Reference Guide for HealthSmart Providers

 Reference Guide for
HealthSmart Providers
Table of Contents I. Contact Quick List ............................................................................................. 2 II. About HealthSmart ........................................................................................... 3 III. Provider Data Update Process ........................................................................... 5 IV. Important Definitions ....................................................................................... 8 V. Network Participation ..................................................................................... 11 Network Credentialing Guidelines ................................................................................... 11 Participation Program Requirements ............................................................................... 12 Delegated Credentialing Requirements ........................................................................... 14 Dispute/Complaint Resolution ......................................................................................... 15 VI. Products ......................................................................................................... 16 ACCEL Network ................................................................................................................ 17 HealthSmart Preferred Care............................................................................................. 18 HealthSmart Preferred Care GEPO ................................................................................... 18 Emerald Health Network .................................................................................................. 19 Interplan Health Group .................................................................................................... 20 HealthSmart Payors Organization .................................................................................... 21 Workers Compensation Network ..................................................................................... 22 IHG/Dentinex Dental Network ......................................................................................... 23 Ancillary Care Services ..................................................................................................... 24 High Performance Network ............................................................................................. 25 Auto Liability Network ..................................................................................................... 25 HealthSmart National ...................................................................................................... 25 VII. Patient Procedures & Services ......................................................................... 26 VIII. Claim Submissions and Reimbursement .......................................................... 27 Claim Submissions ............................................................................................................ 27 Claim Reimbursement ...................................................................................................... 28 Complaint & Appeal Procedures ...................................................................................... 29 Provider Relations ............................................................................................................ 29 IX. Electronic & Online Services ............................................................................ 30 Electronic Data Interchange (EDI) Clearinghouse ............................................................ 30 Online Services & Resources ............................................................................................ 31 Online Claim Status Instructions ...................................................................................... 32 X. Frequently Asked Questions ............................................................................ 37 06/01/2010 Reference Guide for HealthSmart Providers page ‐1‐ I. Contact Quick List Contact Quick List •
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Go to: healthsmart.com Email: [email protected] •
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To check Online Claim Status for HealthSmart Preferred Care To view information on repricing codes To request a participating provider application To learn about EDI services To update demographic information To register for online access To check Credentialing status Speak with a Provider Relations Representative Inquire about fee schedules Request an orientation or in‐service Email: • [email protected] for HealthSmart Preferred Care network To submit additions, changes, & termination to • [email protected] provider data information or panel for Interplan Health Group network • [email protected] for Emerald Health Network network To verify member information with any of the following • Eligibility See phone numbers on the member’s ID card • Benefits • Precertification requirements • Claim payment status 06/01/2010 Reference Guide for HealthSmart Providers page ‐2‐ II. About HealthSmart About HealthSmart Comprehensive & Innovative Healthcare Solutions HealthSmart Holdings is a holding company comprised of several healthcare related subsidiaries (the HealthSmart companies). Collectively, the HealthSmart companies are dedicated to providing comprehensive and innovative healthcare solutions to meet our clients’ needs. Our goal is to change the face of healthcare — improve health and reduce costs — by developing the latest technology, utilizing a dedicated and creative team of professionals and offering a fully‐integrated inventory of wholly‐owned products and services. Our flexibility allows us to custom fit our services to the needs of any organization to find the healthcare solution that is smarter than any other. As a healthcare solutions company, we are dedicated to the pursuit of delivering services and tools to our clients and their members that not only reduces costs but more importantly, improves the members’ health and well being. Our commitment and our ability to deliver on this critical mission are made possible by our sincere desire to partner with our clients. This partnership is paramount to better understanding the needs of the members and to deliver a solution that is meaningful and valuable. We firmly believe that our integrated healthcare solution will deliver the necessary results for you. Well‐developed Services Provide Nearly Endless Savings Options In the last several years, HealthSmart acquired several top‐notch companies, developed innovative technologies and utilized dedicated and creative professionals to position itself as a comprehensive healthcare solutions company with a fully‐integrated inventory of wholly‐owned products and services. They proudly serve over 1 million member lives across the country in distinct but synergistically linked business units within the healthcare marketplace. Our healthcare