-888-646-6864

Phone: 717-787-5681
Fax: 717-214-7223
Fax: 717-441-3800 or 717-441-3777
Email: [email protected]
Website: https://www.dhs.pa.gov/docs/Publications/Pages/Medical-Assistance-Provider-Forms.aspx
ADVANCE DIRECTIVES
The Patient Self-Determination Act of 1990, effective December 1, 1991, requires providers of services and health
maintenance organizations under the Medicare and Medicaid programs to assure that individuals receiving
services will be given an opportunity to participate in and direct health care decisions affecting themselves and be
informed of their right to have an advance directive. An advance directive is a legal document through which a
Member may provide directions or express preferences concerning his or her medical care and/or to appoint
someone to act on his or her behalf. Advance directives are used when the Member is unable to make or
communicate decisions about his or her medical treatment.
Advance directives are prepared before any condition or circumstance occurs that causes the Member to be
unable to actively decide about his or her medical care.
In Pennsylvania, there are two types of advance directives:

• Living will or health care instructions
• Appointment of a Health Care Power of Attorney
Providers are required to comply with federal and state laws regarding advance directives (also known as health
care power of attorney and living wills), as well as contractual requirements, for adult Members. In addition, GHP
Family requires that providers obtain and maintain advance directive information in the Member’s medical record.
Requirements for providers include:

• Maintaining written policies that address a Member’s right to make decisions about their medical care,
including the right to refuse care.
• Providing Members with written information about advance directives.
• Documenting the Member’s advance directives or lack of one in his or her medical record.
• Communicating the Member’s wishes to attending staff in hospitals or other facilities.
• Not discriminating against a Member or making treatment conditional on the basis of his or her decision to
have or not have an advance directive.
• Providing staff education on issues related to advance directives.
GHP Family provides information about advance directives to Members in the Member Handbook, including the
Member’s right to make decisions about their medical care, how to obtain assistance in completing or filing a living
will or health care power of attorney, and general instructions.
For additional information or Complaints regarding noncompliance with advance directive requirements, you can
contact:
78
Pennsylvania Office of Attorney General
Strawberry Square, 16th Floor
Phone: (717) 787-3391
REIMBURSEMENT & CLAIMS SUBMISSION REIMBURSEMENT/FEE-FOR-SERVICE

PAYMENT
GHP Family will reimburse Participating Providers at fee-for-service rates described in the Participating Provider‘s
individual GHP Family Agreement. MA fee-for-service fee schedules can be viewed on the DHS website:
https://www.humanservices.state.pa.us/outpatientfeeschedule.
BILLING INSTRUCTIONS
Medical Assistance Enrollment & PROMISe ID Number Required

All providers who provide services to HealthChoices Members must be enrolled in the Commonwealth’s Medical
Assistance (MA) program and possess an active PROMISe™ Provider ID to bill for services. For information on
how to enroll in PROMISe™ and enrollment forms, please visit the DHS’s Web site at:
https://www.dhs.pa.gov/providers/Providers/Pages/PROMISe-Enrollment.aspx.
Member Eligibility Verification

A MA Identification Card, titled Pennsylvania ACCESS Card, is an identification card issued by DHS to each MA
recipient. The card can be used by MA-enrolled Health Care Providers to access DHS’s Eligibility Verification
System (EVS) and verify the recipient’s MA eligibility and specific covered benefits. Prior to rendering or billing for
services, providers should verify each Member’s eligibility for benefits through the online eligibility information from
the EVS. The EVS offers Medicaid providers the information to make an informed decision prior to rendering a
service or item.
The plastic ACCESS Card has a magnetic strip designed for swiping through a point-of-sale (POS) device to
access eligibility information through the EVS. The MA recipient’s current eligibility status and verification of which
MCO they may be participating with can be obtained by either swiping the ACCESS Card or by calling the EVS
phone number (800) 766-5387.
If a Member presents to a Provider’s office and states he/she is a MA recipient, but does not have an ACCESS
Card, eligibility can still be obtained by using the Member’s date of birth (DOB) and Social Security number (SS#)
when the call is placed to EVS.
For more information regarding the EVS and ways to access eligibility data, visit the following:
https://promise.dpw.state.pa.us/portal/Default.aspx?alias=promise.dpw.state.pa.us/portal/provider.
In addition to the ACCESS Card, Members will receive a GHP Family identification card upon enrollment with GHP
Family. Below is a sample of the GHP Family identification card:
79
Payment for Medically Necessary Services
In accordance with Pennsylvania Code 55, Chapter 1101, DHS will only pay for Medically Necessary services for
covered benefits. DHS defines Medically Necessary services as a service or benefit that is compensable under the
MA Program and meets any one of the following standards:
• The service or benefit will, or is reasonably expected to, prevent the onset of an illness, condition, or disability.
• The service or benefit will, or is reasonably expected to, reduce, or ameliorate the physical, mental or
developmental effects of an illness, condition, injury or disability.
• The service or benefit will assist the Member to achieve or maintain maximum functional capacity in performing
daily activities, considering both the functional capacity of the Member and those functional capacities that are
appropriate for Members of the same age.
Determination of Medical Necessity for covered care and services, whether made on a Prior Authorization,
Concurrent Review, Retrospective Review, or on an exception basis, must be documented in writing. The
determination is based on medical information provided by the Member, the Member’s family/caretaker, and the
PCP, as well as any other providers, programs, agencies that have evaluated the Member. All Medical Necessity
determinations must be made by qualified and trained health care providers.
DHS has established benefit packages based on category of assistance, program status code, age, and, for some
packages, the existence of Medicare coverage or a Deprivation Qualifying Code. Participating Providers are
expected to provide services in the amount, duration and scope set forth by DHS and based on the Member’s
benefit package. GHP Family will ensure that services are sufficient in amount, duration, or scope to reasonably
be expected to achieve the purpose for which the services are furnished. GHP Family will not arbitrarily deny or
reduce the amount, duration, or scope of a Medically Necessary service solely because of the Member’s
diagnosis, type of illness or condition.
Provider Billing
GHP Family accepts both electronic and manual Claims submissions. To assist us in processing and paying
Claims efficiently, accurately, and timely, GHP Family encourages providers to submit Claims electronically. To
facilitate electronic Claims submissions, GHP Family has developed business relationships with major
clearinghouses, including Change Healthcare.
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GHP Family receives EDI Claims directly from these clearinghouses, processes them through pre-import edits to
ensure the validity of the data, HIPAA compliance and Member enrollment and then uploads them each Business
Day. Within 24 hours of file receipt, GHP Family provides production reports and control totals to all trading
partners to validate successful transactions and identify errors for correction and resubmission.
Providers can submit paper Claims to GHP Family’s designated post office box. Paper Claims are scanned into
our system each Business Day.
Claims Department
Geisinger Health Plan
PO Box 160
Glen Burnie, MD 21060
Co-payments
Certain services require a Member co-payment. This amount should be collected from the Member by the provider
and deducted from the amount billed to GHP Family.
Providers must submit all Claims whether the Member made full payment. Providers should not deny services to a
Member even if the Member has not made full payment of their cost-sharing amounts.
It is important for providers to document on the Claim submitted the amount that the Member paid or the amount
the provider has billed to the Member.
Coordination of Benefits/Third Party

GHP Family will act as the primary payer on the following services (unless existing primary coverage is available
and known at the time of service):
• Preventive pediatric care (including EPSDT services to children), and services to children having medical
coverage under a Title IV-D child support order
• As mandated by DHS, GHP Family will process and pay claims for the services above, even when records
indicate GHP Family is the secondary payer to an existing primary plan. GHP Family may initiate subsequent
recovery efforts once the primary plan appropriately processes claims for these services.
Providers must always ensure GHP Family receives encounter data for all covered services provided to members,
even when third party insurance is primary and GHP Family is the payer of last resort; and even when no
additional payment from GHP Family is expected.
GHP Family is the payer of last resort on all other services. Providers must bill third party insurance before
submitting a Claim to GHP Family. GHP Family will pay the difference between the primary insurance payment
and GHP Family allowable amount. Providers cannot balance bill Members.
If the primary insurance carrier denies the Claim as a non-covered service, the Claim with the denial may be
submitted to GHP Family for a coverage determination under the Member’s program. It is the provider’s
responsibility to obtain the primary insurance carrier’s explanation of benefits (EOB) or the remittance advice for
services rendered to Members that have insurance in addition to GHP Family. The primary carrier’s EOB or
remittance advice should accompany any Claims submitted for payment. A detailed explanation of how the Claim
was paid or denied should be included if not evident from the primary carrier’s EOB or the remittance advice. This
information is essential for GHP Family to coordinate benefits.
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If a service is non-covered or benefits have been exhausted from the primary carrier, the provider is required to get
an updated letter every January and July to submit with each Claim. Claims submitted without the EOB for
Members where third-party insurance is indicated will be denied in most cases.
In the event a Claim is paid by GHP Family and it is later discovered the Member has other insurance, the
payment made to the provider will be recovered by either GHP Family or DHS.
GHP Family will neither unreasonably delay payment nor deny payment of Claims because they involved an injury
stemming from an accident such as a motor vehicle accident, where the services are otherwise covered. Those
funds under the scope of these Other Resources shall be recovered and retained by the Commonwealth.
If assistance with the billing of third-party payers is required, please contact a Provider Account Manager at (800)
876-5357.
To prevent denials for coding mismatches, Claims submitted to the primary carrier on a form that differs from GHP
Family’s requirements should be clearly marked with COB Form Type Conversion.
Timely Claim Submission Requirements

GHP Family requires that Claims be submitted within 180 days from the date of service. Providers have 365 days
from the earliest date of service to correct and resubmit Claims if the initial submission was within the 180-day time
period whether or not the Claim was denied on the first submission. GHP Family requires Clean Claim
submissions for processing.
Claims Payment Timeframes

In compliance with federal regulations applicable to Medicaid managed care plans, GHP Family processes Clean
Claims in the following timeframes:
• 90.0% of Clean Claims must be adjudicated within thirty (30) days of receipt
• 100.0% of Clean Claims must be adjudicated within forty-five (45) days of receipt
• 100.0% of all Claims must be adjudicated within ninety (90) days of receipt
These timeframes apply to the HealthChoices Program. Most Claims are processed by GHP Family within ten (10)
days of receipt.
National Provider Identifier (NPI)

Any Claims submitted by a provider must follow HIPAA regulations regarding NPI numbers and the new Claim
forms. Any Claims received not in compliance will be returned.
Compliance
The CMS-1500 form contains fields for the NPI numbers. Field 17 requires the NPI of the referring physician, if
appropriate. Field 24J is available for the NPI number of the provider rendering service(s). Field 32 requires the
NPI of the facility location if other than office. Field 33 should be completed with the billing provider’s NPI number.
The new UB-04 form requires the NPI number of the billing provider in field 56. The NPIs of the attending
physician and the operating physician should be in fields 76 and 77 respectively.
EDI Claims
Your electronic billing vendor should have provided you with the newest version of the software to comply with the
NPI requirements. If EDI Claims are rejected, please check with your vendor first. If you are experiencing any
issues with EDI Claims, please contact our Provider Relations Department at (800) 876-5357.
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Acceptable Claims Forms
GHP Family requires all providers to use one of the following forms when submitting Claims: A CMS 1500
(formerly HCFA 1500) billing form is used to submit Claims for all professional services including ancillary services
and professional services billed by a hospital.
Hospital inpatient and outpatient services, dialysis services, nursing home room and board, and inpatient hospice
services must be billed on the UB 04 billing form. GHP Family will not process Claims received on any other type
of Claim form.
Completing a CMS 1500

The CMS 1500 (formerly HCFA 1500) billing form is used to submit Claims for all professional services. When
submitting a CMS 1500 form, certain fields are required (see CMS 1500 required fields section).
CMS 1500 Documentation

