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Geisinger Health Plan Behavioral Health Professional Services Questionnaire, page 1

Moderate · 53/100Form Complexity Index

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What this form asks for

The AI fills all of it, from your answers or your documents.

The Geisinger Health Plan Behavioral Health Professional Services Questionnaire is a provider information form that documents a practitioner’s demographics, accepted age groups, languages, specialties, therapies/treatments offered, and conditions they are willing to treat. Geisinger Health Plan uses the responses to help members and referring providers identify appropriate behavioral health services and connect patients to the right care quickly. It is important because accurate selections improve directory/referral accuracy and ensure members can find providers who match their clinical needs and service preferences (e.g., telehealth, MAT, testing, PHP/IOP).

Fillable fields140

Pages5

Sections32

Questions that depend on earlier answers1

Form Complexity IndexModerate, 53/100

The AI checks your answers before you download

16 checks built for this form, so a wrong date or a missing answer is caught before anyone else sees it.

Provider Name presence and legal-name format

Validates that the Provider name field is completed and contains a plausible full legal name (e.g., first and last name, not only initials or a single word). This is important for directory accuracy, credentialing alignment, and avoiding duplicate or ambiguous listings. If validation fails, the submission should be rejected or routed for manual review with a request to provide the full legal provider name.

Credentials (degree/license/designation) required and standardized

Checks that Credentials are provided and match an allowed set or pattern (e.g., MD, DO, PhD, PsyD, LCSW, LPC, LMFT, CRNP) and are not free-text placeholders like "N/A" when a credential is required. Standardizing credentials improves search/filtering and reduces misrepresentation risk. If invalid, the form should prompt the submitter to select/enter a recognized credential or be flagged for verification.

Provider NPI format and checksum validation

Ensures the Provider NPI is present and is exactly 10 digits, numeric-only, and passes the NPI Luhn check-digit algorithm. This prevents directory mismatches and downstream claim/referral routing errors. If validation fails, block submission and request correction because an invalid NPI can break provider identification.

Address completeness and deliverability checks

Validates that Address includes required components (street, city, state, ZIP) and that ZIP is 5 digits (or ZIP+4 in a valid format). A complete address is necessary for member access, mapping, and network directory compliance. If incomplete or malformed, the submission should be rejected or returned for correction.

County required and consistent with address

Checks that County is provided and, when possible, is consistent with the submitted ZIP/city/state (e.g., via a ZIP-to-county reference). This supports accurate regional directory listings and referral routing. If the county is missing or inconsistent, flag for correction or manual review to prevent incorrect geographic placement.

Group Name required when applicable and not conflicting with provider name

Validates that Group Name is completed when the submission indicates a group practice (or when multiple practitioners are implied) and that it is not identical to the Provider name unless the provider is a sole proprietor. This reduces duplicate listings and clarifies whether services apply to an individual or a group. If validation fails, prompt the submitter to clarify the practice entity name.

And 10 more checks

Listing Phone Number format and plausibility
Fax number format validation (if provided/required)
Email address format and domain validation
Age groups selection required (at least one checked)
Language selection integrity and 'Other' specification requirement
Specialization selection consistency with services offered
Services/therapies selection required (at least one checked)
Condition willingness-to-treat selection required and 'Other' completion
PHP/IOP grid completeness and internal consistency
Attestation signature and date required; date format and not in the future

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How to Fill Out GHP BH Services Questionnaire (HPM50) Online for Free in 2026

What the AI walks you through.

Enter provider and practice identifiers: provider name, credentials, NPI, address, county, group name, and listing phone number.
Select the age groups the provider accepts (children, adolescents, adults, geriatrics).
Select all languages the provider can use to communicate with patients (including ASL and any “Other” language).
Check any areas of specialization (e.g., eating disorders, autism spectrum disorders, chronic pain, PTSD/trauma, LGBTQ+ issues).
Check all services/therapies/treatments offered (e.g., CBT/DBT/EMDR, medication management, testing, telehealth, MAT, TMS/ECT/esketamine, IBHS/PIBHS).
Indicate which conditions the provider would treat if referred and complete the PHP/IOP section (if applicable) by population and program type.
Review for accuracy, sign and date the affirmation, and provide contact details (email, relationship to practice, fax number), then submit via fax (570-271-5297) or email ([email protected]).

