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Provider material for NaviNet

Ops Bulletins - Briefly - Forms - Education - Provider Guide

 

OpsBulletins

2023_08_18_OPS_NDC_verify_Gold_Commercial_NDC_unit_postpone
2023_08_18_OPS_Cohere_IP_postpone
2023_07_28_OPS_Cohere_MSK_card_pain_auth
2023_06_16_OPS_Cohere_IP_postpone
2023_05_01_OPS_FQHC_RHC_grpbill_GHPFamily
2023_04_28_OPS_NDC_verify_Gold_Commercial
2023_03_15_OPS_Cohere_full_launch_V2
2023_12_15_OPS_GOLD_provider_bulletin
2022_11_16_OPS_Cohere_HH_OPRehab_Chiro_auth
2022_07_08_OPS_DME_diabetic_CGM_policy_change
2022_01_03_OPS_30day_readmissions_followup
2021_10_26_OPS_GOLD_provider_bulletin
2021_09_30_OPS_30day_readmissions
2021_09_20_OPS_EVV_effective
2021_07_29_OPS_MA-CHIP_postPHE_revalidation
2021_05_18_OPS_HH_overpay - HHH1 fee schedule
2021_02_15_OPS_Zelis_claim_edits
2020_11_30_OPS_HealthHelp_card_auth
2020_11_30_OPS_HealthHelp_MSKpain_auth
2020_10_29_OPS_DME_TH
2020_10_23_OPS_Gold_provider_bulletin
2020_10_01_OPS_MA_30day_readmit
2020_07_01_OPS_HealthHelp_rad_auth
2020_11_01_OPS_GOLD_provider_bulletin
2019_12_01_OPS_7day_readmit_process_change
2019_10_29_OPS_MA_statewide_PDL
2019_09_11_OPS_MA_30day_readmit
2019_09_03_OPS_837_edits_enc_data
2019_08_26_OPS_NDSC_notice_req_end
2019_05_28_OPS_medrec_access
2019_05_09_OPS_CHIP_enroll_claim_denial_notice
2019_05_08_OPS_MA_enroll_claim_denial_notice
2018_10_25_OPS_2019_Gold_provider_bulletin
2018_08_01_OPS_rad_NDSC_interim
2018_07_20_OPS_IP_prior_auth_changes
2018_06_15_OPS_radauth_NDSC_interim
2018_04_15_OPS_Marketplace_plans_referral_overview
2018_03_27_OPS_GOLD_provider_bulletin
2018_01_30_OPS_PEBTFHomeHealthPriorAuthChange
2017_12_18_OPS_PEBTFHomeHealthPriorAuthChange
2017_09_22_OPS_7day_readmissions
2017_09_15_OPS_GHP_KIDS_MA_validation
2017_08_11_OPS_NIA_notice_noauth
2017_06_30_GHP_Kids_Referral_Ops
2017_06_30_UPDATE_OPS_7day_readmissions_payment
2017_06_05_UPDATE_OPS_7day_readmissions_payment
2017_05_01_OPS_7day_readmissions_payment-2
2017_04_01_OPS_HomeHealthPriorAuthChange
2017_03_24_planned_inpatient_admission_auth_Ops
2017_03_06_commercial_group_referral_Ops 2017_02_28_NDC_GHPFamily_payment
2017_02_08_MOON_notice
2017_01_04_Gold_provider_bulletin
2016_12_01_Gold_Referral_Ops