companies include the following and we invite you to explore the numerous services and options available in each area. • THE HEALTHSMART PREFERRED PROVIDER NETWORKS, which includes PPO networks HealthSmart Preferred Care Network, Interplan Group Health Network, Emerald Health Network and more • HEALTHSMART BENEFITS SOLUTIONS INC., the sixth largest employee benefit third party administrator in the nation • HEALTHSMART CARE MANAGEMENT SOLUTIONS LP, a full‐service care management company with a URAC accredited Utilization Management program • HEALTHSMART RX, INC., a full‐service prescription benefit manager • HEALTHSMART PRIMARY CARE CLINICS LP, which manages on‐site employer‐sponsored healthcare clinics • HEALTHSMART INFORMATION SYSTEMS INC., an information technology provider with the experience of over 100 million EDI transactions We guarantee forward‐thinking, high‐quality products and services along with secure networks, credentialed providers, seamless administration and a dedication to making a positive, smarter impact on our customers and their members . . . for life! 06/01/2010 Reference Guide for HealthSmart Providers page ‐3‐ II. About HealthSmart Vision, Mission and Values Our Vision To be the healthcare industry’s leading provider of innovative solutions. Our Mission To provide our clients with the highest quality healthcare solutions utilizing the latest technology and a resourceful team of professionals focused on reducing costs and improving our members’ health. Core Values •
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QUALITY: We are committed to providing superior healthcare products and services to all our customers, clients, brokers and consultants. PRODUCTIVITY: We collectively strive for a winning approach that provides excellent results and continued growth. FULFILLMENT: We maintain a positive work environment and promote the personal values required for a successful professional career. VALUE: We create ongoing value and growth for our shareholders by maintaining a corporate culture that delivers a positive financial result. COMMUNITY: We are dedicated to the communities and charities we share with all our associates and clients. 06/01/2010 Reference Guide for HealthSmart Providers page ‐4‐ III. Provider Data Update Process Provider Data Update Process Making Additions, Terminations and Changes HealthSmart Preferred Care Email: Fax: Mail: [email protected]. 806.473.2525, Attention: Data Management HealthSmart Preferred Care Attn: Data Management 2002 W. Loop 289, Ste 121 Lubbock, TX 79407 Verify that information was received: 800.687.0500 Interplan Health Group: Email: Fax: Mail: [email protected]. 806.473.2525, Attention: Data Management Interplan Health Group Attn: Data Management 2002 W. Loop 289, Ste 121 Lubbock, TX 79407 Verify that information was received: 800.613.1124 or 866.511.4757 Emerald Health Network Email: Fax: Mail: [email protected] 216.479.2039, Attention: Data Management Emerald Health Network Attn: Data Management Tower at Erieview 1301 E. 9th Street, Suite 2400 Cleveland, OH 44114 Verify that information was received: 800.613.1124 or 866.511.4757 06/01/2010 Reference Guide for HealthSmart Providers page ‐5‐ III. Provider Data Update Process Update Provider Data 06/01/2010 Go to:
http://www.healthsmart.com/HealthSmartCustomers/Providers.aspx
Click Here to
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Reference Guide for HealthSmart Providers page ‐6‐ III. Provider Data Update Process Data Submission Tips ALL UPDATES—ADDS (DELEGATED PROVIDERS ONLY), TERMS, OR CHANGES MUST BE RECEIVED IN WRITING—
EITHER VIA FAX, EMAIL OR WRITTEN MAILED CORRESPONDENCE If submitting electronically, please submit updates in Excel Be sure to include the provider’s: • Name • TIN • NPI • Specialty • New information to add or change • Old information (if information is being replaced or changed) • Effective date of the change or addition 06/01/2010 Reference Guide for HealthSmart Providers page ‐7‐ IV. Important Definitions Important Definitions Appeals: When a determination is made not to approve or certify a health care service, written notification is sent to the attending physician, hospital, Covered Individual and payor. The notification will include the reason for the non‐
certification and a mechanism for the physician and Covered Individual to appeal. The appeal may be initiated by phone but the follow up must be in writing and must be received within 60 days from the date of the original determination. There are no specific documents required to initiate an appeal; however, the Covered Individual may be requested to complete a release of information form if medical records are needed. Upon return of this form, the Utilization Management Department will request the medical records from the appropriate provider(s). Upon receipt of an appeal, the Utilization Management Department personnel will obtain all information necessary for the appeal and record the process. The information will then be forwarded to a physician consultant of the same or similar specialty as the attending physician. The review will be conducted by a physician who has not previously reviewed the case. If requested, an expedited appeal for emergency care non‐
certification, and non‐certification of continued stay of hospital, for Covered Individuals will be completed within one working day following appeal request and receipt of all information necessary to complete the appeal. If the appeal is requested after discharge or services are provided, the appeals process will be completed with written notification of the outcome. This will be sent no later than 30 days from the receipt for the appeal request and necessary documentation needed to complete the appeal process. The physician, Covered Individual, hospital, and payor will be notified within one working day of decision to either uphold the non‐certification or approve the requested admission, procedure, service or continued stay. Application: Application request for participation can be obtained on the applicable state’s insurance department website, at www.healthsmart.com, or by contacting HealthSmart. Case Management: Is a service designed to identify Covered Individuals that can benefit from close review and management due to length, severity, complexity and/or cost of health care services. Case Managers locate and assess medically appropriate settings for the Covered Individuals, and manage their health care benefits as cost effectively as possible. The goals of Case Management are to ensure that care is provided in the most appropriate setting at least costly price. Quality of care should not be compromised. The Case Manager will work closely with the hospital, the physician, the family and ancillary providers to coordinate provision of services to meet the specific needs of the Covered Individual in need of Case Management services. Since early identification is essential to proactive Case Management, the company providing Utilization Management provides referral of Covered Individuals through pre‐certification and concurrent review process. An identified list of illnesses, injuries and other medical treatments with high potential for case management is used to aid in this process. This list does not limit application of the program to Covered Individuals who may be in need of Case Management services. Certification: The determination made by a licensed, registered or certified health care professional engaged by the Utilization Management program that the health care services rendered by a Preferred Provider meet the requirements of care, treatment and supplies. Certification may also be referred to as “Precertification.” 