GHI HMO SELECT Main numbers: 1-877-244-4466 (877 –2GHI HMO) Medical Director 1-845-340-2300 Mental Health/Substance Abuse Imaging- NYMI Magellan Behavioral Health 1-800-533-1206 1-800-836-2256 Laboratory- Laboratory Corporation of America (see attached laboratory policy) 1-800-854-5940(Specimen Pick-up) 1-800-223-0631(Results) 1-800-631-5250(Ask for Supply Department) Pharmacy- Please refer to the attached list of medications requiring pre-authorization. When contacting GHI HMO Select directly, follow prompts to reach the following departments: Ø Medical Emergency Assistance Ø Member Services (benefits, eligibility, PCP changes, enrollment, etc.) Ø Provider Relations Ø Medical Management (pre-authorization, referrals, in-patient admissions) Claim Submission Electronic Claims Ø Utilize Carrier ID #25531 when submitting to GHI HMO Select electronically Ø When submitting electronically via CareInsite-MedLink, you must utilize the complete name of “GHI HMO Select” in the appropriate data field. Ø GHI HMO Select does not accept electronic claims from National Data Corporation (NDC). Please utilize either Envoy-NEIC or CareInsite-MedLink. Paper Claims Ø Please forward HCFA forms to the following address: Ø GHI HMO Select, Inc. Ø P.O. Box 4141 Ø Kingston, NY 12402 Referral Process Ø GHI HMO SELECT members must have a valid paper referral form in order to visit a specialist. Ø A Referral is valid for six months for a maximum of 3 visits. Ø Up to 6 visits may be authorized for physical therapy. Once the 6 visits are utilized, the physical therapist must submit a treatment plan to GHI HMO directly in order to obtain additional authorization. Ø A Referral to a non-participating provider requires pre-authorization. Ø Paper referrals are for consultations only. Any additional services performed by the specialist may require pre-authorization from GHI HMO Select’s Medical Management Department*. Referral Form Fax Number After issuing a referral, fax a copy of the referral form to 1-888-382-1034 so the referral information can be entered prior to the claim being received. If you prefer, you may mail a copy of the referral to GHI HMO Select at: GHI HMO Select, Inc. 120 Wood Road PO Box 4282 Kingston, NY 12402 Pre-authorization Process Please refer to the attached list of services that require pre-authorization from GHI HMO’s Medical Management Department. Pre-authorization requests may be phoned in using the main number above. However, GHI HMO Select prefers that you fax your requests, using the attached form, to the number below whenever possible. Pre-authorization Fax Number Fax all authorization requests to 1-877-508-2643 using the pre-authorization request form attached. Allow a minimum of 5 business days for GHI HMO’s Medical Management staff to issue the pre-authorization number. The medical management staff will be able to process your request a great deal faster if the pre- authorization forms are filled out completely and if all pertinent office/operative records are submitted along with the request form. **Contact ProMedCo at 845-340-4645 with any questions regarding GHI HMO Select. Office Based Diagnostic Testing - Laboratory GHI HMO has developed relationships with recognized vendors of laboratory services to ensure the highest quality and consistency. It is expected that most diagnostic testing will be completed by those providers and performance standards have been developed regarding both accessibility and timely reporting. We do recognize that some testing is best completed while the patient is in the office, to most efficiently determine their care needs. GHI HMO also appreciates that as health care systems and groups of providers have progressively integrated, the completion and communication of these diagnostic services are tightly woven into that integration. As a result, GHI HMO will support the following office based diagnostic testing as a provider and member convenience: • Laboratory testing as per office CLIA certification Providers of these services are expected to maintain the necessary certifications to ensure quality control and consistency of results. Studies will only be covered for members who are otherwise under the care of a provider in that practice. Reimbursement for such testing will be cost based and will not necessarily be at the same rate as other services. In most cases, our reimbursement will approximate 70% of the Medicare schedules. GHI HMO fully supports those practices that choose to send all diagnostic testing to our recognized vendors. Convenient sample pick-ups can be arranged at your office and you will be reimbursed for your collection costs. In addition, draw stations and imaging facilities are located within thirty minutes of most of our member’s home locations. Whether you choose to utilize the services of our preferred vendors or perform these services in your own practice, our primary goal is to ensure our members receive the diagnostics they require in a manner that facilitates the care you deliver and keeps their premiums at an affordable level. Pharmacy Benefit Prior Authorization and Dispensing Policies Prior authorization by GHI HMO is required for: • Fertility drugs • Tretinoin Topical (Retin-A) for Age>35 • COX-II Inhibitors (Celebrex/Vioxx) • Sporanox • Growth hormones • Interferons • Glatiramer Acetate • Alglucerase Pharmaceuticals which may have restricted dispensation include: • Medications for erectile dysfunction -- limited to 6 doses / month Exclusions based on member contract: • Prescription drugs not obtained at a GHI HMO participating pharmacy • Initial prescriptions or refills in excess of a 34 day supply or one month's cycle of any oral contraceptive drug (Mail order available for up to 3 months supply) • Drugs related to non-covered medical services • OTC drugs • Contraceptive devices such as condoms and spermacidal agents • Drugs not approved by the FDA • Prescription drugs for diet or weight control including anorexic agents • Medications for cosmetic purposes only • Other medications excluded in the member’s specific prescription drug plan Effective 1/1/00 PRIOR AUTHORIZATION PROCESS Prior authorization is intended to ensure the requested service is covered by the member’s benefit and that the provider of service is participating with GHI HMO. Services will also be reviewed to ensure that the most appropriate setting is being utilized and to identify those members who may benefit from our Care Management programs. Prior Authorization is only required for the following services: • All facility based care including Inpatient, Ambulatory Surgery, Inpatient Rehabilitation and Skilled Nursing Facilities • Home Care and Hospice • DME over $250 and all orthotics • Physical therapy (by provider of service) after initial six visits approved by PCP • Cardiac Rehabilitation (by provider of service) after initial assessment • Reconstructive vs. Cosmetic Surgery • Non-participating providers • Specialist to Specialist referrals • Mental Health Services (through Merit Behavioral Care 800-836-2256) • Services requiring Care Management support: − Care outside the GHI HMO service area − Growth Hormone Therapy − Factor VIII & IX Therapy − Alglucerase for Gaucher’s Disease − Beta-Interferon and Glatiramer Acetate for Multiple Sclerosis − Sleep Studies − Pain Management • Referrals for MRIs, MRAs or CT Scans in the NYMI service area require prior authorization by calling 800-533-1206 (Columbia, Dutchess, Greene, Orange, Putnam, Rockland, Ulster, Sullivan, Westchester, New York City). Referrals for MRIs, MRAs or CT Scans for members with PCPs in any other county, must be coordinated with the performing radiologist to ensure the most appropriate imaging study is being provided. Required prior authorization can be obtained by faxing a Prior Authorization Form with supporting documentation to 1-877-508-2643. An authorization number must be obtained from GHI HMO prior to rendering the service to ensure reimbursement. In the event of emergency, GHI HMO must be contacted within 24 hours, or on the next business day.