Geisinger Health Plan® - Provider Guide

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Provider Guide

The Participating Provider Guide (Dev 10/08) is part of your agreement with the Health Plan and is effective March 1, 2010, for all participating providers. It is designed for use by participating providers and their office staff who provide and coordinate services to Health Plan members.

The Participating Provider Guide (Dev 10/08) includes detailed reference information about the Health Plan, referrals and coordination of services, claim reporting requirements, quality improvement, utilization management, member rights and responsibilities, plus much more.

Please contact your provider relations representative if you have any questions concerning the information contained within your Provider Guide.

Table of Contents

Section 1 General Information
Section 2 Referrals
Section 3 Precertification Requirements
Section 4 Reimbursement and Claim Submission
Section 5 Credentialing
Section 6 Provider Administrative Rights
Section 7 Member Rights and Responsibilities
Section 8 Additional Participating Provider Responsibilities
Section 9 Medical Management and Quality Improvement and Accreditation
Section 10 Health Plan Forms
Section 11 Glossary and Acronyms

Full Provider Guide in PDF

Operations Bulletins which amend this Guide

Recent Changes to the Participating Provider Guide

Date Description of Change Section
4/09 Outpatient Hospital Revenue Code Reporting Requirements Section 4
4/09 Vision Services Section 3; Section 4
4/09 LIFE Geisinger Section 1; Section 3
5/09 Post Acute Care Transfer Policy Section 4
6/09 Minimum Standards for Medical Record Documentation - Guidelines updated Section 8
6/09 FEHBP - Patients' bill of Rights in accordance with OPM & HHS Interoperability Standards Section 8, Section 11
6/09 Medical Management Statement Section 1
6/09 EDI Clearinghouse information updated - Emdeon/RelayHealth Section 4
6/09 Health Plan Compliance Program/Fraud, Waste, and Abuse information Section 8
4/09 Urgent Care Facility Credentialing Criteria Section 5
4/09 Routine Non-Emergent Transportation benefit for Gold Secure 2 Members - claim instructions Section 4
6/09 CHIP compliance - Prohibiting the submission of false or fraudulent statements and claims related to any of Health Plan's benefit programs Section 4
8/09 Misc Changes: delete Sayre phone, CRRF form and contact info change, Secure 1/SNP info added, NCP data sheet updated Throughout
8/09 Credentialing Criteria - Non-Credentialed Practitioner information added Section 5
8/09 Newborn billing correction Section 4
9/09 Vision Services Ops Bulletin - Revision - Member benefit limit, services NOT paid at contracted fee schedule rate Section 4
11/09 CHIP product line and CST number Section 1
11/09 CHIP hearing care reimbursement Section 4
1/10 Well-child office visit - waive Member Copay Section 4
1/10 Routine footcare billing - 4 times per year Section 4
1/10 Lab data reporting specifications - added reporting notes Section 8
1/10 NIA Authorization - fax number for clinical notes Section 3
1/10 Consultation codes - no reimbursement when reported for Gold PFFS Section 4
1/10 Gold 2010 changes - eliminate Open 1,3 & 4; add PEBTF; Secure 2 changes; add Secure 3; PDP changes Section 1
2/10 Geisinger Choice product additions: Short Term and Smart Steps Section 1
2/10 CHIP abortion forms Section 10

 

For Participating Providers

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Contacts for Provider
Network Management

If you have questions or need information, please contact your Geisinger Health Plan provider relations representative at the number listed.

Danville:(800) 876-5357

Harrisburg: (888) 281-5338

Scranton: (800) 350-6486

State College: (888) 669-4834