06/01/2010 Reference Guide for HealthSmart Providers page ‐8‐ IV. Important Definitions Concurrent Review: After the admission, the Utilization Management Department will monitor services on a concurrent basis. If the Covered Individual is not discharged within the number of days initially approved, the Utilization Review personnel will contact the attending physician for additional medical information. Both care and services for each case are monitored. Further certification will depend upon the establishment of medical necessity Confidentiality: All Covered Individuals have the right to Rights of Privacy and Confidentiality as provided by State and Federal Law. Confidentiality of Covered Individual’s records and information will be maintained by adhering to all stats and federal laws. This information will be shared only with those agencies who have authority to receive such information. Covered Individual or Person: Any person eligible to receive health services that are covered by a plan administered by HealthSmart or a HealthSmart Network Payor. Discharge Planning: The process that assesses a Covered Individual's needs for treatment after hospitalization in order to help arrange for the necessary services and resources to effect an appropriate and timely discharge from the hospital. Discharge planning is also designed to identify those Covered Individuals who will need care after discharge from the hospital. This care may include home health services, extended care facilities or home I.V. therapy. Early identification will ensure timely discharge thus providing less expensive yet quality care. Emergency Admissions: Notification of Emergency Admission must take place within 48 hours of the admission. HealthSmart Network: A PPO network of facilities, physicians and other health care providers who have agreed to provide service to a Covered Individual. HealthSmart Network Payor: Is a self insured employer, Third Party administrator, insurance company, health services plan, trust, non profit facility service plan, any governmental unit and/or another other entity, which has an obligation to administer, process, provide arrange for or secure access to covered health care services or benefits for delivery to Covered Person(s). Maternity Admissions: The Covered Individual should contact HealthSmart Care Management Solutions or the company providing UM Services for HealthSmart Network payor early in the pregnancy with the expected date of delivery. The Utilization Review personnel will work closely with the physician to monitor the pregnancy for potential high risk. If the pregnancy is determined to be high risk, the case should be referred to a Case Management Nurse for potential intervention. The Utilization Management Department should be notified when the Covered Individual is admitted for labor and delivery. Any other admissions prior to delivery, such as complications of pregnancy, require separate notification. The Utilization Management Department should also be notified if the baby is not going to be discharged with the mother. Medical Criteria: A system used by Utilization Management Department personnel use clearly established, nationally recognized criteria for determining the appropriateness of medical services provided or to be provided. The criteria are reviewed at least annually and revised as indicated. The criteria may contain length of stay parameters based upon expected outcomes of care. National norms such as the PAS length of stay guidelines may also be used to assist in determining appropriate use of medical services 06/01/2010 Reference Guide for HealthSmart Providers page ‐9‐ IV. Important Definitions Outpatient Surgery: The company providing Utilization Management will review selected procedures for recommendation of outpatient surgical setting. When a call is received to pre‐certify a surgical procedure and hospital stay, the Utilization Management Department checks all medical information against established medical criteria to determine whether the procedure may be done safely on an outpatient basis. The Utilization Management Department personnel will then discuss the possibility of using an outpatient facility with the Covered Individual's physician. Pre‐Admission Testing: The company providing Utilization Management may suggest that pre‐admission testing be done whenever hospitalization is necessary. Pre‐admission testing allows the patient to have routine tests such as xrays, lab tests, EKGs, etc., done on an outpatient basis prior to the hospital confinement, which usually results in saving one night's stay in the hospital. During pre‐certification, the attending physician will be asked to determine if testing may be performed on an out‐patient basis. Preferred Provider: A licensed facility or licensed registered or certified health care professional that agrees to provide health care services to Covered Individuals. Preferred Providers may be referenced as Provider, whether one or more. Retrospective Review: The company providing Utilization Management recognizes that there will be Covered Individuals who will not have precertification and concurrent review performed. These cases will be reviewed retrospectively focusing on day of admission and continued hospital stay. The Utilization Management Department personnel will contact the hospital or attending physician to obtain all necessary information. Using established medical criteria, the Utilization Management Department personnel will determine the medical necessity of the hospitalization. If the criteria are met, the hospital admission will be certified. If the medical criteria are not met, the denial and appeal procedures for precertification and concurrent review will be followed. Review Guidelines: Review will be conducted in accordance with the following National Database: 1. HCIA Length of Stay by Diagnosis and Operation, Southern Geographic Region, Annualized Volume, HCIA, Inc. 2. Inter‐Qual, Inc. Healthcare Screening Criteria for Utilization Management, Geographic Annualized Volume. Utilization Management: The process of evaluating proposed hospital admissions and medical services to identify patterns of treatment for quality and appropriateness. This is accomplished through pre‐admission certification, concurrent review, retrospective review, discharge planning and Case Management. Utilization Review: A program established by HealthSmart Care Management Solutions or on behalf of a HealthSmart Network Payor under which a request for care, treatment and/or supplies may be evaluated against established clinical criteria for medical necessity, appropriateness and efficiency. 