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.
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 |
| 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 |
