Transcription
HELPFUL INFORMATIONImportant Telephone NumbersGeisinger Health Plan Family (GHP Family) Phone NumbersGHP Family Member Services .1-855-227-1302(8 a.m. - 5 p.m. Mon. Tue. Thurs. & Fri., Wed. 8 a.m. - 8 p.m.)TTY users call the PA Relay at 711GHP Family Case Management Department .1-800-883-6355GHP Family Pharmacy Member Services .1-855-552-6028GHP Family Special Needs Unit .1-855-214-8100GHP Fraud and Abuse Hotline .1-800-292-1627GHP Family Quality Improvement (EPSDT Services).1-866-847-1216Tel-A-Nurse .1-877-543-5061(24 hours, 7 days a week)State Of Pennsylvania ContactsPA Enrollment Assistance .1-800-440-3989TTY: 1-800-618-4225PA Medical Assistance Provider Compliance Hotline .1-866-379-8477(for reporting suspected fraud and/or abuse – see Section 16 of this Handbook)Pennsylvania Medical Assistance Customer Service Call Center .1-866-542-3015TTY: 1-877-202-3021The Department of Human Services Hotline .1-800-692-7462(for information on eligibility and other requirements for DHSprograms)Clinical Sentinel Health Hotline .1-800-426-2090(Monday through Friday 9 a.m. to 5 p.m.)Pennsylvania Tobacco Cessation Information .1-800-QUIT-NOWWIC Hotline. 1-800-942-9467Web site: www.ghpfamily.comiMember Services 1-855-227-1302, TDD/TTY 711
Behavioral Health Services County Phone Numbers and Web SitesCountyBehavioral Health PlanPhone numberEn EspañolTTY/TDDBradfordCommunity Care Behavioral 1871-877-877-3580CarbonCommunity Care Behavioral 1871-877-877-3580CentreCommunity Care Behavioral 1871-877-877-3580ClintonCommunity Care Behavioral 1871-877-877-3580ColumbiaCommunity Care Behavioral 1871-877-877-3580JuniataCommunity Care Behavioral 1871-877-877-3580LackawannaCommunity Care Behavioral 1871-877-877-3580LuzerneCommunity Care Behavioral 1871-877-877-3580LycomingCommunity Care Behavioral 1871-877-877-3580MifflinCommunity Care Behavioral 1871-877-877-3580MonroeCommunity Care Behavioral 1871-877-877-3580MontourCommunity Care Behavioral 1871-877-877-3580NorthumberlandCommunity Care Behavioral 1871-877-877-3580PikeCommunity Care Behavioral 1871-877-877-3580SchuylkillCommunity Care Behavioral 1871-877-877-3580SnyderCommunity Care Behavioral 1871-877-877-3580SullivanCommunity Care Behavioral 1871-877-877-3580SusquehannaCommunity Care Behavioral 1871-877-877-3580TiogaCommunity Care Behavioral 1871-877-877-3580UnionCommunity Care Behavioral 1871-877-877-3580WayneCommunity Care Behavioral 1871-877-877-3580WyomingCommunity Care Behavioral 1871-877-877-3580iiMember Services 1-855-227-1302, TDD/TTY 711
Medical Assistance Transportation Program (MATP) County Phone NumbersCountyLocal Phone NumberToll Free Phone NumberBradford(570) 888-7330(800) 242-3484Carbon(570) 669-6380(800) 990-4287Centre(814) 355-6807Same as LocalClinton(570) 323-7575(800) 222-2468Columbia(570) 784-8807(866) 936-6800Juniata(717) 242-2277(800) 348-2277Lackawanna(570) 963-6482Same as LocalLuzerne(570) 288-8420(800) 679-4135Lycoming(570) 323-7575(800) 222-2468Mifflin(717) 242-2277(800) 348-2277Monroe(570) 839-8210(888) 955-6282Montour(570) 271-0833Same as LocalNorthumberland(800) 479-2626Pike(570) 296-3408(866) 681-4947Schuylkill(570) 628-1425(888) 656-0700Snyder(570) 522-1390(877) 877-9021Sullivan(570) 888-7330(800) 242-3484Susquehanna(570) 278-6140(866) 278-9332Tioga(570) 659-5330(800) 242-3484Union(570) 522-1390(877) 877-9021Wayne(570) 253-4280(800) 662-0780Wyoming(570) 288-8420(800) 679-4135iiiMember Services 1-855-227-1302, TDD/TTY 711
Your Personal InformationMy Member ID NumberOther Family Members’ ID NumbersOther Family Members’ ID NumbersOther Family Members’ ID NumbersMy PCP’s Name and Phone NumberWeb site: www.ghpfamily.comivMember Services 1-855-227-1302, TDD/TTY 711
Table of Contents1. Introduction. 1Welcome to Geisinger Health Plan Family!. 1Tips for understanding your Handbook and getting other information about GHP Family . 1Important Terms . 1How to contact Member Services . 2Requesting information from Member Services . 2Non-English speaking Members . 2Members who have trouble seeing to read . 3Tel-A-Nurse . 3Information on the GHP Family Web site www.ghpfamily.com . 32. Rights and Responsibilities . 4A Members Rights under the GHP Family plan . 4A Member’s responsibilities under this GHP Family plan . 5Confidentiality and privacy of your medical records and protected health information (PHI) . 6Notice of Privacy Practices . 6You also have certain rights regarding your Personal Health Information . 7To submit a written request regarding your PHI, mail to . 7If you would like to file a complaint, write or call as follows . 8Clinical Sentinel Hotline . 8What is the Clinical Sentinel Hotline? . 8When should I call the Clinical Sentinel Hotline? . 83. Eligibility and Enrollment . 9How to Enroll in GHP Family . 9Identification Cards – GHP Family and ACCESS cards . 9GHP Family Identification Card . 9ACCESS Card . 10What do I have to do to enroll a new family member? . 10How to add a baby . 10How to add other family or household members . 10What Pennsylvania counties are covered by this GHP Family plan? . 10What happens if I move or get a different telephone number? . 11What if I want to change my Health Plan? . 11How will I lose coverage in GHP Family? . 114. Getting Care from PCP’s, specialists and other providers . 13Your Primary Care Practitioner (PCP) . 13Who can be a PCP? . 13How can I change my PCP? . 13What if my PCP leaves the GHP Family network? . 13What care will my PCP provide? . 13PCP office waiting times . 14How long will it take to get an appointment? . 14What is the referral process? . 16Specialist Care . 16Can a Specialist be a PCP? . 16What if my current specialist is not part of the GHP Family network? . 16What is a standing referral? . 17What specialists can I see without a referral (self-refer)? . 17What if I want to get a second opinion? . 17What if there are no specialist providers in the GHP Family network to treat my health problem? . 17Other health care providers . 17Home health care providers . 17Suppliers of Durable Medical Equipment (DME), Prosthetics, Orthotics and other medical supplies . 18Nursing facility providers . 18How do I request a Provider Directory and what can I find in the directory? . 18vMember Services 1-855-227-1302, TDD/TTY 711
