Provider care team
For claims issues, call us:
844-GHP-PROV (844-447-7768)
Authorization forms and resources for out-of-network providers
Complete authorizations online with Cohere
Switch from faxing to Cohere for your authorization requests including inpatient, outpatient and behavioral health.
Enjoy timesaving benefits like automatic approvals and guided submissions, only available through the Cohere portal.
Register in minutes and access benefits for your entire practice.
Note: Continue submitting high-end radiology service requests through HealthHelp.
Radiology service requests and authorizations
Continue submitting high-end radiology service requests through HealthHelp.
Pharmacy forms and resources
Geisinger Gold (Medicare)
- Erythropoietin Stimulating Agents (ESA) Authorization Form
- Geisinger Gold/Medicare Vaccine Coverage
- Geisinger Gold Nonpar Provider Appeal Process Form
- Hepatitis C Pharmacy Benefit Drug Authorization Form
- Medical Benefit Outpatient Drug Authorization Form
- Medical Drug Prior Authorization List (Commercial/Marketplace/Medicare/CHIP)
- Online Prior Authorization Portal (PromptPA)
- Opioid Cumulative Morphine Equivalent Dose (MED) Authorization Form
- Universal Pharmacy Benefit Drug Authorization Form
Geisinger Health Plan/Geisinger Marketplace (Commercial)
- Erythropoietin Stimulating Agents (ESA) Authorization Form
- Hepatitis C Pharmacy Benefit Drug Authorization Form
- Medical Benefit Outpatient Drug Authorization Form
- Medical Drug Prior Authorization List (Commercial/Marketplace/Medicare/CHIP)
- Non-Preferred Buprenorphine Pharmacy Benefit Drug Authorization Form
- Online Prior Authorization Portal (PromptPA)
- Opioid Cumulative Morphine Equivalent Dose (MED) Authorization Form
- Specialty Drug List
- Universal Pharmacy Benefit Drug Authorization Form
GHP Family (Medical Assistance)
Statewide PDL forms
- Search Statewide Preferred Drug List
- Acne Agents, Oral
- Acne Agents, Topical
- Alzheimers Agents PEAP
- Analgesics, Non-Opioid Barbiturate Combinations PEAP
- Analgesics, Opioids Long-Acting PEAP
- Analgesics, Opioids Short-Acting PEAP
- Androgenic Agents PEAP
- Antibiotics- GI and Related Agents
- Antidepressants, Other PEAP
- Antifibrotic Respiratory Agents
- Antihemophilia Agents PEAP
- Antihyperuricemics - Krystexxa PEAP
- Antipsychotics PEAP
- Antivirals- CMV
- Benzodiazepines PEAP
- Blood Glucose Meters and Test Strips PEAP
- Bone Density Regulators PEAP
- Botulinum Toxins PEAP
- Colony Stimulating Factors PEAP
- Continuous Glucose Monitoring Factors
- COPD Agents- Daliresp
- Cytokine and CAM Antagonists PEAP
- Dupixent PEAP
- Enzyme Replacements, Gaucher Disease PEAP
- Erythropoiesis Stimulating Agents
- Estrogens
- GI Motility, Chronic
- Growth Hormones PEAP
- Hepatic and Biliary Agents
- Hepatitis C Agents
- Hereditary Angioedema Agents PEAP
- Hypoglycemics- Incretin Mimetics-Enhancers
- Immunomodulators, Atopic Dermatitis
- Immunosuppressives, Oral - Lupkynis PEAP
- Intra-Articular Hyaluronates PEAP
- Iron Chelating Agents PEAP
- Lipotropics, Other
- Macular Degeneration Agents PEAP
- Migraine Acute Treatment Agents
- Migraine Prevention Agents
- Monoclonal Antibodies - Anti-IL, Anti-lgE, Anti-TSLP
- Multiple Sclerosis PEAP
- Natalizumab
- NSAIDs - Ketorolac PEAP
- Obesity Treatment Agents
- Oncology Agents, Oral PEAP
- Opioid Use Disorder Treatments
- Pituitary Suppressive Agents, LHRH PEAP
- Potassium Removing Agents PEAP
- Proton Pump Inhibitors Less Than 6 y.o. PEAP
- Pulmonary Arterial Hypertension Agents Oral and Inhaled
- Stimulants and Related - Other PEAP
- Stimulants and Related Agents - Provigil, Nuvigil, Sunosi, and Wakix 01-01-20
- Thalidomide and Derivatives PEAP
- Thrombopoietics PEAP
- Ulcerative Colitis Agents
- Urea Cycle Disorder Agents PEAP
- VMAT2 Inhibitors PEAP
Behavioral health forms and resources
Behavioral health providers should have a direct contract and be credentialed with GHP to see GHP patients.