06/01/2010 Reference Guide for HealthSmart Providers page ‐10‐ V. Network Participation Network Participation Network Credentialing Guidelines HealthSmart strives to maintain the highest quality network. This commitment involves credentialing each provider and recredentialing in accordance with the American Accreditation HealthCare Commission standards of credentialing. All providers are required to complete a Provider Application and Agreement. Provider application may be obtain by contacting HealthSmart or the following web site www.healthsmart.com. All requested information must be received to process the application. A National Practitioners Data Bank query will be conducted as verification of each state license to determine whether registration has been suspended or revoked. If a provider has admitting privileges, a query will be sent to the primary network hospital/facility (as applicable) where Provider is appointed to verify clinical privileges. In addition, malpractice experience will be verified. Pending, settled, closed or awarded cases are reviewed by a peer committee. Complete malpractice information must be provided on each malpractice case/suit/settlement (s) that you were involved in for the past five (5) years initial credentialing or recredentialing (three years). Provider liability Insurance minimum requirements are based on state and industry standards per policy year for ALL HealthSmart Providers. Provider shall also insure that his/her employees maintain the applicable general and professional liability insurance coverage. Applicant must not have participated in Medicare or Medicaid fraud. Highest educational status must be verified or current Board Certification verified. The following information must be active (as applicable): • State License • DEA • Controlled Substance Certificate • Malpractice Insurance Certificate HealthSmart offers delegated credentialing for groups that meet URAC or NCQA guidelines for initial and recredentialing of providers. This requires credentialing prior to participation and recredentialing every three years thereafter. Entity’s credentialing policy and procedures are reviewed for compliance with HealthSmart and URAC standards. Each must be approved by the Medical Advisory Committee. A delegated credentialing agreement must be signed to all groups granted delegated status. In addition these groups, agree to an annual audit process, submission of provider updates at the minimum on a quarterly bases, and provide and policy changes. 06/01/2010 Reference Guide for HealthSmart Providers page ‐11‐ V. Network Participation Participation Program Requirements Subcontracts of Physician Agreement The Provider Agreement may be assigned only with the written consent of the Network, and any assignment attempted without such prior consent shall be null and void. Network may assign the Agreement to an affiliated, subsidiary, parent or other related party or successor entity with notification to the Physician. It is expressly agreed that Network may contract with other entities in order to meet its obligations under the Agreement without notifying Physician, any and all subcontracts shall be subject to the terms and condition of the Agreement. It is the responsibility of the Physician to notify the subcontracted provider where they can locate a copy of the HealthSmart Provider Manual. A copy can be found at www.healthsmart.com. Health Care Services Physician shall, as applicable, make available and provide Covered Services to Covered Person(s) in accordance with the terms of this Provider Reference Guide and the applicable Agreement. However, the Physician shall comply with all applicable federal and state laws, licensing requirements and professional standards in respects to Physician services. All such services shall be Medically Necessary, Covered Services rendered in accordance with generally accepted medical practices and standards prevailing in the medical community at the time of treatment and shall be within the scope of Physician’s license. Physician shall provide Covered Services to Covered Person (s) in the same time and manner as customarily and regularly provided to other patients who are not Covered Person (s). Physician shall render Covered Services without regard to race, age, religion, sex, national origin, marital status, sexual orientation and source of payment or disability of Covered Person(s). Medical Records Maintenance of and Access to Medical Records: Physician shall maintain complete and professionally adequate medical records to the extent necessary for continuity of care and in compliance with all applicable laws. Physician shall maintain for at least a four (4) year period of time or for any longer period of time specified by federal, state or local law, and make readily available to Network, Group and governmental agencies with regulatory authority, all medical and related administrative and financial records of the Covered Person (s) that receive covered Services, as required by Network in accordance with this Agreement or pursuant to applicable law. Group (or it’s designee) may request and Physician shall not unreasonable withhold, additional records as may be required to verify that Physician’s charges are reasonable and in line with prevailing community standards, to the extent not prohibited by applicable law. Such records shall be available to Network, Group and governmental agencies with reasonable notice to Physician and during regular business hours for Physician. Confidentiality and Covered Individuals’ Rights As a HealthSmart Provider it is understood all Covered Individuals have the right to: Rights of Privacy and Confidentiality as required by State and Federal Laws. A Covered Individual’s medical information will be released only to persons authorized to receive such information. 06/01/2010 Reference Guide for HealthSmart Providers page ‐12‐ V. Network Participation Patient Rights: •
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Be treated with respect and dignity by network physicians and personnel, and other health care professionals. Be assured privacy and confidentiality for treatments, tests and procedures you receive. Voice concerns about the service and care received Receive timely responses to concerns Be provided with access to health care, physicians, health care professionals and other health care facilities Have coverage decisions and claims processed according to regulatory standards when applicable Choose an advance directive to designate the kind of care you wish to receive should you be unable to express your wishes. Patient Responsibilities, to the extent capable: •
