Identification cards | We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation (for annuitants), or your electronic enrollment system (such as Employee Express) confirmation letter.
If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 844-863-6850 or write to us at Geisinger Health Plan, Customer Services, 100 North Academy Avenue, Danville, PA 17822-3229. You may also request replacement cards through our website at
www.TheHealthPlan.com/federal. |
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Where you get covered care | You get care from “Plan providers” and “Plan facilities.” You will only pay copayments, deductibles, and/or coinsurance.
FEHB Carriers must have clauses in their in-network (participating) providers agreements. These clauses provide that, for a service that is a covered benefit in the plan brochure or for services determined not medically necessary, the in-network provider agrees to hold the covered individual harmless (and may not bill) for the difference between the billed charge and the in network contracted amount. If an in-network provider bills you for covered services over your normal cost share (deductible, copay, co-insurance) contact your Carrier to enforce the terms of its provider contract. |
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Plan providers | Plan providers are physicians and other healthcare professionals in our service area that we contract with to provide covered services to our members. Services by Plan Providers are covered when acting within the scope of their license or certification under applicable state law. We credential Plan providers according to national standards.
Benefits are provided under this Plan for the services of covered providers, in accordance with Section 2706(a) of the Public Health Service Act. Coverage of practitioners is not determined by your state’s designation as a medically underserved area.
We list Plan providers in the provider directory, which we update periodically. The list is also on our website at www.TheHealthPlan.com/federal.
Benefits described in this brochure are available to all members meeting medical necessity guidelines regardless of race, color, national origin, age, disability, religion or sex, pregnancy or genetic information. |
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Plan facilities | This plan provides Care Coordinators for complex conditions and can be reached at 844-863-6850 or www.TheHealthPlan.com/federal for assistance.
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What you must do to get covered care | It depends on the type of care you need. First, you and each family member must choose a primary care provider. This decision is important since your primary care provider provides or arranges for most of your healthcare. You can complete a PCP selection form and mail it, or call us to make a selection. |
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Primary care | Your primary care provider can be a general practitioner, family practitioner, internist or pediatrician. Your primary care provider will provide most of your healthcare.
If you want to change primary care provider or if your primary care provider leaves the Plan, call Customer Services at 844-863-6850 and we will help you select a new one. |
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Specialty care | You can get needed care from a specialty provider without a referral from your primary care provider. You must go to a participating specialty physician to receive covered services.
If you want to know if a specialty care provider is participating call Customer Service at 844-863-6850 and we will help you find one or log onto www.TheHealthPlan.com/federal.
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Hospital care | Your Plan primary care provider or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or other type of facility. |
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- If you are hospitalized when your enrollment begins
| We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 844-863-6850. If you are new to the FEHB Program, we will arrange for you to receive care and provide benefits for your covered services while you are in the hospital beginning on the effective date of your coverage.
If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:
- you are discharged, not merely moved to an alternative care center; or
- the day your benefits from your former plan run out; or
- the 92nd day after you become a member of this Plan, whichever happens first.
These provisions apply only to the benefits of the hospitalized person. If your plan terminates participation in the FEHB Program in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply. In such case, the hospitalized family member’s benefits under the new plan begin on the effective date of enrollment. |
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You need prior Plan approval for certain services | Your primary care provider and specialty care physician can arrange inpatient hospitalizations, the pre-service claim approval process only applies to care shown under Other services.
You must get prior approval for certain services. If you do not get prior approval you will be responsible for costs. |
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| Inpatient hospital admission | Prior authorization is approval in advance to get services. Some in-network medical services are covered only if your doctor or other network provider gets “prior authorization”. |
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Other services | For certain services, however, your provider must obtain prior approval from us. Before giving approval, we consider if the service is covered, medically necessary, and follows generally accepted medical practice. Plan providers must obtain prior authorization for services including but not limited to the following:
- Inpatient hospital admissions
- Skilled Nursing Facility admissions
- Certain outpatient surgeries
- Bariatric surgery for morbid obesity
- Durable medical equipment
- Out-of-network referral requests
- Transplant services
- Non-emergency outpatient radiology testing such as MRI, MRA, CT, PET, nuclear cardiology, echocardiology
- Inpatient mental health and substance misuse disorder treatment
- Certain injectable drugs
- Services associated with non-covered procedures
- Inpatient
- Injection therapy for back pain
- Sex reassignment
Contact customer services at 844-863-6850 for a complete listing of services that require prior authorization. |
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How to request prior authorization for an admission or for Other services | First, your physician, your hospital, you, or your representative, must call us at 844-863-6850  before admission or services requiring prior authorization are rendered.
Next, provide the following information:
- enrollee’s name and Plan identification number;
- patient’s name, birth date, identification number and phone number;
- reason for hospitalization, proposed treatment, or surgery;
- name and phone number of admitting physician;
- name of hospital or facility; and
- number of days requested for hospital stay.
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Non-urgent care claims | For non-urgent care claims, we will tell the physician and/or hospital the number of approved inpatient days, or the care that we approve for other services that must have prior authorization. We will make our decision within 15 days of receipt of the pre-service claim. If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you of the need for an extension of time before the end of the original 15-day period. Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.