2016_08_24_OP_rehab_auth_GHP
2016_05_25_Outpt_Rehab_Prior_Auth_GOLD
2016_04_16_Gold_preventive_coverage_liability
2016_03_30_GOLD_provider_bulletin_PA
2016_03_30_GOLD_provider_bulletin_NJ
2016_03_16_O2_Reimbursement_and_Equipment_Rental_Changes_Ops
2015_12_29_Home_Health_Prior_Authorization_Changes
2015_12_14_Hearing_Aid_Prior_Authorization_for_GHP_Family_members_under_21
2015_11_17_DME_Prior_Authorization_Changes
2015_11_15_Prior_Authorization_Changes_for_Planned_Inpatient_Hospital_Admissions
2015_08_31_Payment_of_Hospice_Claims
2015_08_21_Prior_Authorization_Discontinued_for_All_GHP_Family_Covered_Chiropractic_Services
2015_06_30_DME_Prior_Auth_Changes_nocodes
2015_06_03_Provider_Performance_Data
2015_06_01_OD_Process_Followup_cataract_correction
2015_05_01_OD_Process_Followup
2015_03_30_Gold_non-covered_srvcs_033015
2015_02_27_GOLD_2015_provider_bulletin_NJ_1214
2015_02_13_GOLD_provider_bulletin_PA_1214_rev021215
2015_01_21_PQS_Changes_120914
2014_12_04_Antibiotic_resistance_bulletin_120314
2014_10_30_NIA_CVR_Expansion_GHS
2014_10_30_NIA_CVR_Expansion_90day
2014_10_30_NIA_CVR_Expansion_60day
2014_10_30_NIA_CVR_Expansion_45day
2014_10_30_NIA_CVR_Expansion_30day
2014_07_15_Sequestration_ops_071514_generic
2014_05_30_Med_Transport_MTM_to_ALS_Rendering_Ops
2014_05_30_Med_Transport_MTM_to_ALS_Ordering_Ops
2014_02_13_GOLD_PA_Ops_2014
2013_12_30_PQS_Update
2013_08_20_GHP_Family_NDC_prospective_Ops
2013_06_20_Medical_Spine_Management_Program
2013_05_15_MTM_PostAuth_Ops_051413
2013_04_11_SNF_Precert_Ops_correction_041113
2013_03_06_IP_Precert_Ops_correction_021113-v3
2013_02_27_GHP_Family_Ops_020613
2013_01_31_SNF_Precert_Ops_013113-combo
2013_01_31_IP_Precert_Ops_013113-combo
2013_01_01_GHP_Extra
2012_12_26_GOLD_2013
2012_09_14_New_Medical_Transportation_Manager_MTM_ParAmbulance
2012_09_14_New_Medical_Transportation_Manager_MTM
2012_09_12_DME_Information
2012_08_06_GHP_Patient_Discharge_SNFs
2012_05_01_Online_Referrals_PSC_Registration
2011_12_01_MedImpact_Pharmacy_Benefit_Manager
2011_11_30_Milliman_Care_Guidelines_Med_Mgmt
2011_10_19_GOLD_2012
2011_06_15_Payment_Integrity_Program
2011_06_01_HPylori
2011_04_14_NOMNC_New_Form_and_Matrix
2011_04_04_Zostavax
2011_01_Peds_Vacc_Codes_and_Influenza_Vaccine