Before submitting a Claim a provider should ensure that all required attachments are included.
All Claims that involve other insurance or Medicare must be accompanied by an Explanation of Benefits (EOB) or
a remittance advice that clearly states how the Claim was paid or the reason for payment denial.
Completing the UB 04
The UB 04 form is used when billing for facilities services including hospital inpatient and outpatient services,
dialysis services, nursing home room and board and inpatient hospice service.
UB 04 Documentation
Inpatient, ER and Outpatient hospital Claims above a certain threshold require additional documentation which
may include the medical record and an itemized bill.
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CMS 1500 REQUIRED FIELDS
Sample form:
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CMS 1500 required fields:
Field # Required Field Description
1a Insured’s Id Number – 11-digit Geisinger Health Plan Number can be found on the member ID card
2 Patient’s name — patient’s last name, first name, and middle initial
3 Patient’s birth date — patient’s date of birth (Month, Day, Year); also, patients’ gender
4 Insured’s Name – last name, first name, and middle initial of policyholder
5 Patient’s address — patient’s current address, including city, state, and ZIP code; also, patient’s telephone number
6 Patient’s relationship to the insured — applicable relationship box marked
7 Insured’s address — insured’s current address, including city/state/ZIP code; also, insured’s telephone number
Other Insured’s Name – if the patient is covered by another insurance carrier list the insureds Last Name, First Name and
9 Middle Initial
Other Insured’s Policy and Group Number – if patient has other insurance listed in box 9, please provider other insured policy
9a and group number
10 Is Patients Condition related to – mark the box if condition is related to employment, Auto Accident, Other Accident
11 Insured’s Policy Group or FECA Number – if patient is covered under insured policy, please enter insured’s group number
11a Insured’s Date of Birth – (Month, Day, Year); also insured’s gender
11d Is there another Health Benefit Plan – If yes is checked complete box 9, 9a and 9d
12 Patient’s or Authorized Person’s Signature – Patient has signed release of information from provider
13 Insured’s or Authorized Person’s Signature – authorize payment of medical benefits
17 Referring Provider Name – First Name and Last Name of referring physician
17a No longer required
17b Referring Provider NPI – enter assigned UPIN (Universal Physician Identification Number)
Diagnosis or nature of illness or injury – all diagnoses at the time of the encounter for all diagnoses assessed, managed, or
21 treated should be submitted
Date(s) of service (from and to) formatted in month/day/year
24A NOTE: DME rental services this is the rental period. Dates cannot overlap any previous or future rental cycles
24B Place of Service – Standard 2-digit code where services were rendered
24D Procedures, services, or Supplies – CPT/HCPCS procedure code and modifier if applicate.
24E Diagnosis Pointer – diagnosis or diagnoses code that apply to services performed at time of visit
24F Charges — amount charged for service
24G Days or Units – number of times service was rendered
Rendering Provider ID # - In top box the provider taxonomy code can be billed. In the NPI box the Rendering (Servicing)
Provider name and NPI is required.
NOTE: The Rendering Provider NPI must be an individual NPI and not the group NPI. If the provider is a typical provider
24J type then the DHS Medicaid Provider ID (MPI) is required
25 Federal Tax ID Number – Tax ID of provider rendering the service
26 Patient’s Account No – Provider of service account number for patient
28 Total Charges – Total of all service lines billed
29 Amount Paid – Amount paid by Third Party or Patient
31 Signature Of Physician or Supplier Including Degrees or Credentials – Signature of provider rendering services
Service Facility Location Information – Facility Name and address where services were rendered. 32a is the NPI of the facility
where services where rendered.
32 NOTE: Facility Name and NPI is required when billing with POS 19, 21, 22, 23, 24, 31 or 32
33 Billing Provider Info & PH# - Billing Provider name, Address, and phone number. NOTE Box 33 a is the billing provider NPI
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ENCOUNTER DATA SUBMISSION
To support timely statutory reporting requirements, we encourage PCPs to submit encounter information within
thirty (30) days of the encounter. However, all encounters (Claims) must be submitted within 180 calendar days
after the services were rendered or compensable items were provided.
The following mandatory information is required on the CMS-1500 form for a primary care visit:
• GHP Family Member’s ID number
• Member’s name
• Member’s date of birth
• Other insurance information: company name, address, policy and/or group number, and amounts paid by other
insurance, copy of EOB’s
• Information advising if patient’s condition is related to employment, auto accident, or liability suit
• Name of referring physician, if appropriate
• Dates of service, admission, discharge
• Primary, secondary, tertiary and fourth ICD-10-CM diagnosis codes.
• Authorization or referral number
• CMS place of service code
• HCPCS procedures, service or supplies codes; CPT procedure codes with appropriate modifiers
• Charges
• Days or units
• Physician/supplier federal tax identification number or Social Security Number
• National Practitioner ID (NPI) and Taxonomy Code
• Individual GHP Family assigned practitioner number
• Name and address of facility where services were rendered
• Physician/supplier billing name, address, zip code, and telephone number
• Invoice date
Providers should refer to their contracts for documentation requirements and/or to the provider specific billing
sections of this manual.
EXPLANATION OF PAYMENT (EOP)

For each Claim that is paid or denied the provider receives a remittance advice (remit). If a Claim is denied,
providers receive a remittance advice that summarizes:
• Payment activity for the provider (the provider’s account balance, Claims processed, copayments applied,
interest payments or penalties, discounts, the amount recouped if the beginning balance was negative, and the
net paid amount)
• The check number
• Denial reasons for Claims or line items denied
• Claims inquiry contact information
• Claims resubmission and reconsideration steps and details of resubmissions
• Appeals process
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To access a copy of the EOP including a description of information provided on the remit, please log on to the
secure web portal at http://www.instamed.com/eraeft.
CLAIMS RESUBMISSION
Claims may be resubmitted for two reasons; (1) to submit a corrected Claim or; (2) to submit a previously submitted
Claim to which additional information has been attached. When resubmitting a Claim, providers need to indicate on
the Claim whether it is a corrected Claim or a resubmitted Claim with appropriate supporting documentation.
• Submit a corrected Claim or a request for reprocessing a Claim within the contracted timely filing guidelines.
• Corrected or resubmitted Claims that do not require supporting documentation may be submitted through GHP
Family Electronic Data Interface (EDI) vendors.
• Corrected or resubmitted Claims that require supporting documentation must be submitted on paper to the
GHP Family Claims processing center or be submitted electronically using the online CRRF appeals via
https://www.navinet.net.
GHP FAMILY PAY-FOR-QUALITY PROGRAM

GHP Family’s Pay-for-Quality program was initiated to encourage and promote the focus of quality care for GHP
Family Members. The Pay-for-Quality program is available to physicians in primary care (i.e., Family Practice,
Internal Medicine, and Pediatrics) and Obstetrics and Gynecology. Each specialty within primary care is
considered separately. Additionally, qualifying PCPs meeting measurement thresholds for each applicable
category are eligible for reimbursement through the Pay-for-Quality incentive payment.
Physicians are rewarded for meeting and exceeding certain clinical measurement categories. The Pay-for-Quality
program is not meant to be a static measurement system and will remain flexible to meet changing clinical
practices and quality requirements.
More information about the Pay-for-Quality program (including the GHP Family Pay-for-Quality Manual) is
available online at https://ghpfamily.com or https://www.navinet.net. Your Provider Account Manager is also
available to work with you in meeting Pay-for-Quality measurement criteria to maximize your incentive.
MEMBER RIGHTS & RESPONSIBILITIES
GHP Family Members have the right:

• To be treated with respect, recognizing your dignity and need for privacy, by GHP Family staff and network
providers.
• To get information in a way that you can easily understand and find help when you need it.
• To get information that you can easily understand about GHP Family, its services, and the doctors and other
providers that treat you.
• To pick the network health care providers that you want to treat you.
• To get emergency services when you need them from any provider without GHP Family’s approval.
• To get information that you can easily understand and talk to your providers about your treatment options, risks
of treatment, and tests that may be self-administered without any interference from GHP Family.
• To make all decisions about your health care, including the right to refuse treatment. If you cannot make
treatment decisions by yourself, you have the right to have someone else help you make decisions or make
decisions for you.
• To talk with providers in confidence and to have your health care information and records kept confidential.
• To see and get a copy of your medical records and to ask for changes or corrections to your records.
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• To ask for a second opinion.
• To file a Grievance if you disagree with GHP Family’s decision that a service is not medically necessary for you.
• To file a Complaint if you are unhappy about the care or treatment you have received.
• To ask for a DHS Fair Hearing.
• To be free from any form of restraint or seclusion used to force you to do something, to discipline you, to make it
easier for the provider, or to punish you.
• To get information about services that GHP Family or a provider does not cover because of moral or religious
objections and about how to get those services.
• To exercise your rights without it negatively affecting the way DHS, GHP Family, and network providers treat you.
• To create an advance directive.
• To make recommendations about the rights and responsibilities of GHP Family’s members.
GHP Family Members have the responsibility:

• Provide, to the extent you can, information needed by your providers.
• Follow instructions and guidelines given by your providers.
• Be involved in decisions about your health care and treatment.
• Work with your providers to create and carry out your treatment plans.
• Tell your providers what you want and need.
• Learn about GHP Family coverage, including all covered and non-covered benefits and limits.
• Use only network providers unless GHP Family approves an out-of-network provider or you have Medicare.
• Get a referral from your PCP to see a specialist.
• Respect other patients, provider staff, and provider workers.
• Make a good-faith effort to pay your co-payments.
• Report fraud and abuse to the DHS Fraud and Abuse Reporting Hotline.
CONFIDENTIALITY & PRIVACY OF GHP FAMILY MEMBER MEDICAL RECORDS &

PROTECTED HEALTH INFORMATION (PHI)
GHP Family follows the regulations in the Health Insurance Portability and Accountability Act of 1996 (HIPAA)
including the HITECH Act of 2009. This law protects the privacy of Member medical records and health
information. GHP Family also follows all other state and federal regulations regarding privacy of medical records
and health information. A Member’s medical record and other information (which includes information relating to
HIV/AIDS, substance abuse and behavioral health treatments) received by GHP Family will be kept confidential
(private) as required by law.
MEMBER COMPLAINTS, GRIEVANCES AND DHS FAIR HEARINGS
Overview
DHS defines “Complaint” and “Grievance” as two separate and distinct types of issues. Members and their
representatives (including providers) may file a Complaint or Grievance if they are not able to resolve issues
through informal channels with GHP Family or the DHS. In some instances, Members and their representatives
may request a DHS Fair Hearing.
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Members may agree to be represented by their health care provider in the filing of a Complaint or Grievance or in
the request of a DHS Fair Hearing. Members may also request an expedited review of a Complaint or Grievance.
GHP Family will process an expedited Complaint or Grievance if it determines the Member’s life, physical or
mental health, or ability to attain, maintain, or regain maximum function would be placed in jeopardy by following
the regular
Complaint or Grievance process or if a Member’s provider with the Member’s written authorization provides GHP
Family with a certification that the Member’s life, physical or mental health, or ability to attain, maintain, or regain
maximum function would be placed in jeopardy by following the standard procedures. The provider’s written
certification for an expedited review must state why the usual timeframe for deciding the appeal would jeopardize
the member’s life, health, or ability to attain, maintain or regain maximum function and must include the Provider’s
signature.
For a provider to represent the Member in the conduct of a Grievance, the provider must obtain written consent of
the Member. A provider may not require a Member to sign a document authorizing the provider to file a Grievance
as a condition of treatment. The consent form must maintain the following elements:
• The Member’s name, address, date of birth, and identification number. If the Member is a minor or is legally
incompetent, the name address and relationship to the Member of the person who signed the consent.
• The name, address, and GHP Family provider identification number of the provider who is receiving the
Member’s consent to file a Complaint or Grievance.
• The name and address of GHP Family.
• An explanation of the specific service/item for which coverage was provided or denied to the Member to which
the consent will apply.
• The following statement – “I or my representative may not file a Grievance about the service or item listed in
this consent form unless I or my representative takes back my consent in writing. I have the right to take back
my consent at any time during the Grievance process by telling GHP Family and [Name of Provider] in writing
that I do not want [Name of Provider] to continue the Grievance process for me.”
• The following statement – “My consent to have the Provider file the Grievance for me will automatically no
longer be in effect if the Provider does not file a Grievance or does not continue with the Grievance through the
end of the Grievance review process.
• The following statement – “I or my representative has read, or has been read, this consent form, and have had
it explained to me until I understand it. I or my representative understands the information in this consent form.”
• The dated signature of the Member, or the Member’s representative, and the dated signature of a witness.
A Member who consents to the filing of a Complaint or Grievance by a health care provider may not file a separate
Grievance. The Member retains the right to rescind consent throughout the Grievance.
The Appeal Department has the overall responsibility for the management of the Member Complaint and
Grievance process. This includes:
• Documenting individual Complaints and Grievances
• Coordinating resolutions
• Maintaining logs and records of the Complaints and Grievances
• Tracking, trending, and reporting data
The GHP Family Appeals Coordinator will serve as the primary contact person for the Complaint and Grievance.
The Appeal Department, in collaboration with the Customer Care Department and Provider Relations Department,
is responsible for informing and educating Members and providers about a Member’s right to file a Complaint or
Grievance or request a DHS Fair Hearing and for assisting Members in filing a Complaint or Grievance or in
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requesting a DHS Fair Hearing. Members are advised of their Complaint, Grievance and DHS Fair Hearing rights
and the Complaint, Grievance and DHS Fair Hearing process at the time of enrollment and at least annually
thereafter. Members are provided this information via the Member handbook, Member newsletters and the GHP
Family Web site. The information provided to Members includes, but is not limited to:
• The method for filing a Complaint, Grievance or for requesting a DHS Fair Hearing including procedural steps
and timeframes for filing each level of a Complaint or Grievance or for requesting a DHS Fair Hearing.
• Notification of Member’s rights related to Complaints, Grievances and DHS Fair Hearing, including the right to
voice Complaints or Grievances about GHP Family or care provided.
• The availability of assistance from GHP Family with filing a Complaint, Grievance or requesting a DHS Fair
Hearing along with GHP Family toll-free number and address for filing Complaints, Grievances or requesting a
DHS Fair Hearing.
• Upon request, reasonable assistance with the Complaint, Grievance and DHS Fair Hearing process is
provided to Members. This includes but is not limited to providing oral interpreter services and the tollfree
number for language assistant services.
• TTY/TDD and sign language interpreter capability. GHP Family staff is trained to respond to Members with
disabilities with patience, understanding and respect.
Complaints DHS defines “Complaint” as a dispute or objection regarding a participating provider or the coverage,
operations, or management of GHP Family, which has not been resolved by GHP Family and has been filed with
GHP Family or with DOH or PID, including but not limited to:
• a denial because the requested service or item is not a covered service;
• the failure of GHP Family to provide a service or item in a timely manner, as defined by the Department;
• the failure of GHP Family to decide a Complaint or Grievance within the specified time frames;
• a denial of payment by GHP Family after a service or item has been delivered because the service or item was
provided without authorization by a Provider not enrolled in the MA Program;
• a denial of payment by GHP Family after a service or item has been delivered because the service or item
provided is not a covered service for the Member;
• a denial of a Member’s request to dispute a financial liability, including cost sharing, copayments, premiums,
deductibles, coinsurance, and other Member financial liabilities.
The term does not include a Grievance.
Grievances A “Grievance” is a request to have GHP Family or a utilization review entity reconsider a decision
solely concerning the Medical Necessity and appropriateness of a covered service. Members or their
representatives (including providers) may file a Grievance. A Grievance may be filed regarding GHP Family’s
decision to 1) deny, in whole or in part, payment for a service/item; 2) deny or issue a limited authorization of a
requested service/item, including a determination based on the type or level of service or item; 3) reduce,
suspend, or terminate a previously authorized service/item; 4) deny the requested service/item, but approve an
alternative service/item; and 5) deny a request for a BLE. This definition does not include Complaints.
DHS Fair Hearing

