Managing health coverage decisions

Contact us to request coverage for the medical care you need. You, your doctor or your representative can do this.

• Call:
  800-544-3907 (TDD: 711)
  
  
• Fax:
  570-271-5534
  
  
• Write:
  Geisinger Gold
  Medical Management Department
  100 N. Academy Ave.
  Danville, PA 17822-3218

Standard coverage decision

We generally provide an answer within 14 days of receiving your request.

Fast coverage decision

For urgent health needs, request a fast coverage decision and we'll respond within 72 hours. You must meet 2 requirements:

1. You can get a fast coverage decision only if you're asking for coverage for medical care you have not yet received. You can't get a fast coverage decision if your request is about payment for medical care you've already received.
2. You can get a fast coverage decision only if using standard deadlines could cause serious harm to your health or hurt your ability to function.

If your doctor tells us your health requires a fast coverage decision, we'll give you one.

If you request a fast coverage decision on your own, without your doctor's support, we'll determine if it's necessary based on your health condition.

If your condition doesn't meet the requirements for a fast coverage decision, we'll send you a letter explaining this and will proceed with standard deadlines. The letter will include:

• Confirmation that we'll approve a fast coverage decision if your doctor requests it
• Instructions on filing a "fast complaint" if you disagree with our decision to use standard deadlines instead of the fast coverage decision you requested

Fast coverage decisions

Generally, for a fast coverage decision, we'll give you our answer within 72 hours.

• Under certain circumstances, we can take up to 14 more calendar days.
• If we need extra time, we'll notify you in writing.
• If you believe we shouldn't take extra days, you can file a fast complaint.
• We'll respond to your complaint within 24 hours.
• If we don't provide an answer within 72 hours (or by the extended deadline), you have the right to appeal.

If our answer is yes to part or all of what you requested, we must authorize or provide the coverage within 72 hours after receiving your request. If we extended the decision time, we'll provide the coverage by the end of that extended period.

If our answer is no, we'll send you a detailed written explanation.

Standard coverage decisions

Generally, for a standard coverage decision, we'll give you our answer within 14 days of receiving your request.

• Under certain circumstances, we can take up to 14 more calendar days.
• If we need extra time, we'll notify you in writing.
• If you believe we shouldn't take extra days, you can file a fast complaint.
• We'll respond to your complaint within 24 hours.
• If we don't provide an answer within 14 days (or by the extended deadline), you have the right to appeal. Step 3 below explains how to make an appeal.

If our answer is yes, we must authorize or provide the coverage within 14 days after receiving your request. If we extended the decision time, we'll provide the coverage by the end of that extended period.

If our answer is no, we'll send you a written explanation.

If we say no, you have the right to ask us to reconsider by making an appeal. An appeal means trying again to get the medical care coverage you want. To appeal, contact us.

• Write:
  Geisinger Gold
  Appeal Department
  100 N. Academy Ave.
  Danville, PA 17822-3220
  
  
• Fax:
  570-271-7225
  
  
• In person:
  Geisinger Health Plan
  108 Woodbine Lane
  Danville, PA 17821

Standard (7-day review) appeals must be in writing. For expedited appeals due to urgent health needs, call 800-498-9731 (TTY: 711), 8 a.m. – 8 p.m. ET daily (Oct. 1 – Feb. 14) or weekdays (Feb. 15 – Sept. 30).