Zelis facility claim review

Geisinger Health Plan has authorized Zelis Healthcare LLC to perform facility claim costs solutions for claims exceeding $20,000. Prepayment reviews are part of how we support our provider network to remain aligned with national and state regulatory standards. High-dollar claims reviews have always been and will continue to be conducted and managed by Geisinger Health Plan. This notice only relates to the addition of Zelis as a subcontractor supporting Geisinger Health Plan in performing these reviews.

 

As part of these reviews, Zelis may request itemized bills, medical records or other relevant documentation from patient visits. This helps verify that charges are supported by appropriate coding, clinical validation and diagnosis-related group assignments for reimbursement. Zelis collaborates closely with providers, using preferred methods to gather the records needed for a particular review. They have established contacts and streamlined processes so necessary information is received quickly and efficiently.

 

Under our Business Associate agreement, Zelis is recognized as a HIPAA business associate and shares the same rights and responsibilities as Geisinger Health Plan in handling protected health information (PHI).

 

HIPAA privacy rules allow covered entities (providers and health plans) to disclose PHI to business associates to conduct healthcare operations that would otherwise be performed by the covered entity. Consequently, PHI may be disclosed to Zelis as Geisinger Health Plan’s business associate without the prior written authorization or consent of our members in the performance of medical bill review services.

 

Be ready to provide necessary records and documents to your Zelis representative so your claims can be processed efficiently. Upon receipt of a written request, provide information as soon as possible to Zelis at no charge to the member or Geisinger Health Plan.