A DHS Fair Hearing is a hearing conducted by DHS Bureau of Hearings and Appeals or its subcontractor.
A Member must file a Complaint or Grievance with GHP Family and receive a decision on the Complaint or
Grievance before filing a request for a Fair Hearing. If GHP Family fails to provide written notice of a Complaint or
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Grievance decision within the time frames specified by DHS, the Member is deemed to have exhausted the
Complaint or Grievance process and may request a Fair Hearing.
The Member or the Member’s representative may request a Fair Hearing within one hundred and twenty
(120) days from the mail date on the written notice of GHP Family’s first level Complaint decision or Grievance
decision for any of the following:
1. the denial, in whole or part, of payment for a requested service or item based on lack of Medical Necessity;
2. the denial of a requested service or item because the service or item is not a covered service;
3. the reduction, suspension, or termination of a previously authorized service or item;
4. the denial of a requested service or item but approval of an alternative service or item;
5. the failure of GHP Family to provide a service or item in a timely manner, as defined by the Department;
6. the failure of GHP Family to decide a Complaint or Grievance within the specified time frame;
7. the denial of payment after a service or item has been delivered because the service or item was provided
without authorization by a Provider not enrolled in the MA Program;
8. the denial of payment after a service or item has been delivered because the service or item is not a covered
service for the Member;
9. the denial of a Member’s request to dispute a financial liability, including cost sharing, copayments, premiums,
GHP Family Complaint and Grievance Department provides Members with assistance as necessary, including
interpreter and translation services, in filing Complaints, Grievances and requests for DHS Fair Hearings. Contact
information is:
Geisinger Health Plan Appeals Department

Phone: (866) 577-7733, Opt. 0
Fax: 570-271-7225
GHP Family will accept Complaints and Grievances telephonically via a toll-free telephone number, in writing or by
facsimile. If the Member has a sensory impairment, GHP Family will assign a representative to assist that Member
throughout the Grievance system process. GHP Family will accept Complaints and Grievances through a
TTY/TDD line, Braille; tape or CD and other commonly accepted alternative forms of communication. If a Member
should need a sign language interpreter, GHP Family will provide one at no cost to the Member. Additionally, GHP
Family will train its staff to be aware of speech limitations of some Members with disabilities and treat these
Members with patience, understanding and respect.
If a Complaint or Grievance is received in a written format (surface mail, facsimile, Braille), it will be forwarded to
the Coordinator.
The Coordinator will assign the appropriate category (Complaint or Grievance or DHS Fair Hearing request), level
(first, second, expedited or external) and ensure the required timeframe.
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GHP Family’s Complaints, Grievances, and Fair Hearings Member Handbook Section
(Section 8 – Complaints, Grievances, and Fair Hearings)
If a provider or GHP Family does something that you are unhappy about or do not agree with, you can tell GHP
Family or the Department of Human Services what you are unhappy about or that you disagree with what the
provider or GHP Family has done. This section describes what you can do and what will happen.
Complaints
What is a Complaint?
A Complaint is when you tell GHP Family you are unhappy with GHP Family or your provider or do not agree with
a decision by GHP Family.
Some things you may complain about:

• You are unhappy with the care you are getting.
• You cannot get the service or item you want because it is not a covered service or item.
• You have not gotten services that GHP Family has approved.
• You were denied a request to disagree with a decision that you have to pay your provider.
First Level Complaint
What Should I Do if I Have a Complaint?

To file a first level Complaint:
• Call GHP Family at 1-855-227-1302, PA Relay 711 and tell GHP Family your Complaint, or
• Write down your Complaint and send it to GHP Family by mail or fax, or
• If you received a notice from GHP Family telling you GHP Family’s decision and the notice included a
Complaint/Grievance Request Form, fill out the form and send it to GHP Family by mail or fax.
GHP Family
ATTN: Appeals Department
100 N. Academy Ave.
Fax: 570-271-7225
By Secure Email* at [email protected]
* Because emails are not secure unless encrypted by the sender, you should not include personal
identifying information such as your date of birth or personal medical information unless you
encrypt the email.
Your provider can file a Complaint for you if you give the provider your consent in writing to do so.
When Should I File a First Level Complaint?

Some Complaints have a time limit on filing. You must file a Complaint within 60 days of getting a notice telling
you that:
• GHP Family has decided that you cannot get a service or item you want because it is not a covered service or
item.
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• GHP Family will not pay a provider for a service or item you got.
• GHP Family did not tell you its decision about a Complaint or Grievance you told GHP Family about within 30
days from when GHP Family got your Complaint or Grievance.
• GHP Family has denied your request to disagree with GHP Family’s decision that you have to pay your
provider.
You must file a Complaint within 60 days of the date you should have gotten a service or item if you did not
get a service or item. The time by which you should have received a service or item is listed below:
New Member appointment for your first

We will make an appointment for you…
examination…
with PCP or specialist no later than 7 days after

Members with HIV/AIDS you become a Member in GHP Family unless you
are already being treated by a PCP or specialist.
with PCP or specialist no later than 45 days after

Members who receive Supplemental Security
you become a Member in GHP Family, unless you
Income (SSI)
are already being treated by a PCP or specialist.
with PCP for an EPSDT exam no later than 45

days after you become a member in GHP Family,
Members under the age of 21
unless you are already being treated by a PCP or
specialist.
with PCP no later than 3 weeks after you become

All other Members
a Member in GHP Family.
New Member appointment for your first

We will make an appointment for you…
examination…
Members who are pregnant: We will make an appointment for you…
with OB/GYN provider within 10 business days of

Pregnant women in their first trimester
GHP Family learning you are pregnant.

Pregnant women in their second trimester
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Pregnant women in their third trimester
with OB/GYN provider within 24 hours of GHP

Pregnant women with high-risk pregnancies
Family learning you are pregnant.
Appointment with… An appointment must be scheduled…
PCP
Urgent medical condition within 24 hours.
Routine appointment/health assessment/general within 10 business days.
Physical examination within 3 weeks.
Specialists (when referred by PCP)
Urgent medical condition within 24 hours of referral.
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routine appointment with one of the following
specialists:
• Otolaryngology
• Dermatology
• Pediatric Endocrinology
• Pediatric General Surgery
• Pediatric Infectious Disease
• Pediatric Neurology
• Pediatric Pulmonology
• Pediatric Rheumatology
within 15 business days of referral.
• Dentist
• Orthopedic Surgery
• Pediatric Allergy & Immunology
• Pediatric Gastroenterology
• Pediatric Hematology
• Pediatric Nephrology
• Pediatric Oncology
• Pediatric Rehab Medicine
• Pediatric Urology
• Pediatric Dentistry
routine appointment with all other specialists within 10 business days of referral.
You may file all other Complaints at any time.
What Happens After I File a First Level Complaint?

After you file your Complaint, you will get a letter from GHP Family telling you that GHP Family has received your
Complaint, and about the First Level Complaint review process.
You may ask GHP Family to see any information GHP Family has about the issue you filed your Complaint about
at no cost to you. You may also send information that you have about your Complaint to GHP Family.
You may attend the Complaint review if you want to attend it. GHP Family will tell you the location, date, and time
of the Complaint review at least 10 days before the day of the Complaint review. You may appear at the Complaint
review in person, by phone, or by videoconference. If you decide that you do not want to attend the Complaint
review, it will not affect the decision.
A committee of 1 or more GHP Family staff who were not involved in and do not work for someone who was
involved in the issue you filed your Complaint about will meet to make a decision about your Complaint. If the
Complaint is about a clinical issue, a licensed doctor or licensed dentist will be on the committee. GHP Family will
mail you a notice within 30 days from the date you filed your First Level Complaint to tell you the decision on your
First Level Complaint. The notice will also tell you what you can do if you do not like the decision.
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If you need more information about help during the Complaint process, see page 74.
What to do to continue getting services:
If you have been getting the services or items that are being reduced, changed or denied and you file a
Complaint verbally, or that is faxed, postmarked, or hand-delivered within 15 days of the date on the notice
telling you that the services or items you have been receiving are not covered services or items for you, the
services or items will continue until a decision is made.
What if I Do Not Like GHP Family’s Decision?

You may ask for an external Complaint review, a Fair Hearing, or an external Complaint review and a Fair Hearing
if the Complaint is about one of the following:
• GHP Family’s decision that you cannot get a service or item you want because it is not a covered service or
item.
• GHP Family’s decision to not pay a provider for a service or item you got.
• GHP Family’s failure to decide a Complaint or Grievance you told GHP Family about within 30 days from when
GHP Family got your Complaint or Grievance.
• You did not get a service or item within the time by which you should have received it
• GHP Family’s decision to deny your request to disagree with GHP Family’s decision that you have to pay your
provider.
You must ask for an external Complaint review within 15 days of the date you got the First Level Complaint
decision notice.
You must ask for a Fair Hearing within 120 days from the mail date on the notice telling you the Complaint
decision.
For all other Complaints, you may file a Second Level Complaint within 45 days of the date you got the
Complaint decision notice.
For information about Fair Hearings, see page 75

For information about external Complaint review, see page 69
If you need more information about help during the Complaint process, see page 74
Second Level Complaint
What Should I Do if I Want to File a Second Level Complaint?

To file a Second Level Complaint:
• Call GHP Family at 1-866-577-7733 and tell GHP Family your Second Level Complaint, or
• Write down your Second Level Complaint and send it to GHP Family by mail or fax, or
• Fill out the Complaint Request Form included in your Complaint decision notice and send it to GHP Family by
mail or fax.
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GHP Family’s address and fax number for Second Level Complaints
GHP Family
100 N. Academy Ave.
Fax: 570-271-7225
encrypt the email.
What Happens After I File a Second Level Complaint?

After you file your Second Level Complaint, you will get a letter from GHP Family telling you that GHP Family has
received your Complaint, and about the Second Level Complaint review process.
You may ask GHP Family to see any information GHP Family has about the issue you filed your Complaint about
at no cost to you. You may also send information that you have about your Complaint to GHP Family.
You may attend the Complaint review if you want to attend it. GHP Family will tell you the location, date, and time
of the Complaint review at least 15 days before the Complaint review. You may appear at the Complaint review in
person, by phone, or by videoconference. If you decide that you do not want to attend the Complaint review, it will
not affect the decision.
A committee of 3 or more people, including at least 1 person who does not work for GHP Family, will meet to
decide your Second Level Complaint. The GHP Family staff on the committee will not have been involved in and
will not have worked for someone who was involved in the issue you filed your Complaint about. If the Complaint is
about a clinical issue, a licensed doctor or licensed dentist will be on the committee. GHP Family will mail you a
notice within 45 days from the date your Second Level Complaint was received to tell you the decision on your
Second Level Complaint. The letter will also tell you what you can do if you do not like the decision.
If you need more information about help during the Complaint process, see page 74.
What if I Do Not Like GHP Family’s Decision on My Second Level Complaint?

You may ask for an external review from the Pennsylvania Insurance Department’s Bureau of Managed Care.
You must ask for an external review within 15 days of the date you got the Second Level Complaint decision
notice.
External Complaint Review
How Do I Ask for an External Complaint Review?

Send your written request for an external review of your Complaint to the following:
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Pennsylvania Insurance Department Bureau of Consumer Services
Room 1209, Strawberry Square
Fax: 717-787-8585
You can also go to the “File a Complaint Page” at https://www.insurance.pa.gov/Consumers/Pages/default.aspx.
If you need help filing your request for external review, call the Bureau of Consumer Services at 1-877-881-6388.
If you ask, the Bureau of Consumer Services will help you put your Complaint in writing.
What Happens After I Ask for an External Complaint Review?