Prior Authorization . 18What is the prior authorization process? . 18What services need prior authorization? . 19What is medical necessity? . 19Benefit exceptions . 195. Getting Emergency and Urgent Care . 21What is an emergency? . 21What will happen in the emergency room? . 21What if I get admitted to the hospital? . 21What follow up care should I get after an emergency? . 21What is urgent care? . 21What if I need medical care while I am outside of the GHP Family service area? . 22What if I need transportation to a non-emergency appointment? . 22What if I need transportation that is not an emergency or is not covered by MATP? . 236. Getting Healthy Living Care. 24Preventive services? . 24Where do I go for preventive services? . 24Physical examinations and other tests . 24Services for children up to age 21 – Early and Periodic Screening Diagnosis and Treatment Examinations(EPSDT) . 24What is an Early and Periodic Screening, Diagnosis and Treatment (EPSDT) examination? . 24How often should the EPSDT exams be done? . 24What will the PCP or provider do during the EPSDT exam? . 24What is the Early Intervention Program? . 26How do I get Early Intervention services? . 26Kick the tobacco habit with our help – Stop Tobacco Use Program . 26Do you want help to stop smoking . 26Medicines . 26Counseling Services . 26Help with anxiety, depression or mental health while you are trying to quit . 27GHP Family also offers additional help to stop smoking . 27Family Planning. 27What are family planning services? . 27Care during pregnancy . 28How often do I need to see my obstetrician? . 28What if I already have an obstetrician when I enroll in GHP Family? . 28What do I need to do once my baby is born? . 28What is the GHP program “Right from the Start”? . 28Women, Infants and Children Program (WIC) . 29How do I get WIC? . 297. Getting Special Needs Care and Special Health Programs . 30Special health programs . 30How do I become part of a program? . 31What will the program do for me? . 31What if I don’t want to be in a special health program? . 31Special needs Unit . 31What is a Special Need? . 31How do I contact the Special Needs Unit? . 32What can the Special Needs Unit help me with? . 32Human Immunodeficiency Virus (HIV) / Acquired Immunodeficiency Syndrome (AIDS) Services . 32What are the special services available for HIV/AIDS? . 32How do I get these special services? . 32What provider(s) do I need to see to treat HIV/AIDS? . 33How can I find out about other State services that are not covered by the plan? . 33Behavioral Health Services . 34What Behavioral Health services might be available for me? . 34How do I get Behavioral Health Services? . 35Behavioral Health Contact Information . 35County Behavioral Health Crisis Intervention Phone Numbers . 37viMember Services 1-855-227-1302, TDD/TTY 711
Internet Resources . 378. Dental Care . 38Dental Services for Adult Members (age 21 and over) . 389. Vision Care . 40Vision Care services for Adult members (age 21 and over) . 4010. Pharmacy Covered Services . 41What is the formulary? . 41What is covered under GHP Family pharmacy services? . 41Are there any benefit limits on drugs? . 41What can I do if I am denied a pharmacy service? . 41What if I get a prescription from a non-participating provider? . 41What are my copayments for pharmacy services?.42What drugs are not covered by GHP Family? . 4211. Covered Benefits and Services . 43How to read the covered services chart . 43Covered Services Chart . 43Additional Benefits available for Members . 47Transplant Services and Authorization Requirements . 4812. Copayments and billing . 49Copayment information . 49Who does not have to pay a copayment? . 49What can I do if I think I was charged a copayment that I did not have to pay? . 49What covered services have a copayment? . 49Billing information . 49Are there times when I can be billed? . 49What should I do if I get a bill? . 5013. Services that are not covered. 51What services, treatments and items are not covered by GHP Family? . 5114. Making Decisions about your health care . 53What is an Advance Directive? . 53What is a Living Will? . 53What is a Durable Power of Attorney for Health Care? . 53Things you should know about Advance Directives . 53What if a provider does not follow my Advance Directive? . 54What can I do now to contribute to my health care? . 5415. Complaint, Appeal and Fair Hearing Processes. 55Complaints, Grievances & DHS Fair Hearings . 55Complaints. 55What is a complaint? . 55What should I do if I have a complaint? . 55First Level Complaint . 55When should I file
i Member Services 1-855-227-1302, TDD/TTY 711 HELPFUL INFORMATION Geisinger Health Plan Family (GHP Family) Phone Numbers GHP Family Member Services .1-855-227-1302