 

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Briefly

2023_11_MPU
2023_10_MPU
2023_08_MPU
2023_04_MPU
2023_03_MPU
2022_11_MPU
2022_10_MPU
2022_08_MPU
2022_05_MPU
2022_02_MPU
2021_11_MPU
2021_10_MPU
2021_08_MPU
2021_07_MPU
2021_05_MPU
2021_04_MPU
2021_03_MPU
2021_02_MPU
2021_01_MPU
2020_12_MPU
2020_10_MPU
2020_09_MPU
2020_07_MPU
2020_06_MPU
2020_05_MPU
2020_04_MPU
2020_02_MPU
2020_01_MPU
2019_12_MPU
2019_10_MPU
2019_08_MPU
2019_07_MPU
2019_06_MPU
2019_05_MPU
2019_04_MPU
2019_03_MPU
2019_02_MPU
2018_12_MPU
2018_11_MPU
2018_10_MPU
2018_09_MPU
2018_08_MPU
2018_07_MPU
2018_06_MPU
2018_05_MPU
2018_04_MPU
2018_03_MPU
2018_02_MPU
Fall 2017
Summer 2017
Spring 2017

 

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Forms

Ambulance_transport_education
Ambulance_transport_ordering_ops_combo
Ambulance_transport_rendering_ops_combo
Ambulance_transport_request_form
BH ABA request form
BH Concurrent review form
BH ECT request form
BH Psychological testing request form
BH RTC request form
BH TMS request form
CCHS_Specialty Drug LIst
DME Change Form
DME Extra Codes Sheet
DME Network Precert Form
DME Oxygen_CPAP Precert Form
DME PO Information
DME Recertification Form
DME Respiratory Precert Form
EMHS Specialty Drug List
EMHS_PHCS_Authorization_Form_Phone
EPO Request Form
Formulary Exception Prior Auth Request Form
GHPFamily_opioid_authorization_request_form
ghpfamily_17_Antipsychotics_Authorization_Request_Form
ghpfamily_formularypriorauth
GOLD_MED Form
HCV DAA Prior Authorization Form
Hep_C_Center of Excellence
Hep_C_Prior_Auth_Request_Form
HH_Form
IP_admission_review_write_013113-v2
IP_planned_precert_form_write_031913-v2
IP_Precert_Ops_correction_021113-v3
IP_Rehab_Precert_Worksheet
IP_update_review_write_031913-v2
LA_Atypical_Antipsychotic_Request_Form
Medical Benefit Outpatient Drug Authorization Form
Medicare Vaccines
MSM_Referral_Process
MSM_Therapy_Guidelines
Newborn_Info_form_write_031913-v2
NOMNC_instructions
OD_form
OP_Rad_Prior_Auth_Form_rev_080118
OP_Rehab_Referral_Form
Outpatient Prior Auth Request Form and instructions
PEBTF referral form 122021
SNF_Concurrent_Review_Forms
SNF_Discharge_Planning_Notification
SNF_Precert_Form
SNF_Precert_Ops_correction_041113
Specialty Vendor Drug List with Form
Specialty_Vendor_Drug_Facts_and_information
Specialty_Vendor_Drug_Quick_Reference_Guide
specialtydruglist
Subutex-Suboxone PA Form

Pharmacy Forms

Geisinger Gold (Medicare):

• Online Prior Authorization Portal (PromptPA)
• Universal Pharmacy Benefit Drug Authorization Form
• Geisinger Gold Nonpar Provider Appeal Process Form
• Medicare Incentive Form
• Erythropoietin Stimulating Agents (ESA) Authorization Form
• Geisinger Gold/Medicare Vaccine Coverage
• Hepatitis C Pharmacy Benefit Drug Authorization Form
• Opioid Cumulative Morphine Equivalent Dose (MED) Authorization Form
• Medical Benefit Outpatient Drug Authorization Form

Geisinger Health Plan/Geisinger Marketplace (Commercial):

• Online Prior Authorization Portal (PromptPA)
• Universal Pharmacy Benefit Drug Authorization Form
• Specialty Referral Form – Download and complete the MedImpact Direct Specialty® referral form
• Specialty Drug List
• Fourth Tier Drug List
• Erythropoietin Stimulating Agents (ESA) Authorization Form
• Hepatitis C Pharmacy Benefit Drug Authorization Form
• Non-Preferred Buprenorphine Pharmacy Benefit Drug Authorization Form
• Opioid Cumulative Morphine Equivalent Dose (MED) Authorization Form
• Medical Benefit Outpatient Drug Authorization Form

GHP Family (Medicaid):

• Online Prior Authorization Portal (PromptPA)
• Universal Pharmacy Benefit Drug Authorization Form
• Specialty Drug and Pharmacy List
• Medical Benefit Outpatient Drug Authorization Form

Statewide PDL forms:

