Coverage decisions and appeals

At Geisinger Health Plan, we’ll work with you to make sure you’re satisfied with your health coverage. Have a question about a coverage decision we made? Contact us to talk about it.

A coverage decision is a decision we make about your benefits and coverage, or about the amount we’ll pay for your medical services. Please follow these instructions to request a coverage decision:

Step 1: Request a coverage decision.
Step 2: We consider your request and give you our answer.
Step 3: If we say no, you decide if you want to appeal.

 

Step 1: Request a coverage decision

Start by calling, writing, or faxing us to request coverage for the medical care you want. You, your doctor or your representative can do this.

Call: 800-544-3907 (FREE) (TDD: 711)

Fax: 570-271-5534

Write:
Geisinger Gold
Medical Management Department
100 North Academy Avenue
Danville, PA 17822-3218

Generally, we use the standard deadlines for giving you our decision. For a standard coverage decision, we’ll answer within 14 days after receiving your request.

If your health requires a quick response, request a “fast coverage decision.” A fast coverage decision means we’ll answer within 72 hours.

To get a fast coverage decision, you must meet two requirements:

  • You can get a fast coverage decision only if you’re asking for coverage for medical care you have not yet received. (You can’t get a fast coverage decision if your request is about payment for medical care you’ve already received.)
  • You can get a fast coverage decision only if using standard deadlines could cause serious harm to your health or hurt your ability to function.

If your doctor tells us that your health requires a “fast coverage decision,” we will automatically agree to give you a fast coverage decision.

If you ask for a fast coverage decision on your own, without your doctor’s support, we will decide whether your health requires that we give you a fast coverage decision.

If we decide that your medical condition doesn’t meet the requirements for a fast coverage decision, we’ll send you a letter that says so (and we’ll use the standard deadlines instead). The letter will tell you:

  • If your doctor asks for the fast coverage decision, we’ll automatically give a fast coverage decision.
  • How you can file a “fast complaint” about our decision to give you a standard coverage decision instead of the fast coverage decision you requested

Note: We can take up to 14 more calendar days if you ask for more time, or if we need information (such as medical records from out-of-network providers) that may benefit you. If we decide to take extra days to make the decision, we’ll tell you in writing. If you believe we shouldn’t take extra days, you can file a “fast complaint” about our decision to take the extra days. When you file a fast complaint, we’ll answer your complaint within 24 hours.

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Step 2: We consider your request and give you our answer

Deadlines for fast coverage decisions
Generally, for a fast coverage decision, we’ll give you our answer within 72 hours.

  • As explained above, we can take up to 14 more calendar days under certain circumstances. If we decide to take extra days to make the coverage decision, we’ll tell you in writing.
  • If you believe we should not take extra days, you can file a “fast complaint” about our decision to take extra days. When you file a fast complaint, we’ll give you an answer to your complaint within 24 hours.
  • If we do not give you our answer within 72 hours (or if there is an extended time period, by the end of that period), you have the right to appeal.

If our answer is yes to part or all of what you requested, we must authorize or provide the medical care coverage we have agreed to provide within 72 hours after we received your request. If we extended the time needed to make our coverage decision, we will provide the coverage by the end of that extended period.

If our answer is no to part or all of what you requested, we’ll send you a detailed written explanation as to why we said no.

Deadlines for standard coverage decisions
Generally, for a standard coverage decision, we’ll give you our answer within 14 days of receiving your request.

  • We can take up to 14 more calendar days (“an extended time period”) under certain circumstances. If we decide to take extra days to make the coverage decision, we’ll tell you in writing.
  • If you believe we should not take extra days, you can file a “fast complaint” about our decision to take extra days. When you file a fast complaint, we’ll give you an answer to your complaint within 24 hours.
  • If we don’t give you our answer within 14 days (or if there is an extended time period, by the end of that period), you have the right to appeal. Step 3 below explains how to make an appeal.

If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 14 days after we received your request. If we extended the time needed to make our coverage decision, we will provide the coverage by the end of that extended period.

If our answer is no to part or all of what you requested, we’ll send you a written statement that explains why we said no.

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Step 3: If we say no, you decide if you want to appeal.

Appeals information
If we say no, you have the right to ask us to reconsider this decision by making an appeal. Making an appeal means trying again to get the medical care coverage you want. If you would like to appeal a denial for coverage or payment of services, you may appeal this denial by contacting Geisinger Gold at the following address:

Write
Geisinger Gold
Appeal Department
100 North Academy Avenue
Danville, PA 17822-3220

Fax: 570-271-7225

In person
Geisinger Health Plan
108 Woodbine Lane
Danville, PA 17821

Standard service and payment appeals must be submitted in writing. However, when the member’s life, health or ability to regain maximum function is jeopardized by utilizing the standard appeal process, an expedited appeal may be requested verbally by the member, member representative, or provider by calling 800-498-9731 (TDD: 711), from 8 a.m. - 8 p.m., EST, Monday - Friday (April - September) or seven days a week (October - March).

Grievances
If you have a grievance, we encourage you to first call the Geisinger Gold Customer Service Team at the number below. We will try to resolve any complaint you might have over the phone. If you request a written response to your phone complaint, we will respond in writing to you. If we can’t resolve your complaint over the phone, we have a formal procedure to review your complaints, called the grievance procedure. We must notify you of our decision about your grievance as quickly as your case requires based on your health status, but no later than 30 calendar days after receiving your complaint. We may extend the time frame by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest.

Grievances can be submitted by calling the Gold Customer Service Team at 800-498-9731 (TDD: 711), from 8 a.m. - 8 p.m., EST, Monday - Friday (April - September) or seven days a week (October - March).

Write
Geisinger Gold
Appeal Department
100 North Academy Avenue
Danville, PA 17822-3220

Fax: 570-271-7225

Expedited (Fast) Grievances
As a Geisinger Gold member, you have the right to file an Expedited (Fast) Grievance for services you have not yet received, by following the process below.

Expedited (Fast) Grievances can be initiated or requested when you disagree with the time frames Geisinger Gold establishes for making organization determinations (coverage decisions) or reconsiderations (appeals) for services you have not yet received.

Expedited (Fast) Grievances can be requested or filed by contacting the Geisinger Gold Customer Service Team at 800-498-9731 (TDD: 711), from 8 a.m. - 8 p.m., EST, Monday - Friday (April - September) or seven days a week (October - March).

A medical director will review your Expedited (Fast) Grievance and you will receive a verbal notification of the decision within 24 hours of receipt of your request for an Expedited (Fast) Grievance. Additionally, a written response will be provided to you within 72 hours of the medical director's decision.

 

Contact Information

If you have questions about the grievance, organization determination, or appeals processes, or to obtain an aggregate number of grievances and appeals filed with the plan, please call the Gold Customer Service Team at 800-498-9731(TDD: 711), from 8 a.m. - 8 p.m., EST, Monday - Friday (April - September) or seven days a week (October - March).

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Y0032_17274_1 CMS Approved 10/13/17

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