Common Mistakes in Completing GHP BH Services Questionnaire (HPM50)

The ones the AI is built to catch.

Submitting one form for multiple practitioners when services differ

People often assume one questionnaire covers the whole practice, even when individual clinicians offer different services, age groups, or specialties. This leads to inaccurate directory listings and misdirected referrals (patients may be sent to a provider who doesn’t actually offer the needed service). To avoid this, complete a separate form for each practitioner and only submit a single group form if every practitioner/location truly provides the same services.

Leaving provider identifiers incomplete (NPI, credentials, group name)

Common omissions include missing NPI, incomplete credentials (license type/degree), or an unclear group name. Missing identifiers can delay processing, prevent correct matching in payer systems, and cause directory inaccuracies. Always enter the full individual NPI, list credentials exactly as licensed (e.g., LCSW, LPC, PsyD, MD), and provide the legal group/practice name used for contracting.

Using the wrong phone number for the 'Listing Phone Number'

Many submit a back-office line, personal cell, or a number that is not used for new patient scheduling. The consequence is failed outreach, longer time-to-care, and member frustration when calls go unanswered or routed incorrectly. Use the primary public-facing scheduling/referral number and confirm it is monitored during business hours.

Providing an incomplete address or mismatching location details

People frequently omit suite numbers, use a billing address instead of the service location, or forget to include the county. This can misroute patients, create incorrect network directory entries, and complicate referrals that depend on geography. Enter the full service location address (including suite/floor), verify the county, and use a separate form per facility location if locations differ.

Misunderstanding age group checkboxes (checking all by default)

Some check every age group to appear broadly available, even if they do not treat children, adolescents, or geriatrics. This results in inappropriate referrals and potential scope-of-practice or competency concerns when members are matched incorrectly. Only check age groups you actively accept today, and ensure your selected services (e.g., PIBHS, ABA) align with the ages you treat.

Overstating language capabilities (especially ASL) without true proficiency

A common mistake is checking languages based on limited conversational ability or relying on ad-hoc interpretation, and checking American Sign Language without a qualified ASL-capable clinician. This can create access barriers, clinical misunderstandings, and member complaints when communication needs aren’t met. Only select languages in which you can provide clinical services competently, and use the 'Other' field to specify exact languages and any limitations.

Checking specialized services that are not actually offered at the listed site

Providers sometimes mark high-demand services (e.g., ECT, TMS, esketamine, methadone maintenance, neuropsych testing) even when they are offered by a different entity, require a separate program, or are not available at that location. This leads to incorrect referrals and delays when members discover the service isn’t available. Only check services you directly provide (or your group provides at that location) and that are currently operational, and avoid marking items that are only “planned” or “by referral elsewhere.”

Confusing 'services offered' with 'conditions you will treat'

People often check therapies/treatments (e.g., CBT, DBT, EMDR) but forget to indicate the conditions they will treat, or they check conditions without offering the corresponding services. This mismatch can cause poor referral matching and inappropriate expectations for members. Review both sections together and ensure your checked conditions align with your actual competencies and the treatments you provide.

Not completing 'Other' fields or using vague entries

When selecting 'Other' for languages or conditions, many leave it blank or write unclear terms (e.g., “all issues,” “most disorders”). This reduces the usefulness of the directory and can trigger follow-up requests for clarification. If you select 'Other,' specify the exact language/condition/service and keep it clinically clear and searchable (e.g., “Italian,” “Somatic symptom disorder,” “Perinatal loss counseling”).

Incorrectly filling out PHP/IOP grid (mixing levels of care and age bands)

The PHP/IOP section is easy to misread, and people may check boxes without confirming the program type (PHP vs IOP), diagnosis track (ED/MH/SUD), or the correct age category. This can result in referrals to programs that don’t exist or don’t serve that population, delaying care. Carefully verify each checked box corresponds to an actual program you offer, and confirm the correct level of care and age range before marking it.

Missing affirmation signature/date or incomplete submitter details

Forms are often returned without a signature, date, email, relationship to practice, or fax number. This can invalidate the attestation, delay directory updates, and require rework by the health plan. Ensure the authorized person signs and dates the form and provides complete contact details so Geisinger can confirm any unclear responses quickly.

Frequently Asked Questions About GHP BH Services Questionnaire (HPM50)

Is it really free for 7 days?