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Know and confirm your benefits before receiving treatment Contact an appropriate health care professional when you have a medical need or concern. Show your health care ID card before receiving health care services Pay any necessary copayment at the time you receive treatment Use emergency room services only for injury or illness that , in the judgment of a reasonable person, requires immediate treatment to avoid jeopardy to life or health Keep scheduled appointments 06/01/2010 Reference Guide for HealthSmart Providers page ‐13‐ V. Network Participation Delegated Credentialing Requirements HealthSmart offers delegated credentialing for groups that meet URAC or NCQA guidelines for initial and recredentialing of practitioners. Upon approval by HealthSmart’s Medical Advisory Committee, the groups are granted delegation status and will sign a Delegated Credentialing Agreement. The delegated entity agrees to: Reporting On a monthly basis, submit to HealthSmart a report capturing any actions taken related to providers which include changes in licensing status, additions, changes and/or terminations pertaining to the group and/or any other changes that is significant to individuals in the credentialing or recredentialing process. Provider a Quarterly Roster of groups, practitioners with changes from the previous roster highlighted and readily identifiable. This master list will serve as notice of change in name, address, phone number, fax number, specialty and termination status. Compliance All credentialing and recredentialing services will comply with current URAC or NCQA guidelines as well as, HealthSmart standards or other mandatory regulatory body requirements and standards as appropriate. Program Change Notification Delegated group will provide 15 days advance notice to HealthSmart of any material changes to the organization or to it’s performance of any of the delegated functions. Physician Status Notification Delegated group will notify HealthSmart within 10 days of a hospital revokes or suspends the clinical privileges of a physician except in the case of non‐compliance with medical record requirements. Audit HealthSmart reserves the right to annually monitor and audit delegated entities performance of credentialing and recredentialing by examining credentialing files and member’s medical records. Monitoring and/or audits will be conducted on site or by fax with a 30 day advance written notice. HealthSmart access to files will not include information related to peer review committees, or any other confidential information related to credentialing. Corrective Action If deficiencies in service are identified by HealthSmart, the delegated entity will provide a written response within 15 days that either: 1. Disputes the deficiency and provides supporting evidence 2. Submits a corrective action plan, including procedures and timelines. In the event that the parties fail to reach an agreement on the existence of a deficiency, or the appropriate corrective action and timeframe, HealthSmart reserves the right to terminated the Delegated Credentialing agreement with 15 days notice. 06/01/2010 Reference Guide for HealthSmart Providers page ‐14‐ V. Network Participation Dispute/Complaint Resolution Dispute Resolution The dispute resolution and/or appeal resolution mechanism is available to any participating provider that wishes to initiate the process. If a participating provider has a grievance or complaint related to a change in the provider’s status within the network, or any action taken by HealthSmart related to a Practitioner's professional competency or conduct, they may contact the HealthSmart Medical Director, Credentialing Manager, Quality Management Coordinator or any HealthSmart staff person to initiate the dispute process. If the matter cannot be resolved informally within a reasonable time to the Provider’s satisfaction, the Practitioner may submit a written grievance to the HealthSmart Credentialing Manager within 30 days of the date of notification requesting reconsideration. If the Practitioner submits a written request for reconsideration within 30 days the matter will be discussed during the next Medical Advisory Committee (MAC) meeting. If the MAC upholds the original decision of the Committee, the Practitioner may request an appeal within 20 days of notification of the decision. An Ad Hoc Committee will be developed that consists of three qualified individuals, of which at least one will be a participating provider who is otherwise not involved in network management, who was not involved with the original decision rendered, and one who is a clinical peer of the Practitioner who filed the dispute. Once a decision rendered on behalf of the Ad Hoc Committee, the HealthSmart Credentialing Manager will send a letter to the appealing provider notifying him/her of the decision. If the Practitioner is still not satisfied with the outcome, he or she may send in a written request within 30 days of the receipt of the letter, requesting a second level of appeal. The second level of appeal will be considered by a separate Ad Hoc Committee which will be comprised of three qualified individuals of which at least one will be participating provider who is otherwise not involved in network management, who was not involved in the original or first level of appeal decision, and one who is a clinical peer of the practitioner who filed the dispute. The final decision of the second‐level appeal Ad Hoc Committee will be final and binding. HealthSmart will automatically remove any provider from the network, if the provider Poses an immediate threat to the health or safety of our members until further investigation can be conducted. The specific provider being investigated will be reviewed by the HealthSmart Medical Advisory Committee and the Medical Director. In the case of disputes as to any issues that may arise in connection with the respective rights and obligates of the parties under this Agreement, arbitration will be entered into. Each party will notify the other, in writing, of the name of it representative's) who will have primary responsibility for communications with the other party. If such representatives are unable to resolve the dispute, either party shall demand submission of the dispute to arbitration before a single arbitrator in accordance with the Alternative Dispute Resolution Service Rules of Procedure for Arbitration, as published by the American Health Lawyers Association The party requesting such arbitration shall pay the arbitrator’s fee. The decision of the representative or, if applicable, the arbitrator, shall be final and binding upon the parties. Provider Responsibility for Complaint Resolution Provider and/or Provider Representatives will cooperate with the network in investigating the inquires and complaints. Provider will notify if complaints are received against provider and/or practice. Provider will participate and cooperate in development and verification of information received by HealthSmart Medical Director regarding information on profiling patterns. 06/01/2010 Reference Guide for HealthSmart Providers page ‐15‐ VI. Products Products HealthSmart Network Solutions — which encompasses several provider networks such as HealthSmart Preferred Care, Interplan Health Group and Emerald Health Network, among others — brings together nationwide healthcare coverage, credentialed providers, seamless administration, state‐of‐the‐art healthcare management services, and a dedication to making a positive impact on our customers. Our wholly‐owned provider networks fall into the following network types: Preferred Provider Organization (PPO) •
