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 800-821-6136 or write to us at GEHA, P. O. Box 21542, Eagan, MN 55121. You may also request replacement cards through our website: www.geha.com.
|Where you get covered care||You can get care from any “covered provider” or “covered facility”. How much we pay – and you pay – depends on the type of covered provider or facility you use and who bills for the covered services. If you use our preferred providers, you will pay less.|
We provide benefits for the services of covered providers as required by 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.
Under the Plan, we consider covered providers to be medical practitioners who perform covered services when acting within the scope of their license or certification under applicable state law.
These covered providers may include: a licensed doctor of medicine (M.D.) or a licensed doctor of osteopathy (D.O.); chiropractor; nurse midwife; nurse anesthetist; audiologist; dentist; optometrist; licensed clinical social worker; licensed clinical psychologist; licensed professional counselor; licensed marriage and family therapist; podiatrist; speech, physical and occupational therapist; nurse practitioner/clinical specialist; nursing school administered clinic; physician assistant; registered nurse first assistants; certified surgical assistants; board certified behavior analyst; board certified assistant behavior analyst; registered behavior technician; Christian Science practitioner, and a dietitian as long as they are providing covered services which fall within the scope of their state licensure or statutory certification.
The terms “doctor”, “physician”, “practitioner” or “professional provider” includes any provider when the covered service is performed within the scope of their license or certification. The term “primary care physician” includes family or general practitioners, pediatricians, obstetricians/gynecologists and medical internists, and mental health/substance use disorder treatment providers.
Practitioners must be licensed in the state where the patient is physically located at the time services are rendered.
Covered facilities include:
- Freestanding ambulatory facility
- A facility which is licensed by the state as an ambulatory surgery center or has Medicare certification as an ambulatory surgical center, has permanent facilities and equipment for the primary purpose of performing surgical and/or renal dialysis procedures on an outpatient basis; provides treatment by or under the supervision of doctors and nursing services whenever the patient is in the facility; does not provide inpatient accommodations; and is not, other than incidentally, a facility used as an office or clinic for the private practice of a doctor or other professional.
- If the state does not license Ambulatory Surgical Centers and the facility is not Medicare certified as an ambulatory surgical center, then they must be accredited with AAAHC (Accreditation Association for Ambulatory Health Care), AAAASF (American Association for Accreditation for Ambulatory Surgery Facilities), IMQ (Institute for Medical Quality) or TJC (The Joint Commission).
- Ambulatory Surgical Facilities in the state of California do not require a license if they are physician owned. To be covered these facilities must be accredited by one of the following: AAAHC (Accreditation Association for Ambulatory Health Care), AAAASF (American Association for Accreditation for Ambulatory Surgery Facilities), IMQ (Institute for Medical Quality) or TJC (The Joint Commission).
- Christian Science nursing organization/facilities that are accredited by The Commission for Accreditation of Christian Science Nursing Organization/Facilities Inc.
A facility which meets all of the following:
- Primarily provides inpatient hospice care to terminally ill persons;
- Is certified by Medicare as such, or is licensed or accredited as such, by the jurisdiction it is in;
- Is supervised by a staff of M.D.’s or D.O.’s, at least one of whom must be on call at all times;
- Provides 24-hour-a-day nursing services under the direction of an R.N. and has a full-time administrator; and
- Provides an ongoing quality assurance program.
- Skilled Nursing Facility licensed by the state or certified by Medicare if the state does not license these facilities. See limitations on page (Applies to printed brochure only).
- An institution which is accredited as a hospital under the Hospital Accreditation Program of The Joint Commission (TJC) or the Commission on Accreditation of Rehabilitation Facilities (CARF) or is certified by Medicare; or
- A medical institution which is operated pursuant to law, under the supervision of a staff of doctors, and with 24-hour-a-day nursing service, and which is primarily engaged in providing general inpatient acute care and treatment of sick and injured persons through medical, diagnostic, and major surgical facilities, all of which must be provided on its premises or have such arrangements by contract or agreement; or
- An institution which is operated pursuant to law, under the supervision of a staff of doctors and with 24-hour-a-day nursing service and which provides services on the premises for the diagnosis, treatment, and care of persons with mental/substance use disorders and has, for each patient, a written treatment plan which must include diagnostic assessment of the patient and a description of the treatment to be rendered and provides for follow-up assessments by, or under, the direction of the supervising doctor.
The term hospital does not include a convalescent home or skilled nursing facility, or any institution or part thereof which: a) is used principally as a convalescent facility, nursing facility, or facility for the aged; b) furnishes primarily domiciliary or custodial care, including training in the routines of daily living; or c) is operating as a school.