Questionnaires
Forms
- Behavioral health outpatient prior authorization request form
- Complete online through Cohere.
- Behavioral health services review form [inpatient admissions (any type), partial hospitalization program and intensive outpatient program]
- Behavioral health ABA request form
- Complete online through Cohere.
- Effective Jan. 1, 2023, in-network applied behavioral analysis for autism with a valid diagnosis no longer needs prior authorization. For coverage or prior authorization queries, call our care connector team at 888-839-7972.
- Behavioral health ECT request form
- Complete online through Cohere.
- Behavioral health psychological testing request form
- Complete online through Cohere.
- Behavioral health TMS request form
- Complete online through Cohere.
- Behavioral health discharge form
Other forms and resources
In alphabetical order
Ambulance
- Non-Emergent Transport Form
- Complete online through Cohere.
- Non-Emergent Ambulance Transportation (NEAT) update
DME
- DME ordering through Tomorrow Health
- Effective Jan. 1, 2021, place DME orders with Tomorrow Health.
- DME Precertification Additional Code Form
- Complete online through Cohere.
- DME Precertification Form
- Complete online through Cohere.
- DME Authorization Change Form
- Complete online through Cohere.
- DME Re-Certification Form
- Complete online through Cohere.
Home health
- Effective Jan. 16, 2023, you can submit home health prior authorization requests through Cohere Health.
- Home Health Services Request Form
- Complete online through Cohere.
Inpatient
Medical benefit outpatient drug
Oncology benefits management program
- Chemotherapy Prior Authorization Form
- Complete online through OncoHealth OneUM.
- Radiotherapy Prior Authorization Form
- Complete online through OncoHealth OneUM.
Outpatient rehabilitation
- Effective Jan. 16, 2023, you can submit outpatient therapy services prior authorization requests through Cohere Health
- Outpatient Rehabilitation Therapy Services Request Form
- Complete online through Cohere.
Other outpatient services
- Effective Oct. 1, 2023, you can submit prior authorization requests for most outpatient services through Cohere Health.
- Outpatient Prior Authorization Form
- Complete online through Cohere.
Referrals (including PEBTF)
Shift care and private duty nursing
- Shift Care Notification Form
- Agencies must submit member status changes for shift care services within 5 days.
- Private Duty Nursing/Shift Care Form
- Prescribing providers should relay patient and provider information to GHP Medical Management for initial shift care/private duty nursing referrals.
Additional forms and resources
- Newborn Information Form
- NOMNC-Sample Instructions
- Open Negotiation Period Form
- Organizational Determination Form
- Prior Authorization List
- Request for Independent External Review of an Adverse Benefit Determination
- Members can use this form to request the Pennsylvania Insurance Department review a healthcare coverage decision by their plan. Commercial plans only.
- Physician Certification for Expedited Review
- Providers can use this form to certify that normal timeframes for a healthcare coverage decision review would seriously jeopardize the life or health of the covered person or would jeopardize the covered person's ability to regain maximum function.
Provider support
Provider account management
Other provider support
Access links for Availity®, NaviNet®, InstaMed®, pharmacy support, case management and more