If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information. |
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Urgent care claims | If you have an urgent care claim (i.e., when waiting for the regular time limit for your medical care or treatment could seriously jeopardize your life, health, or ability to regain maximum function, or in the opinion of a physician with knowledge of your medical condition, would subject you to severe pain that cannot be adequately managed without this care or treatment), we will expedite our review and notify you of our decision within 72 hours. If you request that we review your claim as an urgent care claim, we will review the documentation you provide and decide whether or not it is an urgent care claim by applying the judgment of a prudent layperson that possesses an average knowledge of health and medicine.
If you fail to provide sufficient information, we will contact you within 24 hours after we receive the claim to let you know what information we need to complete our review of the claim. You will then have up to 48 hours to provide the required information. We will make our decision on the claim within 48 hours of (1) the time we received the additional information or (2) the end of the time frame, whichever is earlier.
We may provide our decision orally within these time frames, but we will follow up with written or electronic notification within three days of oral notification.
You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM. Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us at 844-863-6850 . You may also call OPM’s FEHB 3 at 202-606-0737 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review. We will cooperate with OPM so they can quickly review your claim on appeal. In addition, if you did not indicate that your claim was a claim for urgent care, call us at 844-863-6850 . If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim). |
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| A concurrent care claim involves care provided over a period of time or over a number of treatments. We will treat any reduction or termination of our pre-approved course of treatment before the end of the approved period of time or number of treatments as an appealable decision. This does not include reduction or termination due to benefit changes or if your enrollment ends. If we believe a reduction or termination is warranted we will allow you sufficient time to appeal and obtain a decision from us before the reduction or termination takes effect.
If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim. |
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Emergency inpatient admission | If you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function, you, your representative, the physician, or the hospital must telephone us within two business days following the day of the emergency admission, even if you have been discharged from the hospital. |
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Maternity Care | Members have direct access to obstetrical and gynecological services. They may select a participating health care provider to obtain maternity and gynecological covered services including medically necessary and appropriate follow-up care for diagnostic testing relating to the maternity and gynecological care. Covered services must be within the scope of practice of the selected participating healthcare provider.
You do not need precertification of a maternity admission for a routine delivery. However, if your medical condition requires you to stay more than 48 hours after a vaginal delivery or 96 hours after a cesarean section, then your physician or the hospital must contact us for precertification of additional days. Further, if your baby stays after you are discharged, your physician or the hospital must contact us for precertification of additional days for your baby.
Note: When a newborn requires definitive treatment during or after the mother’s hospital stay, the newborn is considered a patient in their own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.
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If your treatment needs to be extended | If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim. |
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| How to get approval for... | |
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| Hospital benefits may be provided at a Plan participating hospital on either an inpatient or outpatient basis or at an ambulatory surgical center as authorized in advance by your primary care provider, but a participating specialist, by your obstetrical or gynecological participating healthcare provider (for services within their scope of practice) or by the Plan's designated Behavioral Health Benefit Program. Hospital benefits may also be authorized in advance by the Plan for covered services not available through a participating provider. Inpatient benefits are provided for as long as the hospital stay is determined medically necessary by the Plan and not determined to be custodial, convalescent or domiciliary care. |
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- How to precertify an admission
| It is the responsibility of your admitting physician to obtain precertification from the Plan for your inpatient hospital admission. |
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- What happens when you do not follow the precertification rules when using non-network facilities
| All covered services must be received by a Plan participating provider or facility. Any service or care received outside of this Plan's network or service area, without precertification from the Plan, except in the case of emergency care, will be the financial responsibility of the member. We will only pay for emergency services. We will not pay for any other healthcare services received outside of our service area or network unless the service has received prior Plan approval. |
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Circumstances beyond our control
| Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case, we will make all reasonable efforts to provide you with the necessary care. |
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If you disagree with our pre-service claim decision | If you have a pre-service claim and you do not agree with our decision regarding precertification of an inpatient admission or prior approval of other services, you may request a review in accord with the procedures detailed below. If your claim is in reference to a contraceptive, call 844-863-6850.
If you have already received the service, supply, or treatment, then you have a post-service claim and must follow the entire disputed claims process detailed in Section 8. |
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To reconsider a non-urgent care claim | Within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision. Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure.
In the case of a pre-service claim and subject to a request for additional information, we have 30 days from the date we receive your written request for reconsideration to
1. Precertify your hospital stay or, if applicable, arrange for the healthcare provider to give you the care or grant your request for prior approval for a service, drug, or supply; or
2. Ask you or your provider for more information.
You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days.
If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due. We will base our decision on the information we already have. We will write to you with our decision.
3. Write to you and maintain our denial. |
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| To reconsider an urgent care claim | In the case of an appeal of a pre-service urgent care claim, within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision. Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure. Unless we request for additional information, we will notify you of our decision within 72 hours after receipt of your reconsideration request. We will expedite the review process, which allows oral or written requests for appeals and the exchange of information by telephone, electronic mail, facsimile, or other expeditious methods. |
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| To file an appeal with OPM | After we reconsider your pre-service claim, if you do not agree with our decision, you may ask OPM to review it by following Step 3 of the disputed claims process detailed in Section 8 of this brochure. |
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