- Residential Treatment Centers (RTCs) must be accredited by a nationally recognized organization (e.g. CARF, Council on Accreditation (COA) or The Joint Commission (formerly JCAHO)) and licensed by the state, district or territory (if applicable) to provide residential treatment for medical conditions, mental health conditions and/or substance use disorder. If the RTC is not accredited nationally, or if state licensure is available but not obtained, the facility must be Medicare certified. Accredited health care facilities (see page (Applies to printed brochure only) for exclusions.) provide 24-hour residential evaluation, treatment, and comprehensive specialized services relating to the individual's medical, physical, mental health, and/or substance use disorder therapy needs.
- Partial Hospital Program or Intensive Outpatient Treatment Facility
- Is licensed by the state, district or territory (if applicable) (See Section 5(e), Services we do not cover, page (Applies to printed brochure only));
- And is accredited for behavioral health services by a nationally recognized organization.
Specialty care: If you have a chronic or disabling condition and
- lose access to your specialist because we drop out of the Federal Employees
Health Benefits (FEHB) Program and you enroll in another FEHB plan; or
- lose access to your PPO specialist because we terminate our contract with your specialist for reasons other than for cause,
you may be able to continue seeing your specialist and receiving any PPO benefits for up to 90 days after you receive notice of the change. Contact us or, if we drop out of the Program, contact your new plan.
If you are in the second or third trimester of pregnancy and you lose access to your PPO specialist based on the above circumstances, you can continue to see your specialist and your PPO benefits will continue until the end of your postpartum care, even if it is beyond the 90 days.
- 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 800-821-6136. For members residing in Delaware, Florida, Louisiana, Maryland, North Carolina, Oklahoma, Texas, Virginia, Washington DC, West Virginia and Wisconsin, call UnitedHealthcare Clinical Services at 877-585-9643. If you are new to the FEHB Program, we will reimburse you 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;
- 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 in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply. In such cases, the hospitalized person's benefits under the new plan begin on the effective date of enrollment.
You need prior Plan approval for certain services
The pre-service claim approval processes for inpatient hospital admissions (called precertification) and for other services, are detailed in this Section. A pre-service claim is any claim, in whole or in part, that requires approval from us in advance of obtaining medical care or services. In other words, a pre-service claim for benefits (1) requires precertification or preauthorization and (2) will result in a reduction of benefits if you do not obtain precertification or preauthorization.
- Inpatient hospital admission
(including Residential Treatment Centers, Skilled Nursing Facility, Long Term Acute Care, or Rehab Facility)
Precertification is the process by which – prior to your inpatient hospital admission – we evaluate the medical necessity of your proposed stay and the number of days required to treat your condition. Unless we are misled by the information given to us, we won’t change our decision on medical necessity.
In most cases, your physician or hospital will take care of requesting precertification. Because you are still responsible for ensuring that your care is precertified, you should always ask your physician or hospital whether or not they have contacted us.
How to precertify an admission to a Hospital, Residential Treatment Centers, Skilled Nursing Facility, Long Term Acute Care or Rehab Facility
First, you, your representative, your physician or your hospital must call Conifer Health Solutions (Medical Management Service – IMMS) before a hospital admission, residential treatment center admission, or services requiring precertification are rendered. The toll-free number is 800-242-1025. For members residing in Delaware, Florida, Louisiana, Maryland, North Carolina, Oklahoma, Texas, Virginia, Washington DC, West Virginia and Wisconsin, call UnitedHealthcare Clinical Services at 877-585-9643.
For admissions to Skilled Nursing Facilities, Long Term Acute Care Facilities, or Rehabilitation Facilities please call OrthoNet to precertify at 877-304-4419. For members residing in Delaware, Florida, Louisiana, Maryland, North Carolina, Oklahoma, Texas, Virginia, Washington DC, West Virginia and Wisconsin, call UnitedHealthcare Clinical Services at 877-585-9643.
Next, provide the following information:
- enrollee’s name and plan identification number;
- patient’s name, birth date, and phone number;
- reason for hospitalization, proposed treatment, or surgery;
- name and phone number of admitting doctor;
- name of hospital or facility; and
- number of days requested for hospital stay.
We will then tell the doctor and/or hospital the number of approved inpatient days and we will send written confirmation of our decision to you, your doctor, and the hospital.
You must get precertification for certain services. Failure to do so will result in the following penalties:
- We will reduce our benefits for the Inpatient Hospital stay, Long Term Acute Care stay or Rehabilitation Facility stay by $500 if no one contacts us for precertification. If the stay is not medically necessary, we will only pay for any covered medical services and supplies that are otherwise payable on an outpatient basis.
- We will reduce our benefits for the Skilled Nursing Facility stay if no one contacts us for precertification. If the stay is not medically necessary we will not pay any benefits.