• Acne Agents, Oral PEAP
• Acne Agents, Topical PEAP
• Alzheimers Agents PEAP
• Analgesics, Non-Opioid Barbiturate Combinations PEAP
• Analgesics, Opioids Long-Acting PEAP
• Analgesics, Opioids Short-Acting PEAP
• Androgenic Agents PEAP
• Antianginal Agents - Ranexa PEAP
• Antibiotics, GI - Xifaxan PEAP
• Antibiotics, GI - Zinplava PEAP form
• Antidepressants, Other PEAP
• Antihemophilia Agents (NEW) PEAP
• Antihyperuricemics - Colchicine (NEW) PEAP
• Antihyperuricemics - Krystexxa (NEW) PEAP
• Antimigraine Agents, Other - Acute Treatments PEAP
• Antimigraine Agents, Other - CGRP Inhibitors PEAP
• Antipsychotics PEAP
• Antivirals, CMV - Prevymis (NEW) PEAP
• Benzodiazepines PEAP
• Bile Salts - Cholbam (NEW) PEAP form
• Bile Salts - Ocaliva PEAP form
• Blood Glucose Meters and Test Strips PEAP
• Bone Density Regulators - Evista PEAP
• Bone Density Regulators - Evenity, Forteo, Teriparatide, Tymlos PEAP
• Bone Density Regulators PEAP
• Botulinum Toxins PEAP
• Colony Stimulating Factors PEAP
• COPD Agents - Daliresp (NEW) PEAP form
• Cytokine and CAM Antagonists (NEW) PEAP
• Enzyme Replacements, Gaucher Disease PEAP
• Erythropoiesis Stimulating Proteins PEAP
• Estrogens, PEAP
• GI Motility, Chronic - Constipation PEAP
• GI Motility, Chronic - Diarrhea PEAP
• Hepatitis C Agents PEAP
• Hereditary Angioedema Agents PEAP
• Hypoglycemics, Incretin Enhancers PEAP
• Hypoglycemics, Incretin Mimetics - Symlin PEAP
• Hypoglycemics, Incretin Mimetics PEAP
• Hypoglycemics, Insulins - Soliqua and Xultophy (NEW) PEAP form
• Hypoglycemics, SGLT2 Inhibitors PEAP
• Hypoglycemics, TZDs PEAP
• Idiopathic Pulmonary Fibrosis Agents, PEAP
• Intra-Articular Hyaluronates PEAP
• Iron Chelating Agents (NEW) PEAP
• Lipotropics, Other - Juxtapid PEAP
• Lipotropics, Other - PCSK9 Inhibitors PEAP
• Macular Degeneration Agents PEAP
• Migraine Acute Treatment Agents, PEAP
• Monoclonal Antibodies - Anti-IL, Anti-IgE (NEW) PEAP
• Multiple Sclerosis PEAP
• NSAIDs - Ketorolac PEAP
• Oncology Agents, Oral PEAP
• Opioid Dependence Treatments - Probuphine PEAP form
• Opioid Dependence Treatments - Sublocade (NEW) PEAP form
• Opioid Dependence Treatments, Oral PEAP
• Pituitary Suppressive Agents, LHRH PEAP
• Platelet Aggregation Inhibitors - Zontivity (NEW) PEAP Form
• Potassium Removing Agents (NEW) PEAP
• Progestational Agents - Makena, Hydroxyprogesterone Caproate PEAP form
• Proton Pump Inhibitors Less Than 6 y.o. PEAP
• Pulmonary Arterial Hypertension Agents PEAP
• Sickle Cell Anemia Agents PEAP
• Stimulants and Related - Provigil Nuvigil, Sunosi, Wakix PEAP
• Stimulants and Related Agents PEAP
• Thalidomide and Derivatives PEAP form
• Thrombopoietics (NEW) PEAP
• Tysabri PEAP Form
• Urea Cycle Disorder Agents (NEW) PEAP
• VMAT2 Inhibitors - Austedo PEAP
• VMAT2 Inhibitors - Ingrezza PEAP
• VMAT2 Inhibitors - Xenazine PEAP

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Education/Resources 

Credentialing files

Pros:

• 2023_09_25
• 2023_09_11
• 2023_08_28
• 2023_08_14
• 2023_07_24
• 2023_07_10
• 2023_06_26
• 2023_06_12
• 2023_05_22
• 2023_05_08
• 2023_04_24
• 2023_04_10
• 2023_03_27
• 2023_03_13
• 2023_02_27
• 2023_02_13
• 2023_01_23
• 2023_01_16
• 2022_12_30
• 2022_12_12
• 2022_11_28
• 2022_11_07
• 2022_10_24
• 2022_10_10
• 2022_09_26
• 2022_09_12
• 2022_08_22
• 2022_08_08
• 2022_07_25
• 2022_07_11
• 2022_06_27
• 2022_06_13
• 2022_05_23
• 2022_05_09
• 2022_04_25
• 2022_04_11
• 2022_03_28
• 2022_03_14
• 2022_02_28
• 2022_02_14
• 2022_01_25
• 2022_01_17
• 2021_12_27
• 2021_12_13
• 2021_11_22
• 2021_10_25
• 2021_10_11
• 2021_09_27
• 2021_09_13
• 2021_08_23
• 2021_07_26
• 2021_07_12
• 2021_06_28
• 2021_06_14
• 2021_05_24
• 2021_05_10
• 2021_04_26
• 2021_04_12
• 2021_03_22
• 2021_02_08
  
