The Participating Provider Guide (Dev 10/08) is part of your agreement with the Health Plan and is effective February 15, 2009, 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. Major revisions to the Participating Provider Guide since the last published version (8/05) can be downloaded here.
Please contact your provider relations representative if you have any questions concerning the information contained within your Provider Guide.
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
Operations Bulletins which amend this Guide
Recent Changes to the Participating Provider Guide
| Date | Description of Change | Section |
| 11/08 | Geisinger Gold 2009 | Section 1 |
| 12/08 | PQS Changes | Section 4 |
| 1/09 | IVR Information | Throughout |
| 1/09 | LIFE Geisinger | Section 1; Section 3 |
| 1/09 | Refund Policy | Section 4 |
| 2/09 | IVR (Interactive Voice Response) detail | Section 1 |
| 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 5Â |
| 4/09 | Routine Non-Emergent Transportation benefit for Gold Secure 2 Members - claim instructions | Section 4Â |
| 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 |