The Insurance Department will get your file from GHP Family. You may also send them any other information that
may help with the external review of your Complaint.
You may be represented by an attorney or another person such as your representative during the external review.
A decision letter will be sent to you after the decision is made. This letter will tell you all the reason(s) for the
decision and what you can do if you do not like the decision.
If you have been getting the services or items that are being reduced, changed or denied and your request for
an external Complaint review is postmarked or hand-delivered within 15 days of the date on the notice telling
you GHP Family’s First Level Complaint decision that you cannot get services or items you have been
receiving because they are not covered services or items for you, the services or items will continue until a
decision is made. If you will be asking for both an external Complaint review and a Fair Hearing, you must
request both the external Complaint review and the Fair Hearing within 15 days of the date on the notice telling
you GHP Family’s First Level Complaint decision. If you wait to request a Fair Hearing until after receiving a
decision on your external Complaint, services will not continue.
Grievances
What is a Grievance?
When GHP Family denies, decreases, or approves a service or item different than the service or item you
requested because it is not medically necessary, you will get a notice telling you GHP Family’s decision.
A Grievance is when you tell GHP Family you disagree with GHP Family’s decision.
What Should I Do if I Have a Grievance?

To file a Grievance:
• Call GHP Family at 1-855-227-1302, PA Relay 711 and tell GHP Family your Grievance, or
• Write down your Grievance and send it to GHP Family by mail or fax, or
• Fill out the Complaint/Grievance Request Form included in the denial notice you got from GHP Family and
send it to GHP Family by mail or fax.
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GHP Family’s address and fax number for Grievances:
GHP Family
100 N. Academy Ave.
Fax: 570-271-7225
encrypt the email.
Your provider can file a Grievance for you if you give the provider your consent in writing to do so. If your provider
files a Grievance for you, you cannot file a separate Grievance on your own.
When Should I File a Grievance?

You must file a Grievance within 60 days from the date you get the notice telling you about the denial,
decrease, or approval of a different service or item for you.
What Happens After I File a Grievance?

After you file your Grievance, you will get a letter from GHP Family telling you that GHP Family has received your
Grievance, and about the Grievance review process.
You may ask GHP Family to see any information that GHP Family used to make the decision you filed your
Grievance about at no cost to you. You may also send information that you have about your Grievance to GHP
Family.
You may attend the Grievance review if you want to attend it. GHP Family will tell you the location, date, and time
of the Grievance review at least 10 days before the day of the Grievance review. You may appear at the
Grievance review in person, by phone, or by videoconference. If you decide that you do not want to attend the
Grievance review, it will not affect the decision.
A committee of 3 or more people, including a licensed doctor or licensed dentist, will meet to decide your
Grievance. The GHP Family staff on the committee will not have been involved in and will not have worked for
someone who was involved in the issue you filed your Grievance about. GHP Family will mail you a notice within
30 days from the date your Grievance was received to tell you the decision on your Grievance. The notice will also
tell you what you can do if you do not like the decision.
If you need more information about help during the Grievance process, see page 74.
If you have been getting services or items that are being reduced, changed, or denied and you file a Grievance
verbally, or that is faxed, postmarked, or hand-delivered within 15 days of the date on the notice telling you that
the services or items you have been receiving are being reduced, changed, or denied, the services or items
will continue until a decision is made.
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What if I Do Not Like GHP Family’s Decision?
You may ask for an external Grievance review or a Fair Hearing or you may ask for both an external Grievance
review and a Fair Hearing. An external Grievance review is a review by a doctor who does not work for GHP
Family.
You must ask for an external Grievance review within 15 days of the date you got the Grievance decision
notice.
You must ask for a Fair Hearing from the Department of Human Services within 120 days from the date on the
notice telling you the Grievance decision.
For information about Fair Hearings, see page 75

For information about external Grievance review, see below
If you need more information about help during the Complaint process, see page 74
External Grievance Review
How Do I Ask for External Grievance Review?

To ask for an external Grievance review:
• Call GHP Family at 1-866-577-7733 TTY 711 and tell GHP Family your Grievance, or
• Write down your Grievance and send it to GHP Family by mail to:
GHP Family
100 North Academy Ave.
Fax: 570-271-7225
encrypt the email.
GHP Family will send your request for external Grievance review to the Pennsylvania Insurance Department.
What Happens After I Ask for an External Grievance Review?

GHP Family will notify you of the external Grievance reviewer’s name, address and phone number. You will also
be given information about the external Grievance review process.
GHP Family will send your Grievance file to the reviewer. You may provide additional information that may help
with the external review of your Grievance to the reviewer within 15 days of filing the request for an external
Grievance review.
You will receive a decision letter within 60 days of the date you asked for an external Grievance review. This letter
will tell you all the reason(s) for the decision and what you can do if you do not like the decision.
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If you have been getting the services or items that are being reduced, changed, or denied and you ask for an
external Grievance review verbally or in a letter that is postmarked or hand-delivered within 15 days of the date
on the notice telling you GHP Family’s Grievance decision, the services or items will continue until a decision
is made. If you will be asking for both an external Grievance review and a Fair Hearing, you must request both
the external Grievance review and the Fair Hearing within 15 days of the date on the notice telling you GHP
Family’s Grievance decision. If you wait to request a Fair Hearing until after receiving a decision on your
external Grievance, services will not continue.
Expedited Complaints and Grievances
What Can I Do if My Health Is at Immediate Risk?

If your doctor or dentist believes that waiting 30 days to get a decision about your Complaint or Grievance, could
harm your health, you or your doctor or dentist may ask that your Complaint or Grievance be decided more
quickly. For your Complaint or Grievance to be decided more quickly:
• You must ask GHP Family for an early decision by:
o Calling GHP Family at 1-855-227-1302, PA Relay 711
o Faxing a letter or the Complaint/Grievance Request Form to 570-271-7225, or;
o Sending an email to [email protected].
• Your doctor or dentist should fax a signed letter to 570-271-7225 within 72 hours of your request for an early
decision that explains why GHP Family taking 30 days to tell you the decision about your Complaint or
Grievance could harm your health.
If GHP Family does not receive a letter from your doctor or dentist and the information provided does not show
that taking the usual amount of time to decide your Complaint or Grievance could harm your health, GHP Family
will decide your Complaint or Grievance in the usual time frame of 45 days from when GHP Family first got your
Complaint or Grievance.
Expedited Complaint and Expedited External Complaint

A committee of 3 or more people, including a licensed doctor, will meet to decide your Complaint. If the Complaint
is about dental services, the expedited Complaint review committee will include a dentist. The GHP Family staff on
the committee will not have been involved in and will not have worked for someone who was involved in the issue
you filed your Complaint about.
You may attend the expedited Complaint review if you want to attend it. You can attend the Complaint review in
person, but may have to appear by phone or by videoconference because GHP Family has a short amount of time
to decide an expedited Complaint. If you decide that you do not want to attend the Complaint review, it will not
affect the decision.
GHP Family will tell you the decision about your Complaint within 48 hours of when GHP Family gets your doctor’s
or dentist’s letter explaining why the usual time frame for deciding your Complaint will harm your health or within
72 hours from when GHP Family gets your request for an early decision, whichever is sooner, unless you ask
GHP Family to take more time to decide your Complaint. You can ask GHP Family to take up to 14 more days to
decide your Complaint. You will also get a notice telling you the reason(s) for the decision and how to ask for
expedited external Complaint review, if you do not like the decision.
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If you did not like the expedited Complaint decision, you may ask for an expedited external Complaint review from
the Insurance Department within 2 business days from the date you get the expedited Complaint decision
notice. To ask for expedited external review of a Complaint:
• Call GHP Family at 1-866-577-7733, PA Relay 711 and tell GHP Family your Complaint, or
• [email protected], or
• Write down your Complaint and send it to GHP Family by mail or fax:
GHP Family
100 N. Academy Ave.
Fax: 570-271-7225
Expedited Grievance and Expedited External Grievance

A committee of 3 or more people, including a licensed doctor or licensed dentist, will meet to decide your
Grievance. The GHP Family staff on the committee will not have been involved in and will not have worked for
someone who was involved in the issue you filed your Grievance about.
You may attend the expedited Grievance review if you want to attend it. You can attend the Grievance review in
person, but may have to appear by phone or by videoconference because GHP Family has a short amount of time
to decide the expedited Grievance. If you decide that you do not want to attend the Grievance review, it will not
affect our decision.
GHP Family will tell you the decision about your Grievance within 48 hours of when GHP Family gets your doctor’s
or dentist’s letter explaining why the usual time frame for deciding your Grievance will harm your health or within
72 hours from when GHP Family gets your request for an early decision, whichever is sooner, unless you ask
GHP Family to take more time to decide your Grievance. You can ask GHP Family to take up to 14 more days to
decide your Grievance. You will also get a notice telling you the reason(s) for the decision and what to do if you do
not like the decision.
If you do not like the expedited Grievance decision, you may ask for an expedited external Grievance review or an
expedited Fair Hearing by the Department of Human Services or both an expedited external Grievance review and
an expedited Fair Hearing. An expedited external Grievance review is a review by a doctor who does not work for
GHP Family.
You must ask for expedited external Grievance review within 2 business days from the date you get the
expedited Grievance decision notice. To ask for expedited external review of a Grievance:
• Call GHP Family at 1-866-577-7733, PA Relay 711 and tell GHP Family your Grievance, or
• [email protected], or
• Write down your Grievance and send it to GHP Family by mail or fax:
GHP Family
100 N. Academy Ave.
Fax: 570-271-7225
GHP Family will send your request to the Insurance Department within 24 hours after receiving it. You must ask for
a Fair Hearing within 120 days from the date on the notice telling you the expedited Grievance decision.
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What Kind of Help Can I Have with the Complaint and Grievance Processes?
If you need help filing your Complaint or Grievance, a staff member of GHP Family will help you. This person can
also represent you during the Complaint or Grievance process. You do not have to pay for the help of a staff
member. This staff member will not have been involved in any decision about your Complaint or Grievance.
You may also have a family member, friend, lawyer or other person help you file your Complaint or Grievance.
This person can also help you if you decide you want to appear at the Complaint or Grievance review.
At any time during the Complaint or Grievance process, you can have someone you know represent you or act for
you. If you decide to have someone represent or act for you, tell GHP Family, in writing, the name of that person
and how GHP Family can reach him or her.
You or the person you choose to represent you may ask GHP Family to see any information GHP Family has
about the issue you filed your Complaint or Grievance about at no cost to you.
You may call GHP Family’s toll-free telephone number at 1-855-227-1302, PA Relay 711 if you need help or have
questions about Complaints and Grievances, you can contact your local legal aid office at 1-800-322-7572 or call
the Pennsylvania Health Law Project at 1-800-274-3258.
Persons Whose Primary Language Is Not English

If you ask for language services, GHP Family will provide the services at no cost to you.
Persons with Disabilities

GHP Family will provide persons with disabilities with the following help in presenting Complaints or Grievances at
no cost, if needed. This help includes:
• Providing sign language interpreters;
• Providing information submitted by GHP Family at the Complaint or Grievance review in an alternative format.
The alternative format version will be given to you before the review; and
• Providing someone to help copy and present information.
Department of Human Services Fair Hearings

In some cases you can ask the Department of Human Services to hold a hearing because you are unhappy about
or do not agree with something GHP Family did or did not do. These hearings are called “Fair Hearings.” You can
ask for a Fair Hearing after GHP Family decides your First Level Complaint or decides your Grievance.
What Can I Request a Fair Hearing About and By When Do I Have to Ask for a Fair Hearing? Your request
for a Fair Hearing must be postmarked within 120 days from the date on the notice telling you GHP Family’s
decision on your First Level Complaint or Grievance about the following:
• The denial of a service or item you want because it is not a covered service or item.
• The denial of payment to a provider for a service or item you got and the provider can bill you for the service or
item.
• GHP Family’s failure to decide a First Level Complaint or Grievance you told GHP Family about within 30 days
from when GHP Family got your Complaint or Grievance.
• The denial of your request to disagree with GHP Family’s decision that you have to pay your provider.
• The denial of a service or item, decrease of a service or item, or approval of a service or item different from the
service or item you requested because it was not medically necessary.
• You’re not getting a service or item within the time by which you should have received a service or item.
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You can also request a Fair Hearing within 120 days from the date on the notice telling you that GHP Family failed
to decide a First Level Complaint or Grievance you told GHP Family about within 30 days from when GHP Family
got your Complaint or Grievance.
How Do I Ask for a Fair Hearing?