Yes. You pay $0 today. Cancel before Nov 1 and you are never charged. Keep it, and it is $19.99 a month for 5 fills of your GHP BH Services Questionnaire (HPM50).

Can I fill other forms too?

This plan is for your GHP BH Services Questionnaire (HPM50): your own AI agent fills it as often as 5 times a month. To fill other forms and upload your own, choose a Professional plan from your account.

How do I cancel?

From your account, in two clicks, any time. No email, no call.

How does the AI fill out GHP BH Services Questionnaire (HPM50)?

You answer a few questions in plain words, or upload your insurance card. The AI reads what you give it and puts each answer into the right field of GHP BH Services Questionnaire (HPM50), on every page, in seconds. It checks the answers against the form's own rules, and you review and change anything before you download, print or sign.

What happens to my information?

It is encrypted in transit and at rest, and it is never used to train AI.

How complex is GHP BH Services Questionnaire (HPM50) to fill out?

GHP BH Services Questionnaire (HPM50) has a Form Complexity Index of 53 out of 100, in the moderate tier: 140 fillable fields across 5 pages. Instafill.ai's AI fills it in under a minute, with every field there for you to review before you download.

What is the purpose of the Geisinger Health Plan Behavioral Health Professional Services Questionnaire?

This questionnaire helps Geisinger Health Plan members and referring providers find the right behavioral health services quickly. The information you provide is used to describe your services, specialties, and patient populations you accept.

Who should complete this questionnaire?

Behavioral health practitioners and/or practices (including facilities) that want Geisinger Health Plan members and referring providers to understand what services they offer should complete it. Complete it as accurately as possible based on your scope of practice.

Do I need to submit a separate form for each practitioner or location?

Yes—complete a questionnaire for each practitioner at your practice or for each facility location. If all practitioners or all locations provide the same services, you may submit one form for the whole group.

How do I submit the completed questionnaire?

You can fax the completed form to 570-271-5297 or email it to [email protected]. Make sure the form is signed and dated before submitting.

What basic provider information is required at the top of the form?

You should provide the provider name, credentials (degree/license/designation), NPI, address, county, group name, and a listing phone number. This information helps Geisinger identify and list the provider correctly.

What does 'Listing Phone Number' mean, and which number should I use?

The listing phone number is the number Geisinger members and referring providers should call to reach you for services. Use the main scheduling or intake number whenever possible.

How do I complete the age groups section?

Check all age groups you accept in your practice: Children (≤12), Adolescents (13–17), Adults (18–64), and/or Geriatrics (≥65). Only select groups you are currently able and willing to see.

How should I fill out the languages section if we offer interpretation or bilingual staff?

Check the languages you can communicate with patients in (e.g., American Sign Language, Spanish) and write in any additional languages under “Other.” Only select languages that are reliably available for patient communication in your practice.

What is the difference between 'specialize in' and 'would you treat if referred'?

“Specialize in” indicates areas where you have focused expertise or specialized services. “Would you treat if referred” indicates conditions you are willing to treat even if they are not a primary specialty.

Do I need to check every therapy or service we offer, like CBT, DBT, EMDR, or telehealth?

Yes—check all services, therapies, and treatments you actually provide. The more complete the list, the easier it is for members to find a provider who offers the specific service they need.

How should we answer items like ECT, TMS, esketamine treatment, or methadone maintenance if we refer those out?

Only check these services if your practitioner or location directly provides them. If you typically refer patients elsewhere for these treatments, leave them unchecked.

What are PHP and IOP, and how do we complete that section?

PHP (Partial Hospitalization Program) and IOP (Intensive Outpatient Program) are structured higher levels of care. If your group offers PHP and/or IOP, check the appropriate boxes by diagnosis type (ED, MH, SUD) and by age group.

What if we treat a condition or offer a service that is not listed on the form?

Use the “Other:” line in the conditions section to write in additional conditions you treat. For items not listed elsewhere, include the closest applicable selections and provide the additional detail where the form allows.

Who is allowed to sign the affirmation at the end of the form?

The form should be signed by the person completing it who can attest the selections are accurate and within the practice’s scope (often the practitioner, practice manager, or authorized administrative staff). Include the date, email, relationship to the practice, and fax number.

How long does processing take after I submit the questionnaire?

The form does not list a specific processing timeframe. If you need confirmation or an update, contact Geisinger Health Plan using the submission email ([email protected]) and reference the provider name and NPI.

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