Frequently asked questions

If you require hospitalization following an emergency, your emergency department doctor should notify Geisinger Health Plan within 48 hours or the next business day, whichever is later, of the emergency services you received. 

After you have been discharged from an emergency room, any additional follow-up medical services must be authorized by your physician, preferred OB/GYN physician or behavioral health manager (for behavioral health follow-up services) for maximum coverage.

Emergency services provided by non-preferred providers will be covered only until Geisinger Health Plan determines your condition has stabilized and your care can be safely transferred to a participating provider. You have the option to receive care with a non-preferred provider; however, you will have significantly higher cost-sharing at your out-of-network benefit level.

When you go to the emergency room, you will be required to pay an applicable emergency room copays, but they will be waived if you are directly admitted to the hospital. 

You may be placed in an observation bed after an emergency room visit. This is not the same as an admission. If you are kept for observation and later discharged without being admitted, you will be charged an emergency room copay.

Precertification is a process for PPO members where services are reviewed for medical necessity by your health plan prior to being performed or provided:

• All non-emergency hospital admissions
• Certain outpatient procedures 
• Certain medications

If you choose a preferred provider for the above services, your provider is responsible for obtaining precertification from your health plan.

However, if you choose a non-preferred provider for the above services, the non-preferred provider may obtain precertification from your health plan, but it is ultimately your responsibility to make sure precertification occurs prior to the services being performed.

To obtain precertification from the health plan, call the customer service number found on the back of your member ID card. Our medical management staff will review your request. You will receive a phone call and written response when your request has been approved or denied.

Note: A service must be “medically necessary” to be covered and meet the terms and conditions in your benefit documents.

Prior authorization is a process for HMO members where your health plan reviews whether a procedure or service is medically necessary before being performed. This process is initiated by your participating provider unless otherwise indicated in your benefit documents as being a member responsibility. Your provider should assist you with getting approval before treatment. Receiving prior authorization does not guarantee payment: the service must be medically necessary and meet the terms and conditions of your benefit documents.

You may call the customer service number found on the back of your member ID card for an explanation of what covered services require prior authorization.

You do not need a referral to visit a:

• Participating OB/GYN provider
• Participating mental health provider or facility for outpatient services (in most cases)
• Participating alcohol/chemical dependency provider for outpatient and/or inpatient substance abuse services

To see if you need a referral, call the customer service number found on the back of your member ID card.

No. These services are not covered:

• Routine eye exams
• The purchase, fitting or adjustment of corrective devices including, but not limited to, eyeglasses, contact lenses and hearing aids

An exam to diagnose the refractive error of the eye may be covered by supplemental coverage. To see if you are covered, view your plan's Benefits and Services Details Document.

Urgent care is the immediate treatment of urgent but not life-threatening conditions. You can receive urgent care from your primary care provider. Urgent care facilities can also provide walk-in care, and they offer evening and weekend hours. If you need urgent care, contact your primary care provider's office or Tel-A-Nurse for advice.

Find an urgent care facility near you.

Emergent care is needed when there is an immediate threat to a person's life or someone else's life, a threat of grave disability or active childbirth. In these cases, dial 911 immediately.  

When you travel outside the Health Plan’s 42-county service area, these services are covered:

• Urgent care services
• Emergency services

Non-emergency services by non-participating providers are not covered unless approved in advance by a Health Plan medical director. To get approval, call the customer service number on the back of your member ID card.

Yes. Transportation by land or air ambulance is covered in an emergency or when approved by a Health Plan medical director.

You must make every reasonable effort to:
• Request a transport by a participating transportation provider to a participating provider
• Assist in such transfer to the extent physically able or medically possible

Members who seek urgent or emergency care outside the Health Plan network will be returned to a network facility as soon as the emergency is over and the member’s condition is stable.

Routine office visits
Visits to your primary care provider (PCP) require a copay. The amount you pay is shown on your Schedule of Benefits.

Emergency services
You pay your emergency room copay for emergency services up to an annual aggregate maximum copayment amount. To see your copay amounts, view your Schedule of Benefits.

Copays will be waived if you have an emergency and are admitted to the hospital as an inpatient. 

If your PCP or Tel-A-Nurse refers you to the emergency room because your doctor's office couldn’t see you during normal office hours, you pay an office visit copay, not an emergency room copay.

Our local discounts program offers members discounts on local health-related services, including fitness center memberships, massage, chiropractic, eyeglasses, vision care and more.

All you need is your Geisinger Health Plan member ID card. No referral is necessary.

A formulary exception is a request for the Health Plan to cover a drug not currently available on our formulary. Pennsylvania state law requires a provider to initiate a formulary exception. 

If you need an exception, a Health Plan representative can review your need and contact your provider. To begin the process, you can:

• Send a secure message
• Call the customer service number on the back of your member ID card.