• 2021_01_25

Facilities:

• 2023_09_25
• 2023_08_28
• 2023_07_24
• 2023_06_26
• 2023_05_22
• 2023_04_24
• 2023_03_27
• 2023_02_27
• 2023_01_23
• 2022_12_30
• 2022_11_28
• 2022_10_24
• 2022_09_29
• 2022_08_22
• 2022_07_25
• 2022_06_27
• 2022_05_23
• 2022_04_25
• 2022_03_28
• 2022_02_28
• 2022_01_25
• 2021_12_27
• 2021_11_22
• 2021_10_25
• 2021_09_27
• 2021_08_23
• 2021_07_26
• 2021_06_28
• 2021_05_24
• 2021_04_26
• 2021_03_22
• 2021_01_25

 

GHP Family (Medicaid)

GHP Family provider manual

• Policy 1 - SIU
• Policy 45 - Reg Compliance

P4Q manual - 2018 
P4Q manual - 2019
P4Q manual - 2020
P4Q manual - 2021
P4Q manual - 2022
P4Q manual - 2023

PA_DOH_NewSchoolVaccinationRequirements_2017
MA_99-18-01_RevisedHealthCareBenefitPackagesProviderReferenceChart
MA_99-18-02_Updates2017EPSDTProgramPeriodic
ORP_Clarification_CHART_082418

EVV_HHCS_notice_1122
EVV_infosheet_G0156_for_PCS_081123
EVV_HHCS_notice_1123

GHP General

Ambulance Alliance/Cohere notice
Provider care team - claims resolution
BH_service_sheet_PRO
BH_service_sheet_FAC
BH_MH_Service_Sheet
BH_orientation_invitation
BH orientation PDF 1119
BioIQ_overview_2018
BioIQ_kitinfo_2018
Datashare_trifold_2018
HEDIS behavioral health documentation guide 0418
HEDIS booklet - 0317
HEDIS documentation guide - 0317
HEDIS_guide_2019
HHH_supply_info
NDSC_service_desc_0818
MHA benchmarks 2019
MHA benchmark
Participating Provider Guide 2011 (old guide)
Patient care conversation sheet
PQS manual - 2017
PQS manual - 2018
PQS manual - 2019
PQS manual - 2020
PQS manual - 2021
PQS manual - 2022 - old/expired
PQS manual - 2022 - new/revised
PQS manual - 2023

All plans overview
Flu vaccine product info 2017
ONAF OB Care user guide
MRRT
Member reassignment (MRRT) instructions
Zelis edits guide
Avalon edits guide
Avalon archived policies

WOL

Covid-19 SNF auth waiver

AMP

NN AMP infosheet
NN AMP FAQ
NN AMP user guide
NN AMP townhall presentation
NN AMP diagnosis correction form
NN AMP attribution guide

Cohere

Cohere WTC
Cohere FAQ
Cohere clinical scope soft launch
Cohere MSK, Card, IPM FAQ

GHP Kids (CHIP)

CHIP_MAID_enrollment_training
CHIP_MAID_AttachmentA_CHIPProviderTypes
CHIP_MAID_AttachmentB_ProviderTypesRequiredtoObtainaCriminalBackgroundCheck
CHIP_MAID_AttachmentC_ProviderTypesthatPayApplicationFee
CHIP_MAID_AttachmentD_HardshipExceptionRequestForm

Neighborly

SNAP referral flyer EPIC
SNAP Program Flyer non-EPIC

Geisinger Gold (Medicare)

SNP_Model_of_Care_0318
DUOS_initial_outreach

 

RACE

RACEoutreachphases
RACEletter_pluscatalog
RACEdocreq
RACEdochints

 