You do not need precertification in these cases:
- You are admitted to a hospital outside the United States;
- You have another group health insurance policy that is the primary payor for the hospital stay; or
- Medicare Part A is the primary payor for the hospital stay.
Note: If you exhaust your Medicare hospital benefits and do not want to use your Medicare lifetime reserve days, then we will become the primary payor and you do need precertification.
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 preauthorization. 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.
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 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 800-821-6136. You may also call OPM’s FEHB 2 at 202-606-3818 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, then call us at 800-821-6136. 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).
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.
- The Federal Flexible Spending Account Program – FSAFEDS
- Health Care FSA (HCFSA) – Reimburses you for eligible out-of-pocket health care expenses (such as copayments, deductibles, physician prescribed over-the-counter drugs and medications, vision and dental expenses, and much more) for you and your tax dependents, including adult children (through the end of the calendar year in which they turn 26).
- FSAFEDS offers paperless reimbursement for your HCFSA through a number of FEHB and FEDVIP plans. This means that when you or your provider files claims with your FEHB or FEDVIP plan, FSAFEDS will automatically reimburse your eligible out-of-pocket expenses based on the claim information it receives from your plan.
- 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 phone us within two business days following the day of the emergency admission, even if you have been discharged from the hospital. If you do not phone the Plan within two business days, penalties may apply - see Warning under Inpatient hospital admission earlier in this Section and If your hospital stay needs to be extended below.
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 confinement, the newborn is considered a patient in his or her own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.
Confinements of infants in the neonatal care unit require preauthorization. Your provider needs to call us at 800-821-6136 or visit www.geha.com. For members residing in Delaware, Florida, Louisiana, Maryland, North Carolina, Oklahoma, Texas, Virginia, Washington DC, West Virginia and Wisconsin call UnitedHealthcare Clinical Services at 877-585-9643.
- If your hospital stay needs to be extended
If your hospital stay - including for maternity care - needs to be extended, you, your representative, your doctor or the hospital must ask us to approve the additional days. If you remain in the hospital beyond the number of days we approved and did not get the additional days precertified, then:
- for the part of the admission that was medically necessary, we will pay inpatient benefits, but,
- for the part of the admission that was not medically necessary, we will pay only medical services and supplies otherwise payable on an outpatient basis and will not
pay inpatient benefits.
- Other services that require preauthorization
Some surgeries and procedures, services and equipment require precertification or preauthorization. GEHA has coverage policies for many services and procedures; refer to www.geha.com/coverage-policies for a complete list.
For members residing in the following states, your provider must call UnitedHealthcare Clinical Services at 877-585-9643 for any services listed below, with the exception of those marked with an asterisk: Delaware, Florida, Louisiana, Maryland, North Carolina, Oklahoma, Texas, Virginia, Washington DC, West Virginia and Wisconsin.
For the asterisked (*) services, and for all other members, you or your provider need to call us at 800-821-6136 or visit www.geha.com for preauthorization information:
- ACI (Autologous Cultured Chrondrocytes), also called Genzyme tissue repair (or Carticel) for knee cartilage damage;
- Ablative and surgical treatment of venous insufficiency including sclerotherapy and microphlebectomy;
- Advanced wound therapy provided in an outpatient setting such as skin substitutes, negative pressure wound therapy (wound vac systems), hyperbaric oxygen therapy (HBO);
- *Applied behavioral therapy;
- Back/spine surgeries;
- Bariatric procedures;
- Blepharoplasty or any other type of eyelid surgery or brow lift;
- Botox injections;
- Breast reconstruction except immediate reconstruction for diagnosis of cancer;
- Certain prescription drugs including Total Parenteral Nutrition;
- Chronic dialysis provided at a dialysis unit, outpatient hospital facility or in the home;
- Coma stimulation;
- Durable medical equipment (DME);
- ECT (electroconvulsive therapy);
- Enteral nutrition;
- Epidural injections;
- Experimental/investigational surgery or treatment;
- Facet injections;
- Genetic testing;
- Growth hormone therapy (GHT);
- Gynecomastia treatment-cosmetic (see mammoplasty);
- *High tech outpatient radiology/imaging;
- Home health services provided by a qualified medical social worker (M.S.W.);
- Injectable drugs for arthritis, psoriasis or hepatitis;
- Injectable hematopoietic drugs (drugs for anemia, low white blood count);
- Inpatient hospital mental health and substance use disorder benefits, inpatient care at residential treatment centers and intensive day treatment;
- Intrathecal pump insertion for pain management (morphine pump, baclofen pump);
- Low-dose computed tomography (LDCT);
- Mammoplasty, reduction (unilateral/bilateral);
- Mastectomy performed prophylactically;