Your request for a Fair Hearing must be in writing. You can either fill out and sign the Fair Hearing Request Form
included in the Complaint or the Grievance decision notice or write and sign a letter.
If you write a letter, it needs to include the following information:

• Your (the Member’s) name and date of birth;
• A telephone number where you can be reached during the day;
• Whether you want to have the Fair Hearing in person or by telephone;
• The reason(s) you are asking for a Fair Hearing; and
• A copy of any letter you received about the issue you are asking for a Fair Hearing about.
You must send your request for a Fair Hearing to the following address:
Department of Human Services

Office of Medical Assistance Programs – HealthChoices Program
Complaint, Grievance and Fair Hearings
P.O. Box 2675
Harrisburg, PA 17105-2675
Fax: 1-717-772-6328
*Because emails are not secure unless encrypted by the sender, you should not include personal identifying
information such as your date of birth or personal medical information unless you encrypt the email. You may
send a request for a Fair Hearing through email and provide your personal identifying information in a letter
mailed to the above address.
What Happens After I Ask for a Fair Hearing?

You will get a letter from the Department of Human Services’ Bureau of Hearings and Appeals telling you where
the hearing will be held and the date and time for the hearing. You will receive this letter at least 10 days before
the date of the hearing.
You may come to where the Fair Hearing will be held or be included by phone. A family member, friend, lawyer or
other person may help you during the Fair Hearing. You MUST participate in the Fair Hearing.
GHP Family will also go to your Fair Hearing to explain why GHP Family made the decision or explain what
happened.
You may ask GHP Family to give you any records, reports and other information about the issue you requested
your Fair Hearing about at no cost to you.
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When Will the Fair Hearing Be Decided?
The Fair Hearing will be decided within 90 days from when you filed your Complaint or Grievance with GHP
Family, not including the number of days between the date on the written notice of the GHP Family’s First Level
Complaint decision or Grievance decision and the date you asked for a Fair Hearing.
If you requested a Fair Hearing because GHP Family did not tell you its decision about a Complaint or Grievance
you told GHP Family about within 30 days from when GHP Family got your Complaint or Grievance, your Fair
Hearing will be decided within 90 days from when you filed your Complaint or Grievance with GHP Family, not
including the number of days between the date on the notice telling you that GHP Family failed to timely decide
your Complaint or Grievance and the date you asked for a Fair Hearing.
The Department of Human Services will send you the decision in writing and tell you what to do if you do not like
the decision.
If your Fair Hearing is not decided within 90 days from the date the Department of Human Services receives your
request, you may be able to get your services until your Fair Hearing is decided. You can call the Department of
Human Services at 1-800-798-2339 to ask for your services.
If you have been getting the services or items that are being reduced, changed or denied and you ask for a Fair
Hearing and your request is postmarked or hand-delivered within 15 days of the date on the notice telling you
GHP Family’s First Level Complaint or Grievance decision, the services or items will continue until a decision is
made.
Expedited Fair Hearing
What Can I Do if My Health Is at Immediate Risk?

If your doctor or dentist believes that waiting the usual time frame for deciding a Fair Hearing could harm your
health, you may ask that the Fair Hearing take place more quickly. This is called an expedited Fair Hearing. You
can ask for an early decision by calling the Department at 1-800-798- 2339 or by faxing a letter or the Fair Hearing
Request Form to 717-772-6328. Your doctor or dentist must fax a signed letter to 717-772-6328 explaining why
taking the usual amount of time to decide your Fair Hearing could harm your health. If your doctor or dentist does
not send a letter, your doctor or dentist must testify at the Fair Hearing to explain why taking the usual amount of
time to decide your Fair Hearing could harm your health.
The Bureau of Hearings and Appeals will schedule a telephone hearing and will tell you its decision within 3
business days after you asked for a Fair Hearing.
If your doctor does not send a written statement and does not testify at the Fair Hearing, the Fair Hearing decision
will not be expedited. Another hearing will be scheduled and the Fair Hearing will be decided using the usual time
frame for deciding a Fair Hearing.
*Because emails are not secure unless encrypted by the sender, you should not include personal identifying
information such as your date of birth or personal medical information unless you encrypt the email.
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You may call GHP Family’s toll-free telephone number at 1-855-227-1302, PA Relay 711 if you need help or
have questions about Fair Hearings, you can contact your local legal aid office at 1-800-322- 7572 or call the
Pennsylvania Health Law Project at 1-800-274-3258.
PROVIDER APPEALS AND DISPUTES

GHP Family offers providers 1) an informal and formal dispute process for expressing dissatisfaction with a GHP
Family decision that directly impacts the provider and 2) an informal and formal appeals process to request
reversal of a denial by GHP Family. The definitions and processes for Provider Appeals and a Provider Disputes
are as follows:
Provider Appeal – A request from a Provider for reversal of a denial by GHP Family, about the three (3) major
types of issues that are to be addressed in a Provider Appeal system as outlined in the Provider Dispute
Resolution System. The three (3) types of Provider Appeals issues are:
1. Provider credentialing denial by GHP Family.
• If a provider communicates dissatisfaction with a credentialing determination, Credentials Committee, at its

next scheduled meeting, will review information provided by the provider and decide. If the provider’s
credentialing or recredentialing is denied, the provider has thirty (30) Business Days from receipt of notice
to file an appeal.
2. Claims denied by GHP Family for Participating Providers participating in GHP Family’s network. This includes
payment denied for services already rendered by the Participating Provider to the Member.
• Informal Process – All Participating Providers should use the existing Claim Research Request Form
(CRRF) process as outlined in the Provider Service Center.
• Formal Process – If a Participating Provider sends another CRRF stating 2nd level appeal, or requests
additional review on a previously reviewed CRRF, the Provider Dispute/Appeals Committee (PDAC), will
hear all formal Provider Appeals and make a determination within sixty (60) days.
3. Termination of Participating Provider Agreement by GHP Family based on quality of care or service.
Suspension, non-renewal, or termination of Participating Provider’s participation initiated by GHP Family entitles
the Participating Provider to an appeal hearing upon timely and proper request by the Participating Provider for
said appeal for any of the following reasons:
• Business need;
• Breach of Agreement;
• Suspected fraud and abuse;
• Non-compliant behavior that jeopardizes Member satisfaction;
• Temporary sanction, suspension or restriction by Medicare, any licensing board or professional review
organization (Organizational Providers only*); and/or
• Failure to immediately notify Health Plan of substantive changes in credentialing information including, but not
limited to, adverse licensure actions, termination/cancellation of professional liability insurance or sanctions from
billing private, federal or state health insurance programs (Organizational Providers only*).
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Participating Providers will have five (5) Business Days from receipt of notice to file a written request for a hearing
to appeal suspension, non-renewal, or termination of GHP Family participation. Requests for a hearing shall:
• Specify in detail the reason(s) the Participating Provider wishes to contest the suspension, non-renewal or
termination decision;
• Be delivered certified or registered mail to the GHP Family contact who executed the notice to Participating
Provider of non-renewal/termination;
• Specify if Participating Provider intends to be represented by an attorney at the hearing;
• Include the name, address, phone, fax and email (if available) of Participating Provider’s attorney, if applicable;
• Include a list of the name(s), title(s), address(es) and phone number(s) of any witnesses expected to testify on
behalf of Participating Provider at the hearing; and
• Include copies of all additional information Participating Provider wishes to present at the hearing.
Provider Dispute – A written communication to GHP Family, made by a provider, expressing dissatisfaction with
a Health Plan decision that directly impacts the provider. This does not include decisions concerning Medical
Necessity. Following are the informal and formal process:
Informal Provider Dispute Process - When a written Provider Dispute is received, it will be forwarded to the
appropriate department within GHP Family for resolution. The dispute will be researched and responded to within
45 days of receipt. This initial response is considered the informal settlement process for the dispute.
Formal Provider Dispute Process - If a provider disagrees with our initial response and sends in an additional
written inquiry within sixty (60) days of incident being disputed, the Provider Dispute/Appeals Committee will hear
all formal Provider Disputes and make a determination. Once received, dispute will be reviewed, and a decision
will be rendered within sixty (60) days after receipt. GHP Family may request an extension of up to thirty (30) days,
if necessary.
GHP Family’s Provider Dispute/Appeal Committee includes the following personnel:

• Director, PNM
• Manager, Operations/Reimbursement Services
• Medical Director, Medicaid
• Medical Director (practicing physician) – GHP
• Claims Designee
• Provider Account Manager, PNM
REGULATORY COMPLIANCE
CULTURAL COMPETENCY
Cultural Competency & Interpretive Services for the Disabled and Those with Limited English Proficiency
Members are to receive covered services without concern about race, ethnicity, national origin, religion, gender,
age, gender identification, mental or physical disability, sexual orientation, genetic information or medical history,
ability to pay or ability to speak English.
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GHP Family expects contracted providers to treat all Members with dignity and respect as required by federal law.
Title VI of the Civil Rights Act of 1964 prohibits discrimination on the basis of race, color, and national origin in
programs and activities receiving federal financial assistance, such as Medicaid.
GHP Family policies conform with federal government Limited English Proficiency (LEP) guidelines stating that
programs and activities normally provided in English must be accessible to LEP persons. Services must be
provided in a culturally effective manner to all Members, including those with Limited English Proficiency (LEP) or
reading skills, those with diverse cultural and ethnic backgrounds, those who are deaf or hard of hearing, the
homeless and individuals with physical and mental disabilities. To ensure Members’ privacy, they must not be
interviewed about medical or financial issues within hearing range of other patients.
In compliance with federal and state requirements:
GHP Family makes certain that LEP Members and Members who are deaf or hard of hearing have access to
health care and benefits by providing a range of language assistance services at no cost to the Member or the
provider. GHP Family offers translation and interpreter services, including sign language interpreters, to providers
and Members free of charge. These interpreters are qualified and familiar with medical terminology. The use of
professional interpreters, rather than family or friends, is strongly encouraged. GHP offers telephonic
interpretation. Providers can make advance arrangements for personal interpreters. Contact your Provider
Account Manager or the Customer Care Department to learn more about these services.
• Bilingual staff members are available in the Member services department to assist LEP Members.
• Member Materials, such as the Member handbook, are available in English, Spanish, and each prevalent
language as determined by DHS.
GHP Family provides alternative methods of communication for Members who are visually or hearing impaired,
including Braille, audio tapes, large print and/or computer diskette. Upon Member request, we will make all written
materials disseminated to Members accessible to visually impaired Members. GHP Family must provide sign
language interpreters and TTY or Pennsylvania Telecommunication Relay Service for communicating with
Members who are deaf or hearing impaired, upon request.
GHP Family must include appropriate instructions on all materials about how to access, or receive assistance with
accessing, desired materials in an alternate format.
MAINSTREAMING
Pursuant to their Agreement, GHP Family Participating Providers must not intentionally segregate Members in any
way from other persons receiving services.
GHP Family investigates Complaints and takes affirmative action so that Members are provided covered services
without regard to race, color, creed, sex, religion, age, national origin, ancestry, marital status, sexual orientation,
language, MA status, health status, disease or pre-existing condition, anticipated need for health care or physical
or mental handicap, except where medically indicated. Examples of prohibited practices include, but are not limited
to, the following:
a. Denying or not providing a Member any covered service or access to a participating facility within the GHP
Family Network. GHP Family policy provides access to complex interventions such as cardiopulmonary
resuscitations, intensive care, transplantation, and rehabilitation when Medically Necessary. Health care and
treatment necessary to preserve life must be provided to all persons who are not terminally ill or permanently
unconscious, except where a competent Member objects to such care on his/her own behalf.
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b. Subjecting a Member to segregated, separate, or different treatment, including a different place or time from
that provided to other Members, public or private patients, in any manner related to the receipt of any GHP
Family covered service, except where Medically Necessary.
c. The assignment of times or places for the provision of services based on the race, color, creed, religion, age,
sex, national origin, ancestry, marital status, sexual orientation, income status, program membership,
language, MA status, health status, disease or preexisting condition, anticipated need for health care or
physical or mental disability of the participants to be served.
HIPAA AND CONFIDENTIALITY
HIPAA NOTICE OF PRIVACY PRACTICES

GHP Family maintains strict privacy and confidentiality standards for all medical records and Member health care
information, according to federal and state standards. Providers can access up-to-date Health Insurance
Portability and Accountability Act (HIPAA) Notice of Privacy Practices on our website at www.ghpfamily.com. This
includes explanations of Members’ rights to access, amend, and request confidential communication of, request
privacy protection of, restrict use and disclosure of, and receive an accounting of disclosures of Protected Health
Information (PHI).
If you need to contact the Privacy Office you may call or write as follows:
Geisinger Privacy Officer
MC 40-38
100 North Academy Ave
Danville, PA 17822
Telephone: 570-271-7360
CONFIDENTIALITY REQUIREMENTS
Providers are required to comply with all federal, state and local laws and regulations governing the confidentiality
of medical information including all laws and regulations pertaining to, but not limited to the Health Insurance
Portability and Accountability Act (HIPAA) and applicable contractual requirements.
Providers are contractually required to safeguard and maintain the confidentiality of data that addresses medical
records and confidential provider and Member information, whether oral or written in any form or medium. All
"individually identifiable health information" held or transmitted by a covered entity or its business associate, in any
form or media, whether electronic, paper, or oral is considered confidential PHI.
“Individually identifiable health information” is information, including demographic data, that relates to:
a. The individual’s past, present or future physical or mental health or condition

b. The provision of health care to the individual
c. The past, present, or future payment for the provision of health care to the individual
d. Information that identifies the individual or for which there is a reasonable basis to believe it can be used to
identify the individual
e. Individually identifiable health information includes many common identifiers (e.g., name, address, birth date,
Social Security Number)
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Excluded from PHI are employment records that a covered entity maintains in its capacity as an employer and
education and certain other records subject to, or defined in, the Family Educational Rights and Privacy Act, 20
U.S.C. § 1232g.
Providers’ offices and other sites must have mechanisms in place that guard against unauthorized or inadvertent
disclosure of confidential information to anyone outside of GHP Family.
Release of data to third parties requires advance written approval from DHS, except for releases of information for
the purpose of individual care and coordination among providers, releases authorized by Members or releases
required by court order, subpoena or law.
MEMBER PRIVACY RIGHTS