Notices/Memos

2020_03_16_PE_LIFEGeisinger_claims
2018_11_16_PE_GHPFamily_VFC_notice
2018_09_10_PE_NDSC_rad_specialnotice-FINAL
2018_04_12_PE_EVV_survey_HHH_GHPFamily
2018_01_19_PE_GHP_Family_enrollment_billing_reminder-FINAL
2017_12_18_PE_GeisingerTPA_2018_group_level_exception_process
2017_10_20_PE_GeisingerTPA_2018_renewal_combo
2017_07_14_PE_GHPFamily_Opiod_edit_notice_peds
2017_06_20_PE_LexisNexis_notice_final
2017_08_15_PE_GHPFamily_opiod_auth_adults

 

PEBTF

PEBTF_townhall_presentation

 

Who to Call

WTC_card

 

 

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Provider Guide

General Information

GHP at a glance
Contact information
Web site and interactive voice response (IVR)
Electronic transactions
GHP responsibilities
Fraud, waste and abuse
Protected health information (PHI)
Provider Performance Data
General provisions
Definitions

Additional Participating Provider Responsibilities

Minimum standards for medical record documentation
Termination of physician/member relationship
Accessibility of primary care services
Network access and reciprocity
Dual eligible member cost sharing
Advertising guidelines
Credentialing
Ambulance service requirements
DME/P&O service requirements
GHP Kids/CHIP/Bright Futures pediatric care resources

Billing and Reimbursement

Payment schedules     
Copayments/coinsurance and deductibles     
Claim submission     
Claim status inquiry     
Claim reconsideration process     
Coordination of benefits
Replacement claims
Telehealth services    

Professional providers billing guidelines     

• Anesthesiology     
• Assistant at surgery services     
• Consultations     
• Locum tenens     
• Immunizations     
• Mastectomy bra      
• Maternity care and delivery     
• Breast pumps     
• Appropriate modifier usage     
• Multiple surgical procedures     
• New technology or unusual and rare procedures     
• Outpatient hyperbaric oxygen therapy services (HBO)     
• Outpatient rehabilitative services     
• Professional site of service payment differential     
• Routine nail reduction     
• Unattended electrical stimulation therapy     
• Unlisted service or procedure     
• Vision services     
• Well-child office visits     
• Wisdom teeth extraction     

Ancillary/facility providers billing guidelines     

• Ambulance services     
• Ambulatory surgical centers
• Behavioral health services
• Hospital outpatient departments     
• Ambulatory surgical services for outpatient hospital reporting     
• Multiple hospital imaging procedure payment reduction     
• Case rate payments for readmissions related to original admission     
• Diagnosis related group (MS-DRG)     
• Post-acute care transfer     
• Durable medical equipment (DME) services     
• Home health/hospice prior authorization     
• Observation services     
• Outpatient services prior to an admission     
• Skilled nursing care     
• Never events/hospital acquired conditions (HAC)/present on admissions indicators (POA)

Health insurance prospective payment system (HIPPS) code reporting requirement     
Physician quality summary for primary care physicians     

Referrals and Precertifications/Prior Authorizations

Referrals
Prior authorization contacts
Prior authorization overview
Inpatient hospitalization
Observation
Inpatient rehabilitation admission
Skilled nursing facility (SNF) admission
Home health/hospice and home infusion
Durable medical equipment (DME)
Outpatient physical, occupational and speech therapies
Outpatient radiology and cardiac imaging
Pharmacy
Ambulance (Pennsylvania only)
Experimental/investigational or unproven services
Transplant services
LIFE Geisinger Services
Behavioral health

Disputes, Appeals and Grievances

Provider disputes & appeals (non-medical)
Provider appeal for adverse medical determination - gatekeeper products
Provider grievance on behalf of member for adverse medical determination – non-gatekeeper products
Compliance with grievance, complaint and appeal procedures

Care Delivery Management

Proven Health Navigator® (medical home)
Population management programs
Transitions of care
Nurse case managers/health managers
Antibiotic resistance initiative
Behavioral health

Member Rights and Responsibilities

Commercial plans     

• Member rights     
• Member responsibilities     
  

Gold plans     

• Member rights     
• Member responsibilities     

Products

 

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