- Morbid obesity surgeries;
- *Non-surgical outpatient cancer treatment, including chemotherapy and radiation;
- *Organ and tissue transplant procedures;
- Orthognathic surgery (jaw), including TMJ;
- Other selected therapy services including cardiac and pulmonary rehabilitation;
- Prosthetic devices;
- Psychological testing;
- Rhinoplasty and septoplasty;
- Scar revisions;
- Skilled Nursing: Outpatient - Includes Home Skilled Nursing Care, intravenous (IV) therapy, and TPN;
- Sleep studies (in-lab) attended or performed in a heath care facility (home sleep studies do not require preauthorization);
- Speech generating devices;
- Surgical correction of congenital anomalies;
- Surgical treatment of gender dysphoria;
- Surgical treatment of hyperhidrosis (benefits will not be approved unless alternative therapies such as botox injections or topical aluminum chloride and pharmacotherapy have been unsuccessful);
- Sympathectomy by thoracoscopy or laparoscopy;
- TMS (Transcranial Magnetic Stimulation);
- *Transplants, except cornea (for kidney transplant notification instructions, refer to Section 5(b), page (Applies to printed brochure only), under Organ/Tissue Transplants);
- UPPP Uvulopalatopharyngoplasty;
- *Ventricular assistive device (VAD) including post-hospital device supplies;
- Vision therapy; and
- Other surgeries, as identified by the Plan.
- Radiology/Imaging procedures preauthorization
Radiology preauthorization is the process by which prior to scheduling specific imaging procedures we evaluate the medical necessity of your proposed procedure to ensure the appropriate procedure is being requested for your condition. In most cases your physician will take care of preauthorization. Because you are still responsible for ensuring that we are asked to preauthorize your procedure, you should ask your doctor to contact us.
The following outpatient radiology/imaging services need to be preauthorized:
- CT - Computerized Axial Tomography;
- MRI - Magnetic Resonance Imaging;
- MRA - Magnetic Resonance Angiography;
- NC - Nuclear Cardiac Imaging Studies; and
- PET - Positron Emission Tomography.
How to preauthorize a radiology/imaging procedure:
For outpatient CT, MRI, MRA, NC and PET studies, you, your representative or your doctor must call eviCore Healthcare before scheduling the procedure. The toll-free number is 866-879-8317. Provide the following information: patient's name, plan identification number, birth date, requested procedure, clinical support for request, name and phone number of ordering provider. Once you have received preauthorization approval, see below for scheduling services.
After you obtain preauthorization from eviCore Healthcare, you may be contacted for optional assistance in scheduling your radiology/imaging procedure(s).
You will not be contacted for this service if you have other primary coverage, Medicare A and B primary or Medicare Part B only.
You must get preauthorization for certain services. Failure to do so will result in a reduction of our benefits for these procedures by $100 if no one contacts us for preauthorization. If the procedure is not medically necessary, we will not pay any benefits.
You do not need preauthorization in these cases:
- You have another health insurance policy that is the primary payor, including Medicare Part A and B or Part B only;
- The procedure is performed outside the United States;
- You are an inpatient in a hospital or observation stay; or
- The procedure is performed as an emergency.
- 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.
If you disagree with our pre-service claims decision
If you have a pre-service claim and you do not agree with our decision regarding precertification of an inpatient admission or preauthorization of other services, you may request a review in accord with the procedures detailed below.
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.
- 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:
- Precertify your hospital stay or, if applicable, arrange for the health care provider to give you the care or grant your request for preauthorization for a service, drug, or supply; or
- 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.
- Write to you and maintain our denial.
- 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 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 phone, electronic mail, facsimile, or other expeditious methods.
- 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.
For covered services you receive by physicians and hospitals outside the United States and Puerto Rico, send a completed Overseas Claim Form and the itemized bills to: GEHA, Foreign Claims Department, P.O. Box 21542, Eagan, MN 55121. Obtain Overseas Claim Forms from www.geha.com.
Precertification is not required when procedures are performed or you are admitted to a hospital outside of the United States. However, the procedure/service to be performed, the number of days required to treat your condition, and any other applicable benefit criteria, will be reviewed for benefit eligibility and/or medical necessity.
If you have questions about the processing of overseas claims, contact us at 877-320-9469 or by email at firstname.lastname@example.org. If possible, include a receipt showing the exchange rate on the date the claimed services were performed. Covered providers outside the United States will be paid at the PPO level of benefits, subject to deductible and coinsurance.
When members living abroad are stateside and seeking medical care, contact us at 800-821-6136, or visit www.geha.com to locate an in-network provider. If you utilize an out-of-network provider, out-of-network benefits would apply.