Geisinger’s privacy policy assures that all Members are afforded the privacy rights permitted under HIPAA and
other applicable federal, state, and local laws and regulations, and applicable contractual requirements. Our
privacy policy conforms with 45 C.F.R. (Code of Federal Regulations): relevant sections of the HIPAA that provide
Member privacy rights and place restrictions on uses and disclosures of protected health information (§164.520,
522, 524, 526 and 528).
Our policy also assists GHP Family personnel and providers in meeting the privacy requirements of HIPAA when
Members or authorized representatives exercise privacy rights through privacy request, including:
a. Making information available to Members or their representatives about GHP Family’s practices regarding their
PHI
b. Maintaining a process for Members to request access to, changes to, or restrictions on disclosure of their PHI
c. Providing consistent review, disposition, and response to privacy requests within required time standards
d. Documenting requests and actions taken Member Privacy Requests
e. Members may make the following requests related to their PHI (“privacy requests”) in accordance with federal,
state, and local law:
o Make a privacy Complaint

o Receive a copy of all or part of their designated record set
o Amend records containing PHI
o Receive an accounting of health plan disclosures of PHI o Restrict the use and disclosure of PHI o Receive
confidential communications o Receive a Notice of Privacy Practices
A privacy request must be submitted by the Member or Member’s authorized representative. A Member’s
representative must provide documentation or written confirmation that he or she is authorized to make the
request on behalf of the Member or the deceased Member’s estate. Except for requests for a health plan Notice of
Privacy Practices, requests from Members or a Member’s representative must be submitted to GHP Family in
writing.
PRIVACY PROCESS REQUIREMENTS

GHP Family’s processes for responding to Member privacy requests shall include components for the following:
VERIFICATION
If the requester is the Member, GHP Family personnel shall verify the Member’s identity; verification examples
include asking for the last four digits of Member’s Social Security Number, Member’s address, and Member’s date
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of birth. If the requester is not the Member, GHP Family personnel shall require an Authorization for Use or
Disclosure completed by the Member to verify the requester’s authority to obtain the Member’s information. If the
requester identifies him/herself as a Member’s authorized representative, GHP Family personnel shall require a
healthcare Power of Attorney (POA) or comparable document for a representative to act on behalf of the Member.
REVIEW, DISPOSITION, AND RESPONSE

GHP Family personnel review and disposition of privacy requests shall comply with applicable federal, state, and
local laws and regulations, and applicable contractual requirements, including those that govern use and
disclosure of PHI. Responses to privacy requests shall conform to guidelines prescribed by HIPAA, including
response time standards, and shall include a notice of administrative charges, if any, for granting the request.
USE AND DISCLOSURE GUIDELINES

GHP Family personnel are required to use and disclose only the minimum amount of information necessary to
accommodate the request or carry out the intended purpose.
LIMITATIONS
A privacy request may be subject to specific limitations or restrictions as required by law. GHP Family personnel
may deny a privacy request under any of the following conditions:
a. GHP Family does not maintain the records containing the PHI
b. The requester is not the Member and GHP Family personnel are unable to verify his/her identity or authority to
act as the Member’s authorized representative
c. The documents requested are not part of the designated record set (e.g., credentialing information)
d. Access to the information may endanger the life or physical safety of or otherwise cause harm to the Member
or another person
e. GHP Family is not required by law to honor the request (e.g., accounting for certain disclosures)
f. Accommodating the request would place excessive demands on GHP Family or its personnel’s time and GHP
Family resources and is not contrary to HIPAA.
FRAUD AND ABUSE
GHP FAMILY COMPLIANCE PROGRAM

GHP Family is committed to a policy of zero tolerance for fraudulent insurance acts that victimize GHP Family and
its’ stakeholders. Accordingly, GHP Family maintains a robust Compliance Program. GHP Family’s Compliance
Program is designed to oversee the development, implementation and maintenance of a compliance and privacy
program that meets or exceeds federal and state laws and regulations, as well as contractual and accreditation
obligations. GHP Family is committed to ethical and legal conduct that is compliant with all relevant laws and
regulations, and to correcting wrongdoing whenever it may occur in the administration of any of our plans. This
commitment encompasses our organization and any of the parties that we contract with to provide services related
to the administration of our plans. For more detail on our compliance standards, please refer to Geisinger Health
Plan's Code of Conduct available online through www.ghpfamily.com.
Geisinger Health Plan policies are available to providers regarding the following:
Information about the False Claims Act established under sections 3729 through 3733 of Title 31, United States
Code, administrative remedies for false claims and statements established under Chapter 38 of Title 31, United
States Code, any State laws pertaining to civil or criminal penalties for false claims and statements, and
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whistleblower protections under such laws, with respect to the role of such laws in preventing and detecting fraud,
waste, and abuse in Federal health care programs (as defined in Section 1128B(f) [42 U.S.C.A. § 1320a-7b(f)])
can be found at https://www.justice.gov/sites/default/files/civil/legacy/2011/04/22/C-FRAUDS_FCA_Primer.pdf.
Provisions regarding Geisinger Health Plan’s procedures for detecting and preventing fraud, waste and abuse can
be found at https://www.geisinger.org/about-geisinger/corporate/corporate-policies/report-fraud.
DEFINING FRAUD, WASTE, AND ABUSE
Fraud – An intentional deception or misrepresentation made by a person or entity that knows or should know the
deception or misrepresentation could result in some unauthorized benefit to himself/herself or some other
person(s) or entity(ies). The Fraud can be committed by many entities, including GHP Family, a subcontractor, a
Provider, a State employee, or a Member, among others.
Waste – Waste occurs when an act of carelessness in performance and/or lack of training result in otherwise
unnecessary repetition of services or cost.
Abuse – Any practices that are inconsistent with sound fiscal, business, or medical practices, and result in
unnecessary costs to the MA Program, or in reimbursement for services that are not Medically Necessary or that
fail to meet professionally recognized standards or contractual obligations (including the terms of the
HealthChoices RFP, Agreement, and the requirements of state or federal regulations) for health care in a
managed care setting. The Abuse can be committed by GHP Family, a subcontractor, Provider, State employee,
or a Member, among others. Abuse also includes Member practices that result in unnecessary cost to the MA
Program, GHP Family, a subcontractor, or Provider.
REPORTING FRAUD AND ABUSE

Providers can report suspected Fraud and Abuse directly to DHS by:
Phone: (866) DHS-TIPS [(866) 347-8477].
Online https://www.dhs.pa.gov/about/Fraud-And-Abuse/Pages/MA-Fraud-and-Abuse---General-Information.aspx
Fax: 1-717-772-4655, Attn: MA Provider Compliance Hotline

Mail:
Office of Administration
Bureau of Program Integrity
P.O. Box 2675
Reported problems will be referred to the Office of Medical Assistance Program's Bureau of Program Integrity for
investigation, analysis and determination of the appropriate course of action. GHP Family and DHS maintain strict
confidentiality concerning the providers and Members who report suspected Fraud and Abuse.
Suspected Fraud and Abuse can also be reported to GHP Family’s Compliance Department by:
Phone: The GHP Compliance Hot Line at 800-292-1627 or call the Customer Care Team at (855) 227-1302.
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Mail:
Geisinger Health Plan Anti-Fraud Program
When you report fraud, you may remain anonymous. All reports are kept strictly confidential.
EXAMPLES OF RISKS FOR FRAUD, WASTE AND ABUSE

Prescriber Fraud, Waste and Abuse
a. Prescribers Illegal remuneration schemes: Prescriber is offered, or paid, or solicits, or receives unlawful
remuneration to induce or reward the prescriber to write prescriptions for drugs or products.
b. Prescription drug switching: Drug switching involves offers of cash payments or other benefits to a prescriber
to induce the prescriber to prescribe certain medications rather than others.
c. Script mills: Provider writes prescriptions for drugs that are not medically necessary, often in mass quantities,
and often for patients that are not theirs. These scripts are usually written, but not always, for controlled drugs
for sale on the black market, and might include improper payments to the provider.
d. Provision of false information: Prescriber falsifies information (not consistent with medical record) submitted
through a prior authorization or other formulary oversight mechanism to justify coverage. Prescriber
misrepresents the dates, descriptions of prescriptions or other services furnished, or the identity of the
individual who furnished the services.
e. Theft of prescriber’s DEA number or prescription pad: Prescription pads and/or DEA numbers can be stolen
from prescribers. This information could illegally be used to write prescriptions for controlled substances or
other medications often sold on the black market. In the context of e- prescribing, includes the theft of the
provider’s authentication (log in) information. Member Fraud, Waste and Abuse Risks
f. Misrepresentation of status: A Member misrepresents personal information, such as identity, eligibility, or

medical condition to illegally receive the drug benefit. Enrollees who are no longer covered under a drug
benefit plan may still attempt to use their identity card to obtain prescriptions.
g. Identity theft: Perpetrator uses another person’s GHP Family identification card to obtain prescriptions.
h. Prescription forging or altering: Where prescriptions are altered, by someone other than the prescriber or
pharmacist with prescriber approval, to increase quantity or number of refills.
i. Prescription diversion and inappropriate use: Members obtain prescription drugs from a provider, possibly for a
condition from which they do not suffer, and gives or sells this medication to someone else. Also can include
the inappropriate consumption or distribution of a Member’s medications by a caregiver or anyone else.
j. Resale of drugs on black market: Member falsely reports loss or theft of drugs or feigns illness to obtain drugs
for resale on the black market.
k. Prescription stockpiling: Member attempts to “game” their drug coverage by obtaining and storing large
quantities of drugs to avoid out-of-pocket costs, to protect against periods of noncoverage (i.e., by purchasing
a large amount of prescription drugs and then disenrolling), or for purposes of resale on the black market.
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l. Doctor shopping: Member or other individual consults a number of doctors for the purpose of inappropriately
obtaining multiple prescriptions for narcotic painkillers or other drugs. Doctor shopping might be indicative of an
underlying scheme, such as stockpiling or resale on the black market.
m. Improper Coordination of Benefits: Improper coordination of benefits where Member fails to disclose multiple
coverage policies, or leverages various coverage policies to “game” the system.
n. Marketing Schemes: A Member may be victimized by a marketing scheme where a sponsor, or its agents or
brokers, violates the marketing guidelines, or other applicable Federal or state laws, rules, and regulations to
improperly enroll a MA beneficiary. Pharmacy Fraud, Waste and Abuse
o. Inappropriate billing practices: Inappropriate billing practices at the pharmacy level occur when pharmacies
engage in the following types of billing practices:
o Incorrectly billing for secondary payers to receive increased reimbursement.

o Billing for non-existent prescriptions.
o Billing multiple payers for the same prescriptions, except as required for coordination of benefit
transactions.
o Billing for brand when generics are dispensed.
o Billing for non-covered prescriptions as covered items.
o Billing for prescriptions that are never picked up (i.e., not reversing claims that are processed when
prescriptions are filled but never picked up).
o Billing based on “gang visits,” (e.g., a pharmacist visits a nursing home and bills for numerous
pharmaceutical prescriptions without furnishing any specific service to individual patients).
o Inappropriate use of dispense as written (“DAW”) codes.
o Prescription splitting to receive additional dispensing fees. Drug diversion.
p. Prescription drug shorting: Pharmacist provides less than the prescribed quantity and intentionally does not
inform the Member or make arrangements to provide the balance but bills for the fully- prescribed amount.
q. Bait and switch pricing: Bait and switch pricing occurs when a Member is led to believe that drug will cost one
price, but at the point of sale the Member is charged a higher amount.
r. Prescription forging or altering: Where existing prescriptions are altered, by an individual without the
prescriber’s permission to increase quantity or number of refills.
s. Dispensing expired or adulterated prescription drugs: Pharmacies dispense drugs that are expired or have not
been stored or handled in accordance with manufacturer and FDA requirements.
t. Prescription refill errors: A pharmacist provides the incorrect number of refills prescribed by the provider.
u. Pharmacy Illegal remuneration schemes: Pharmacy is offered, or paid, or solicits, or receives unlawful
remuneration to induce or reward the pharmacy to switch Member’s’ to different drugs, influence prescribers to
prescribe different drugs, or steer Member’s’ to plans.
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ADDITIONAL EXAMPLES OF FRAUD:
Recipient fraud is defined as someone who receives cash assistance, Supplemental Nutritional Assistance
Program (SNAP) benefits, Heating/Energy Assistance (LIHEAP), childcare, medical assistance, or other public
benefits while not reporting income, not reporting ownership of resources or property, not reporting who lives in
their household, allowing another person to use his or her ACCESS/MCO card, forging or altering prescriptions,
selling prescriptions/medications, trafficking SNAP benefits, or taking advantage of the system in any way.
Provider fraud is defined as billing for services not rendered; billing separately for services in lieu of an available
combination code; misrepresenting the service/supplies rendered (billing brand-named for generic drugs, upcoding
to more expensive service than was rendered, billing for more time or units of service than provided, and billing
incorrect provider or service location); altering claims; submission of any false data on claims, such as date of
service, provider, or prescriber of service; duplicate billing for the same service; billing for services provided by
unlicensed or unqualified persons; or billing for used items as new.
PROVIDER SCREENING OF EMPLOYEES AND CONTRACTORS FOR EXCLUSION FROM PARTICIPATION