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Covered Person(s) may receive medical care from any licensed healthcare provider. Being that PPO products are distinguished by the option on the part of the Covered Person(s) to receive medical services outside of the Network panel, this will cause a significantly less benefit reimbursement. PPO Participating Provider shall make best efforts to refer only to PPO Network Participating Providers. PCP selection nor referrals are required, although precertification may be required, so contact the plan admin‐
istrator, which is located on the back of the member’s ID card. Precertification is driven by the benefit design. HealthSmart PPOs Include: HealthSmart Preferred Care Interplan Health Group Emerald Health Network Exclusive Provider Organization (EPO) •
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Covered Person(s) may receive medical care from any licensed healthcare provider. EPO products only provide in network coverage only with the exception of emergency services. EPO Participating Providers shall make best efforts to refer only Network Participating Providers. PCP selection nor referrals are required, although precertification may be required, so contact the plan admin‐
istrator, which is located on the back of the member’s ID card. Precertification is driven by the benefit design. HealthSmart EPOs Include: HealthSmart Preferred Care Interplan Health Group Gated Exclusive Provider Organization (GEPO) •
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Only providers participating in the Network’s GEP product shall provide services to GEPO’s Covered Person(s) in the Network Service Area GEPO Participating Providers shall make best efforts to refer only to GEPO Network Participating Providers. Benefits may not be available to Covered Person(s) on services rendered outside of the GEPO Network. The enrolled Covered Person(s) may be required to select a Primary Care Physician (PCP) for the GEPO. The GEPO product encourages steerage into local GEPO providers, and promotes coordination of member treatment through a PCP and/or Utilization Management. The PPO network may not be used to supplement or wrap the GEPO Network in the GEPO service area. Referrals may be required. Precertification is driven by Covered Person(s) benefit design. Participating Providers will be specified as Primary Care Physicians (PCP) or Specialists for this product. HealthSmart GEPOs Include: HealthSmart Preferred Care 06/01/2010 Reference Guide for HealthSmart Providers page ‐16‐ VI. Products HealthSmart Accel Network HealthSmart Accel is a superior managed care provider network designed to facilitate cost containment while offering excellent hospital and physician access. Our Accel Network offers an unparalleled solution to meet the various needs of all our clients in the areas of network management, pharmacy management and other managed care services. Accel Highlights •
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Covered Person(s) may received medical care from any licensed healthcare provider. The enrolled Covered Person(s) will not be required to select Primary Care Physician (PCP) and referrals are not required. Accel Participating Providers shall make best efforts to refer to within the Accel Network. Benefits may be limited on services rendered outside of the Accel Network. Services received out side of the network will be reimbursed at an RBRVS based fee schedule which will result in a higher member financial responsibility. Precertification will be driven by the Covered Person(s) benefit design. Accel Guidelines •
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Accel product will be identified on the member’s ID card Electronic Claim processing, submission, remittance advise and fund transfer will be available as well as online claim status and eligibility Adjudication of all facility claims without requiring an invoice HealthSmart will reprice all claims submitted by the Provider Payment and Audit Guidelines consist with Carrier Guidelines Network and Payor will adhere to predefined payment sand service terms as agreed to in the Accel Network agreement Sample ID Card 06/01/2010 Reference Guide for HealthSmart Providers page ‐17‐ VI. Products HealthSmart Preferred Care The HealthSmart Preferred Care Network is a nationwide Preferred Provider Organization (PPO) formed in 1993 to meet the ever‐changing and growing need for effective management of cost and quality in the healthcare delivery system. HealthSmart Preferred Care has developed a significant regional presence with the southwest United States as our primary focus; however, our extensive provider network is not limited to this region. HealthSmart Preferred Care provides healthcare coverage through direct access and management of a nationwide network. Currently, HealthSmart Preferred Care serves over three quarters of a million covered lives across the nation. With a strong focus on customer service, HealthSmart Preferred Care creates a productive and effective business environment to meet the various needs of the health care delivery system for employers, payors, third party administrators and providers. Sample ID Card HealthSmart Preferred Care GEPO The HealthSmart Preferred Care GEPO is a Gated Exclusive Provider Organization that provides members with the deepest healthcare discounts available from providers in the greater Dallas Fort Worth Metroplex area. The HealthSmart Preferred Care GEPO plan should have GEPO displayed on the member ID cards. The DFW GEPO and the GEPO are different plans with different requirements. If you are unsure which plan you are on, please contact your plan administrator. Sample ID Card 06/01/2010 Reference Guide for HealthSmart Providers page ‐18‐ VI. Products Emerald Health Network For more than two decades, Emerald Health Network (EHN) has prospered as a premier Preferred Provider Organization (PPO) network in the state of Ohio. One of the first PPOs formed in Ohio, EHN has served as a leading healthcare solutions company for both the employer and provider communities since 1983. The network is now comprised of 225 hospitals, 2,500+ ancillary providers and more than 30,000 physician locations throughout Ohio and bordering areas of contiguous states. Emerald Health works directly with customers to provide the very best in benefit offerings aimed at controlling healthcare costs without compromising quality. Emerald’s coverage area has been strengthened and expanded to form one of the strongest Preferred Provider Networks in the Midwest. Emerald Health Network is also the Plan