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Geisinger Health Plan (GHP) has partnered with Zelis Healthcare LLC to support high-cost drug and professional claim cost solutions. This includes professional claims exceeding $20,000 and high-cost drug claims with allowed charges over $3,000.

Prepayment reviews are part of how we support our provider network and make sure we’re aligned with national and state regulatory standards. As always, high-dollar claim reviews continue to be overseen by GHP. This notice simply reflects the addition of Zelis as a trusted subcontractor helping with these reviews.

 Appeals and review requests

Have questions or disagree with the findings from a Zelis review? Request a reconsideration directly with Zelis, as they’re best positioned to review and respond to these determinations.

You may submit a written request to Zelis within 30 days (or within the timeframe outlined in your participating provider agreement). Zelis representatives are also available to discuss review findings and answer questions.

  • Phone: 866-489-9444

  • Email: providerservices.integrity@zelis.com

  • Fax: 855-250-3338

For the most efficient resolution, submit any appeals or supporting documentation directly to Zelis. Requests sent to GHP may not be processed. 

As part of the review process, Zelis may request itemized bills, medical records or other relevant documentation from patient visits. These materials help confirm that charges are supported by appropriate coding, clinical validation and diagnosis-related group (DRG) assignments. Zelis works closely with providers, using established contacts and streamlined processes to gather necessary information as efficiently as possible.

Under our business associate agreement, Zelis operates as a HIPAA business associate and assumes the same responsibilities as GHP in safeguarding protected health information (PHI).

HIPAA privacy rules allow covered entities — such as providers and health plans — to share PHI with business associates for healthcare operations. As a result, PHI may be shared with Zelis without prior member authorization for the purpose of conducting medical bill reviews on behalf of GHP.

To help avoid delays, be prepared to provide requested records promptly. Upon receiving a written request from Zelis, submit documentation as soon as possible. There should be no cost to the member or GHP.

You may see the following remark codes on future explanations of payment:

  • CO45: Charge exceeds the fee schedule, maximum allowable amount or contracted/legislated fee arrangement
  • CO97: The benefit of this service is included in the payment or allowance for another service or procedure that has already been adjudicated
  • N19: Procedure code incidental to the primary procedure
  • CO163: Attachment or other documentation referenced on the claim was not received
  • M127: Missing patient medical records for this service

 

 

 

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