IN FEDERAL HEALTH CARE PROGRAMS
OVERVIEW
Under both State and Federal law, DHS and GHP Family are generally prohibited from paying for any items or
services furnished, ordered, or prescribed by individuals or entities excluded from the MA Program as well as other
Federal health care programs. Medicaid providers and managed care entities who employ or enter into contracts
with excluded individuals or entities to provide items or services to Medicaid recipients when those individuals or
entities are excluded from participation in any Medicare, Medicaid, or other Federal health care programs are
subject to termination of their enrollment in and exclusion from participation in the MA Program and all Federal
health care programs, recoupment of overpayments, and imposition of civil monetary penalties.
The amount of the Medicaid overpayment for such items or services is the actual amount of Medicaid dollars that
were expended for those items or services. When Medicaid funds have been expended to pay an excluded
individual’s salary, expenses, or fringe benefits, the amount of the overpayment is the amount of those expended
Medicaid funds.
All employees, vendors, contractors, service providers, and referral sources whose functions are a necessary
component of providing items and services to MA recipients, and who are involved in generating a claim to bill for
services, or are paid by Medicaid (including salaries that are included on a cost report submitted to DHS), should
be screened for exclusion before employing and/or contracting with them and, if hired, should be rescreened on an
ongoing monthly basis to capture exclusions and reinstatements that have occurred since the last search.
Examples of individuals or entities that providers should screen for exclusion include, but are not limited to:
a. Individual or entity who provides a service for which a claim is submitted to Medicaid;
b. Individual or entity who causes a claim to be generated to Medicaid;
c. Individual or entity whose income derives all, or in part, directly or indirectly, from Medicaid funds;
d. Independent contractors if they are billing for Medicaid services;
e. Referral sources, such as providers who send a Medicaid recipient to another provider for additional services
or second opinion related to medical condition.
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PROCEDURE
To protect the MA Program against payments for items or services furnished, ordered, or prescribed by excluded
individuals or entities; to establish sound compliance practices, and to prevent potential monetary and other
sanctions, providers should:
1. Develop policies and procedures for screening of all employees and contractors (both individuals and entities),
at time of hire or contracting; and, thereafter, on an ongoing monthly basis to determine if they have been
excluded from participation in federal health care programs;
2. Use the following databases to determine exclusion status;
a. Pennsylvania Medicheck List: a data base maintained by DHS that identifies providers, individuals, and
other entities that are precluded from participation in Pennsylvania’s MA Program:
https://www.dhs.pa.gov/about/Fraud-And-Abuse/Pages/Medicheck-List.aspx.
b. If an individual’s resume indicates that he/she has worked in another state, providers should also check
that state’s individual list.
c. List of Excluded Individuals/Entities (LEIE): data base maintained by HHSOIG that identifies individuals
or entities that have been excluded nationwide from participation in any federal health care program. An
individual or entity included on the LEIE is ineligible to participate, either directly or indirectly, in the MA
Program. Although DHS makes best efforts to include on the Medicheck List all federally excluded
individuals/entities that practice in Pennsylvania, providers must also use the LEIE to ensure that the
individual/entity is eligible to participate in the MA Program: https://oig.hhs.gov/fraud/.
d. System for Award Management (SAM): a U.S. Government owned and operated free web site containing
entity registration records and exclusion records. Exclusion records identify those parties excluded from
receiving certain federal contracts, subcontracts, and financial and nonfinancial assistance and benefits.
The SAM exclusions database, located at https://sam.gov/data-services, is the official governmentwide
system of records of debarments, suspensions, and other exclusionary actions.
e. Social Security Administration Death Master File (SSADMF): a Social Security Administration (SSA)
extract of death information on the NUMIDENT, the electronic database that contains SSA records of
Social Security Numbers (SSN) assigned to individuals since 1936, and includes, if available, the deceased
individual’s SSN, first name, middle name, surname, date of birth, and date of death:
https://www.ssa.gov/dataexchange/request_dmf.html.
f. National Plan and Provider Enumeration System (NPPES): a CMS run online registry of National
Provider Identifier (NPI) numbers: https://nppes.cms.hhs.gov/#/.
3. Immediately self-report any discovered exclusion of an employee or contractor, either an individual or entity, to
the Bureau of Program Integrity at https://www.dhs.pa.gov/about/Fraud-And-Abuse/Pages/MA-Provider-
Compliance- Hotline.aspx.
Online Form: https://forms.dhs.pa.gov/dhs-ma-provider-compliance/
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Mail:
Bureau of Program Integrity
MA Provider Compliance Hotline
P.O. Box 2675
Phone: 1-866-379-8477 (includes TTY)
Fax: 717-772-4655- Attention MA Provider Compliance Hotline
4. Develop and maintain auditable documentation of screening efforts, including dates the screenings were
performed and the source data checked and its date of most recent update; and
5. Periodically conduct self-audits to determine compliance with this requirement.
PROVIDER SELF-AUDIT PROTOCOL

The Pennsylvania MA Provider Self Audit Protocol allows providers to voluntarily disclose overpayments or
improper payments of MA funds. The provider self-audit protocol is available on the DHS website at https://
www.dhs.pa.gov/about/Fraud-And-Abuse/Pages/MA-Provider-Selfhttps://www.dhs.pa.gov/about/Fraud-And-
Abuse/Pages/MA-Provider-Self-Audit-Protocol.aspxAudit-Protocol.aspx.
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GLOSSARY
Abuse — Any practices that are inconsistent with sound fiscal, business, or medical practices, and result in
unnecessary costs to the MA Program, or in reimbursement for services that are not Medically Necessary or that
fail to meet professionally recognized standards or contractual obligations (including the terms of the RFP,
Agreement, and the requirements of state or federal regulations) for health care in a managed care setting. The
Abuse can be committed by the GHP Family, subcontractor, Health Care Provider, State employee, or a Member,
among others. Abuse also includes Member practices that result in unnecessary cost to the MA Program, the GHP
Family, a subcontractor, or Health Care Provider.
ACCESS Card — An identification card issued by DHS to each MA Member. The card must be used by MA-
enrolled Health Care Providers to access DHS’s EVS and verify the Member’s MA eligibility and specific covered
benefits.
Actuarially Sound Rates — Rates that reflect, among other elements:
a. the populations and benefits to be covered;

b. the rating groups;
c. the projected Member months for each category of aid;
d. the historical and projected future medical costs expected to be incurred by an efficiently and effectively
operated Medicaid managed care program in the respective county/zone;
e. program changes to the extent they impact actuarial soundness of the rates;
f. trend levels for each type of service;
g. administrative costs expected to be incurred by an efficiently and effectively operated Medicaid managed care
program, including assessment costs and profit consideration.
Actuarially sound rates are developed using sound methods and assumptions that are reasonably attainable by
the Medicaid managed care organizations in the relevant Agreement year and meet the standards of the Actuarial
Standards Board.
Adjudicated Claim — A Claim that has been processed to payment or denial.
Affiliate — Any individual, corporation, partnership, joint venture, trust, unincorporated organization or association,
or other similar organization (hereinafter "Person"), controlling, controlled by or under common control with the
GHP Family or its parent(s), whether such common control be direct or indirect. Without limitation, all officers, or
persons, holding five percent (5%) or more of the outstanding ownership interests of GHP Family or its parent(s),
directors or subsidiaries of GHP Family or parent(s) shall be presumed to be Affiliates for purposes of the RFP and
Agreement. For purposes of this definition, "control" means the possession, directly or indirectly, of the power
(whether or not exercised) to direct or cause the direction of the management or policies of a person, whether
through the ownership of voting securities, other ownership interests, or by contract or otherwise including but not
limited to the power to elect a majority of the directors of a corporation or trustees of a trust, as the case may be.
Agreement — the written binding document between Participating Provider and Health Plan together with any
attachments, exhibits, applicable Provider Guide and the Member benefit plan, as amended from time to time and
made part of the Agreement by reference.
Appeal (Provider) — A request from a Health Care Provider for reversal of a denial by the PHMCO, with regard to
the three (3) major types of issues:
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a. Health Care Provider credentialing denial by the GHP Family;
b. Claims denied by the GHP Family for Health Care Providers participating in the PHMCO’s Network. This
includes payment denied for services already rendered by the Health Care Provider to the Member; and
c. agreement termination by the GHP Family.
Behavioral Health Managed Care Organization (BH-MCO) — An entity, operated by county government or
licensed by the Commonwealth as a risk bearing Health Maintenance Organization (HMO) or Preferred Provider
Organization (PPO), which manages the purchase and provision of Behavioral Health Services under an
agreement with DHS.
Behavioral Health (BH) Services — Mental health and/or drug and alcohol services which are provided by the
BH- MCO.
Business Day(s) — Includes Monday through Friday except for those days recognized as federal holidays and/or
Pennsylvania State holidays.
Case Management — Services which will assist individuals in gaining access to necessary medical, social,
educational and other services.
Centers for Medicare and Medicaid Services (CMS) — The federal agency within the Department of Health and
Human Services responsible for oversight of MA Programs.
Certified Registered Nurse Practitioner (CRNP) — A professional nurse licensed in the Commonwealth of
Pennsylvania who is certified by the State Board of Nursing in a particular clinical specialty area and who, while
functioning in the expanded role as a professional nurse, performs acts of medical diagnosis or prescription of
medical therapeutic or corrective measures in collaboration with and under the direction of a physician licensed to
practice medicine in Pennsylvania..
Claim — A bill from a Health Care Provider of a medical service or product that is assigned a unique identifier (i.e.,
Claim reference number). A Claim does not include an Encounter form for which no payment is made or only a
nominal payment is made.
Clean Claim — A Claim that can be processed without obtaining additional information from the Health Care
Provider of the service or from a third party. A Clean Claim includes a Claim with errors originating in the GHP
Family ’s Claims system. Claims under investigation for Fraud or Abuse or under review to determine if they are
Medically Necessary are not Clean Claims.
Complaint — A dispute or objection regarding a particular Provider or the coverage, operations, or management of
a PH-MCO, which has not been resolved by the PH-MCO and has been filed with the PH-MCO or with PID’s
Bureau of Managed Care (BMC), including, but not limited to:
• a denial because the requested service or item is not a covered service; which does not include BLE
• the failure of the PH-MCO to provide a service or item in a timely manner, as defined by the Department;
• the failure of the PH-MCO to decide a Complaint or Grievance within the specified time frames;
• a denial of payment by the PH-MCO after a service or item has been delivered because the service or item was
provided without authorization by a Provider not enrolled in the MA Program;
• a denial of payment by the PH-MCO after a service or item has been delivered because the service or item
provided is not a covered service for the Member; or
• a denial of a Member’s request to dispute a financial liability, including cost sharing, copayments, premiums,
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This term does not include a Grievance.
Concurrent Review — A review conducted by the GHP Family during a course of treatment to determine whether
the amount, duration and scope of the prescribed services continue to be Medically Necessary or whether any
service, a different service or lesser level of service is Medically Necessary.
County Assistance Office (CAO) — The county offices of DHS that administer all benefit programs, including
MA, on the local level. DHS staff in these offices perform necessary functions such as determining and maintaining
Member eligibility.
Cultural Competency — The ability of individuals, as reflected in personal and organizational responsiveness, to
understand the social, linguistic, moral, intellectual and behavioral characteristics of a community or population,
and translate this understanding systematically to enhance the effectiveness of health care delivery to diverse
populations.
Denial of Services — Any determination made by the GHP Family in response to a request for approval which:
disapproves the request completely; or approves provision of the requested service(s), but for a lesser amount,
scope or duration than requested; or disapproves provision of the requested service(s), but approves provision of
an alternative service(s); or reduces, suspends or terminates a previously authorized service. An approval of a
requested service which includes a requirement for a Concurrent Review by the GHP Family during the authorized
period does not constitute a Denial of Service.
Deprivation Qualifying Code — The code specifying the condition which determines a Member to be eligible in
nonfinancial criteria.
Developmental Disability — A severe, chronic disability of an individual that is:
a. Attributable to a mental or physical impairment or combination of mental or physical impairments.