Manager for the Accountable Health Plan of Ohio (AHPO), a robust provider network in south‐central Ohio. With extensive access and competitive rates in and around the Columbus region, AHPO provides an excellent PPO option for groups with central Ohio membership Sample ID Card 06/01/2010 Reference Guide for HealthSmart Providers page ‐19‐ VI. Products Interplan Health Group Interplan Health Group (IHG) Network delivers network coverage and state‐of‐the‐art healthcare management services. IHG guarantees forward‐thinking, high‐quality products and services along with a secure network, credentialed providers, seamless administration and a dedication to making a positive impact on our customers. With over 600,000 providers and over 5,000 hospitals spanning the United States, our comprehensive network offers a full spectrum of services. What’s more, we contract with our providers directly, ensuring an efficient and personal relationship while tailoring our network to meet the needs of our customers. Our dedication to quality goes further than our PPO network. When a customer integrates our highly developed Care Management program with the IHG PPO network, the reward is greater savings and coordination of care. Sample ID Card 06/01/2010 Reference Guide for HealthSmart Providers page ‐20‐ VI. Products HealthSmart Payors Organization The HealthSmart Payors Organization (HPO) is HealthSmart’s national secondary preferred provider network. Currently, it has over 260,000 directly contracted providers practicing in over 476,000 locations, making HPO the second largest secondary/wrap network in the country. Recently, HealthSmart expanded its focus on reducing medical expenses and claim processing time by employing a strategic national network build‐out program. Already one of the largest directly contracted secondary networks in the country, HPO has recently succeeded in nearly doubling its participation into its PPO network offering, making HPO the best choice for out‐of‐network cost containment. HPO can produce out‐of‐network discounts that are significantly above the national average. By directly contracting with national and regional partner networks, HPO is able to optimize out‐of‐network cost savings in a provider friendly manner while creating comprehensive secondary network solutions that promote ease of administration. In this ever‐changing industry, versatility and the ability to accommodate all client healthcare needs gives HPO a cutting‐edge advantage over the other available options. Sample ID Card 06/01/2010 Reference Guide for HealthSmart Providers page ‐21‐ VI. Products Workers Compensation Network When a worker is injured, nothing is more important than returning him or her to the workplace as quickly and cost effectively as possible. The strength of our contracts is what significantly differentiates HealthSmart from our competition. The primary strength of our network is savings which considerably impacts the cost of claims. Our Workers Compensation Network enlists over 38,000 directly contracted providers in a broad range of specialties who arecommitted and experienced in treating work‐related injuries. Many of our providers are focused on working with payers and employers not only in addressing medical issues but also returning the injured employee to the workplace: • Primary care physicians • Occupational health and rehabilitation therapists • Behavioral health care specialists • Ancillary providers • Hospitals • Diagnostic Networks • Neurologists • Occupational Specialists • Chiropractors • Physical Therapy • Alternative Medicine practitioners • Pharmacy Networks Relationships That Work Because we own direct contracts with our facilities and providers, we have been able to establish efficient and positive working relationships. Our diligence in this area has earned us a reputation as the premier Workers Compensation Network in the western region. What’s more, we’re also one of the most cost effective. For example, the strength of our facility contracts includes provisions with unique outliers that positively impact the cost of medical treatment. Further, our retrospective and prospective pharmacy network partner provides significant savings through superior workers compensation contracts and state‐of‐the‐art technology. Coverage That Covers The Map Not only do we provide broad network coverage that spans the western region, we are also able to carve out specialized networks to meet customers’ requirements in California, Washington and Nevada, with Oregon and Arizona soon to be added. We are also in the process of adding significant workers compensation coverage in the Southeast, Midwest and Southwest to create a network as large as it is strong. High‐Tech and High‐Touch Technology is a key component in providing a superior workers compensation network focused on better outcomes for our customers. Our versatile and adaptable info‐structure enables us to deliver network data easily to our customers for use in channeling and in their bill review processes. We focus on electronic provider and customer connectivity and technology, and our web based repricing system allows us to stay at the forefront of customer workers compensation needs. Individual web sites provide information based on geography and specialty while serving as convenient tools to support the claims process. 06/01/2010 Reference Guide for HealthSmart Providers page ‐22‐ VI. Products IHG / Dentinex Dental Network HealthSmart is proud to offer Dentinex, a well‐regarded dental network for self‐insured and fully‐insured plans. Dentinex, one of California’s premier dental PPO Networks, provides our members access to more than 10,000 dental office locations statewide. With Dentinex, members have expanded dental benefits with lower out‐of‐
pocket costs thanks to our predetermined financially binding fee schedules. In fact, savings average 30% or more and members are even able to receive discounts on cosmetic and non‐covered procedures. Freedom of Choice Our network of thoroughly credentialed dentists and specialists is constantly growing, affording our members a wide range of choice when selecting providers. And in cases where a member’s dentist is not part of the network, our staff works quickly to credential potential providers and welcome them to the Dentinex team. Service Made Simple Creating a simple‐to‐administer and easy‐to‐use network is as important to us as the quality of care our dentists provide. That’s why we offer unparalleled customer service in implementation and ongoing administration of the network. What’s more, our directories, toll free line and Internet look‐up capabilities make it easy for our members to find Dentinex providers. In addition, we can even customize a network for larger groups who need national PPO coverage Sample ID Card 06/01/2010 Reference Guide for HealthSmart Providers page ‐23‐ VI. Products Ancillary Care Services Ancillary Care Services (ACS) is the exclusive provider of ancillary services for HealthSmart’s wholly‐owned provider networks. ACS has been the primary ancillary