b. Manifested before the individual attains age twenty-two (22).
c. Likely to continue indefinitely.
d. Manifested in substantial functional limitations in three or more of the following areas of life activity:
o Self-care;
o Receptive and expressive language;
o Learning;
o Mobility;
o Capacity for independent living; and Economic self-sufficiency.
e. Reflective of the individual’s need for special, interdisciplinary or generic services, supports, or other
assistance that is of lifelong or extended duration, except in the cases of infants, toddlers, or preschool children
who have substantial developmental delay or specific congenital or acquired conditions with a high probability
of resulting in developmental disabilities if services are not provided.
Disease Management — An integrated treatment approach that includes the collaboration and coordination of
patient care delivery systems and that focuses on measurably improving clinical outcomes for a particular medical
condition through the use of appropriate clinical resources such as preventive care, treatment guidelines, patient
counseling, education and outpatient care; and that includes evaluation of the appropriateness of the scope,
setting and level of care in relation to clinical outcomes and cost of a particular condition.
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Dispute (Provider) – A written communication to a GHP Family, made by a Provider, expressing dissatisfaction
with a GHP Family decision that directly impacts the Provider. This does not include decisions concerning Medical
Necessity.
DHS — The Department of Human Services (DHS) of the Commonwealth of Pennsylvania.
(DHS) Fair Hearing — A hearing conducted by DHS, Bureau of Hearings and Appeals.
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) — Items and services which must be made
available to persons under the age of twenty-one (21) upon a determination of Medical Necessity and required by
federal law at 42 U.S.C. §1396d(r).
Early Intervention Program — The provision of specialized services through family-centered

intervention for a child, birth to age three (3), who has been determined to have a developmental delay of twenty-
five percent (25%) of the child's chronological age or has documented test performance of 1.5 standard deviation
below the mean in standardized tests in one or more areas: cognitive development; physical development,
including vision and hearing; language and speech development; psycho-social development; or self-help skills or
has a diagnosed condition which may result in developmental delay.
Eligibility Verification System (EVS) — An automated system available to MA Providers and other specified
organizations for automated verification of MA Members’ current and past (up to three hundred sixty-five [365]
days) MA eligibility, GHP Family Enrollment, PCP assignment, Third Party Resources, and scope of benefits.
Emergency Services — Covered inpatient and outpatient services that: (a) are furnished by a Provider that is
qualified to furnish such service under Title XIX of the Social Security Act and (b) are needed to evaluate or
stabilize an Emergency Medical Condition.
Encounter Data — A record of any covered health care service provided to a GHP Family Member and includes
Encounters reimbursed through Capitation, Fee-for-Service, or other methods of compensation regardless of
whether payment is due or made.
Enrollment Assistance Program (EAP) — The program that provides Enrollment Specialists to assist Recipients
in selecting a PH-MCO and PCP and in obtaining information regarding HealthChoices Physical, Behavioral
Health Services, Community HealthChoices long-term services and supports and service Providers.
Family Planning Services — Services which enable individuals voluntarily to determine family size, to space
children and to prevent or reduce the incidence of unplanned pregnancies. Such services are made available
without regard to marital status, age, sex or parenthood.
Federally Qualified Health Center (FQHC) — An entity which is receiving a grant as defined under the Social
Security Act, 42 U.S.C. 1396d(l) or is receiving funding from such a grant under a contract with the recipient of
such a grant and meets the requirements to receive a grant under the abovementioned sections of the Act.
Fee-for-Service (FFS) — Payment by DHS or GHP Family to Health Care Providers on a per service basis for
health care services provided to Members.
Formulary — An exclusive list of drug products for which the Contractor must provide coverage to its Members,
as approved by DHS.
Fraud — Any type of intentional deception or misrepresentation made by an entity or person with the knowledge
that the deception could result in some unauthorized benefit to the entity, him/herself, or some other person in a
121
managed care setting. The can be committed by many entities, including the GHP Family, a subcontractor, a
Health Care Provider, a State employee, or a Member, among others.
Grievance — A request to have a GHP Family or a utilization review entity reconsider a decision solely
concerning the Medical Necessity and appropriateness of a health care service. A Grievance may be filed
regarding a GHP Family decision to 1) deny, in whole or in part, payment for a service/item; 2) deny or issue a
limited authorization of a requested service/item, including the type or level of service/item; 3) reduce, suspend, or
terminate a previously authorized service/item; 4) deny the requested service/item but approve an alternative
service/item, and 5) deny a request for a BLE. This term does not include a Complaint.
Health Care Provider — A licensed hospital or health care facility, medical equipment supplier or person who is
enrolled in the Pennsylvania MA Program and licensed, certified or otherwise regulated to provide health care
services under the laws of the Commonwealth or state(s) in which the entity or person provides services, including
a physician, podiatrist, optometrist, psychologist, physical therapist, certified registered nurse practitioner,
registered nurse, clinical nurse specialist, certified registered nurse anesthetist, certified nurse midwife, physician’s
assistant, chiropractor, dentist, dental hygienist, pharmacist or an individual accredited or certified to provide
behavioral health services.
HealthChoices Program — The name of Pennsylvania's 1915(b) waiver program to provide mandatory managed
health care to Members.
HealthChoices Zone (HC Zone) — A multiple-county area in which the HealthChoices Program has been
implemented to provide mandatory managed care to Medicaid Members in Pennsylvania.
HIV/AIDS Waiver Program — A Home and Community Based Waiver Program that provides for Expanded
Services to Members who are diagnosed with Acquired Immunodeficiency Syndrome (AIDS) or symptomatic
Human immunodeficiency Virus (HIV) as a cost-effective alternative to inpatient care.
Home and Community Based Waiver Program — Necessary and cost-effective services, not otherwise
furnished under the State’s Medicaid Plan, or services already furnished under the State’s Medicaid Plan but in
expanded amount, duration, or scope which is furnished to an individual in his/her home or community to prevent
institutionalization. Such services must be authorized under the provisions of 42 U.S.C. 1396n.
Medical Assistance (MA) — The Medical Assistance Program authorized by Title XIX of the federal Social
Security Act, 42 U.S.C. 1396 et seq., and regulations promulgated thereunder, and 62 P.S. and regulations at 55
PA Code Chapters 1101 et seq.
Medical Assistance Transportation Program (MATP) — A non-emergency medical transportation service

provided to eligible persons who need to make trips to/from a MA reimbursable service for the purpose of receiving
treatment, medical evaluation, or purchasing prescription drugs or medical equipment.
Medical Management (MM) — An objective and systematic process for planning, organizing, directing and
coordinating health care resources to provide Medically Necessary, timely and quality health care services in the
most cost-effective manner.
Medically Necessary— A service, item, procedure, or level of care compensable under the MA program that is
necessary for the proper treatment or management of an illness, injury, or disability is one that:
• Will, or is reasonably expected to, prevent the onset of an illness, condition, or disability;
• Will, or is reasonably expected to, reduce or ameliorate the physical, mental or developmental effects of an
illness, condition, injury or disability;
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• Will assist the Member to achieve or maintain maximum functional capacity in performing daily activities,
taking into account both the functional capacity of the Member and those functional capacities that are
appropriate for Members of the same age.
Member — An individual enrolled in GHP Family who is eligible to receive physical and/or behavioral health
services under the Medical Assistance (MA) Program of the Commonwealth of Pennsylvania.
Network — All contracted or employed Health Care Providers in the GHP Family who are providing covered
services to Members.
OMAP Hotlines — Department phone lines designed to address and facilitate resolution of issues encountered by
Recipients and their advocates or Providers according to PH-MCO policies and procedures.
Other Resources — With regard to TPL, Other Resources include, but are not limited to, recoveries from
personal injury Claims, liability insurance, first-party automobile medical insurance, and accident indemnity
insurance.
GHP Family Coverage Period — A period during which an individual is eligible for MA coverage and enrolled with
a GHP Family.
Participating Provider – A licensed hospital or health care facility, medical equipment supplier or person who is
enrolled in the Pennsylvania MA Program and licensed, certified or otherwise regulated to provide health care
services under the laws of the Commonwealth or state(s) in which the entity or person provides services, including
a physician, podiatrist, optometrist, physical therapist, certified registered nurse practitioner, registered nurse,
clinical nurse specialist, certified registered nurse anesthetist, certified nurse midwife, physician’s assistant,
chiropractor, dentist, dental hygienist or pharmacist that has a written Provider Agreement with and is credentialed
by GHP Family to provide physical health services to GHP Family Members.
Primary Care Practitioner (PCP) — A specific physician, physician group or a CRNP operating under the scope
of his/her licensure, and who is responsible for supervising, prescribing, and providing primary care services;
locating, coordinating and monitoring other medical care and rehabilitative services and maintaining continuity of
care on behalf of a Member.
Primary Care Practitioner (PCP) Site — The location or office of PCP(s) where Member care is delivered.
Prior Authorization — A determination made by the GHP Family to approve or deny payment for a Provider's
request to provide a service or course of treatment of a specific duration and scope to a Member prior to the
Provider's initiation or continuation of the requested service.
PROMISe™ Provider ID — A 13-digit number consisting of a combination of the 9-digit base NPI Provider
Number and a 4-digit service location.
Provider Reimbursement (and) Operations Management Information System electronic (PROMISe™) — A

Claims processing and management system implemented by DHS that supports the Fee-for-Service and Managed
Care Medical Assistance delivery programs.
Quality Management (QM) — An ongoing, objective and systematic process of monitoring, evaluating and
improving the quality, appropriateness and effectiveness of care.
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Retrospective Review — A review conducted by the GHP Family to determine whether services were delivered
as prescribed and consistent with GHP Family’s payment policies and procedures.
School-Based Health Services — An array of Medically Necessary health services performed by licensed
professionals that may include, but are not limited to, immunization, well childcare and screening examinations in a
school-based setting.
Special Needs Unit — A special dedicated unit within the GHP Family’s and the EAP contractor’s organizational
structure established to deal with issues related to Members with Special Needs.
Third Party Liability (TPL) — The financial responsibility for all or part of a Member’s health care expenses of an
individual entity or program (e.g., Medicare) other than GHP Family.
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GEISINGER HEALTH PLAN FAMILY

• Member eligibility and authorizations

ADDITIONAL GHP FAMILY CONTACT INFORMATION

Department Phone Number [Fax Number] Hours of Operation

Monday, Tuesday, Thursday

DHS CONTACT INFORMATION

Name Phone Number Hours of Operation

TDD: (866) 872-1677

Medical Assistance Provider

Medical Assistance Provider Monday - Friday

Outpatient Providers Practitioner Monday - Friday

BEHAVIORAL HEALTH CONTACT INFORMATION

Behavioral Health Services County Phone Numbers and Websites

COUNTY BEHAVIORAL HEALTH CRISIS INTERVENTION CONTACT INFORMATION

National Suicide Prevention Hotline (800) 273-TALK (8255)

Crisis Intervention Services Phone Numbers

County Contact Information

York/Adams MH/IDD Program

Allegheny County Department of Human Services

Bucks County Dept. Of Mental Health/Developmental Programs

Dauphin County Mental Health/Intellectual Disabilities Program

Juniata Valley Behavioral & Developmental Services

Northumberland County BH/ID Services

Wayne County Behavioral & Developmental Programs

Westmoreland County Behavioral Health & Developmental Programs

Luzerne-Wyoming Counties Mental Health and Developmental Services

Medical Assistance Transportation Program (MATP) County Phone Numbers

Adams 717-846-RIDE (7433) 1-800-632-9063

Entire Agreement/Amendments/Multiple Originals. The Agreement, together with any attachments,

Partial Invalidity/Interpretation. If any term or provision of the Agreement is determined to be invalid or

• Maintaining continuity of each Member’s health care.

MEMBER ASSIGNMENT TO PCP

SPECIALTY CARE PROVIDERS (SCP)

Urgent Medical PCP

PCP WAIT TIMES

APPOINTMENT NOTIFICATION AND FOLLOW-UP

EARLY PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT (EPSDT)

SCHOOL-BASED HEALTH SERVICES

SUSPECTED CHILD ABUSE OR NEGLECT

INFECTION CONTROL MEASURES

PCP PRACTICE ACCEPTANCE STATUS AND MEMBER LIMITATIONS

DIRECT ACCESS AND SELF-REFERRAL

o Selecting a provider to give an annual well-woman gynecological visit

SUBSTANCE ABUSE AND BEHAVIORAL HEALTH

MEDICAL MANAGEMENT & PRIOR AUTHORIZATIONS

MEDICAL MANAGEMENT PLAN

MEDICAL MANAGEMENT STATEMENT

Medical Management Department

QUALITY MANAGEMENT PLAN

POPULATION MANAGEMENT PROGRAMS

Providers may contact GHP Family Special Needs Unit at 855-214-8100.

Chronic Obstructive Pulmonary Disease (COPD)

Complement the Care provided by the PCP and/or SCP

Adult and Pediatric Asthma

Chronic Kidney Disease (CKD)

Coronary Artery Disease (CAD)

Tobacco Cessation (teen and adult)

DISEASE MANAGEMENT PROGRAM DEVELOPMENT

PRACTITIONER PROGRAM CONTENT

ENROLLMENT AND PATIENT PARTICIPATION