network solution for HealthSmart since 2005. Ancillary healthcare services supplement or support the care provided by hospitals and physicians, including laboratories, dialysis centers, free‐standing diagnostic, non‐hospital surgery centers, as well as durable medical equipment such as orthotics and prosthetics, and others. ACS offers cost effective alternatives to physician and hospital‐based services through its comprehensive national network of approximately 2,500 ancillary service providers at over 25,000 sites. As the exclusive provider of ancillary services, for members of HealthSmart’s networks, ACS is positioned to lower ancillary healthcare costs and serve our members with our high quality, cost effective network of providers. The logo for Ancillary Care Services will appear on all HealthSmart member ID cards and ACS providers will be included in HealthSmart's directories. Ancillary services represent one of the fastest growing components of healthcare costs. The ACS network includes 26 primary specialties with over 30 subspecialties. Primary services include: SERVICE GROUP SPECIALTY CATEGORY Testing Therapies Physician Alternatives Post‐Acute Hospital Services Medical Devices Other Services Laboratory
Radiology / Imaging Cardiac Monitoring Sleep Diagnostics Genetic Testing Alternative Therapies
Dialysis Chiropractic Infusion Services Home Health Outpatient Rehab Walk‐In Clinics
Urgent Care Center Hospice
Inpatient Rehab Long Term Acute Care Skilled Nursing Facilities Surgery Center Durable Medical Equipment
Implantable Devices Orthotics & Prosthetics Diabetic Supplies Podiatry
Transportation Vision INCLUDED SUBSPECIALTIES Acupuncture Massage Therapy Specialty Pharmacy Occupational & Physical Therapy Speech Therapy Pain Management Occupational & Physical Therapy Lithotripsy Hearing Aids 06/01/2010 Reference Guide for HealthSmart Providers page ‐24‐ VI. Products High Performance Network The HealthSmart High Performance Network is an exclusive provider panel that provides plan members access to the most cost effective providers in their service area. Members reduce their health care costs by utilizing specific facilities and providers exclusively within a select geographic region. Auto Liability Network With a comprehensive western region Auto Liability Network, we understand successful outcomes should include timely access to experienced providers treating trauma‐related injuries and special medical needs with maximum cost efficiency. The strength of our contracts is what significantly differentiates us from our competition. The primary strength of our network is savings, which considerably impacts the cost of claims. Our network connects members to over 51,000 direct providers and offers a deep contract structure, broad coverage and a level of customer service that fosters personal and efficient working relationships between all entities. And because our contracts specifically identify auto liability as a line of business covered under the contract. Because we own direct contracts with our facilities and providers we have been able to establish efficient and positive working relationships. Our diligence in this area has earned us a reputation as the premier network in the western region. What’s more, we’re also one of the most cost effective. HealthSmart National HealthSmart National Network offers you a single, easy‐to‐navigate point of contact for one of the largest national provider panels available in the United States, including over 5,000 hospitals, all top‐rated tertiary care facilities, and hundreds of thousands of the most respected physicians and healthcare providers in the country. We’ll help you manage the maze of healthcare networks, with a focus on service, simplicity, and savings. Our concept is simple: A national network customized to your exact needs: • One Point of Contact • Time and cost savings • Deep discounts • Effective repricing • Quality and affordable healthcare networks • Selection of providers • Ease of billing 06/01/2010 Reference Guide for HealthSmart Providers page ‐25‐ VII. Patient Procedures & Services Patient Procedures & Services Patient Identification (ID) Cards HealthSmart Covered Individuals are issued an identification card by the HealthSmart Payor. Although each card will differ depending on the HealthSmart Payor, The HealthSmart logo or name should be visible. Below are possible examples: Eligibility Always contact the HealthSmart Payor to obtain eligibility and benefit information before rendering services. Health Plan design may vary and restrictions may apply. At time of service obtain an estimate of patient’s coinsurance, deductible, plan design and copay information to determine Covered Individual’s payment responsibility. Utilization Review To achieve maximum reimbursement for Covered Individual, proposed medical care must be certified by the HealthSmart Payor’s Utilization Review (UR) service. This UR confirmation process can be a combination of telephone, written, or online communication. Depending on the urgency of the medical care, notification requirements will vary. Certifying treatment does not guarantee payment for services rendered to any Covered Individual. When a determination is made not to approve or certify a health care service, written notification is sent to the attending Physician, Hospital, Covered Individual and Payor. The notification will include the reason for the non‐certification and a mechanism for the Physician and Covered Individual to appeal. The appeal may be initiated by phone but the follow up must be in writing and must be received within 60 days from the date of the original determination. There are no specific documents required to initiate an appeal; however, the Covered Individual may be requested to complete a release of information form if medical records are needed. Upon return of this form, the Utilization Management Department will request the medical records from the appropriate provider(s). Upon receipt of an appeal, the Utilization Management Department personnel will obtain all information necessary for the appeal and record the process. The information will then be forwarded to a physician consultant of the same or similar specialty as the attending physician. The review will be conducted by a physician who has not previously reviewed the case. Referrals To assist Covered Individuals avoid a potential reduction in health benefits, please make best efforts to refer Covered Individuals to Preferred Providers participating in the HealthSmart Network. In addition, Preferred Providers shall admit Covered Individuals to participating facilities within the HealthSmart Network except in the case of an emergency. Please contact HealthSmart Provider Customer Service at 800.687.0500. 06/01/2010 Reference Guide for HealthSmart Providers page ‐26‐ VIII. Claims Submission and Reimbursement Claims Submissions and Reimbursement Claims Submissions The HealthSmart Provider Networks are not an insurance company, guarantor, or payor of claims and is not liable for payment of any claims. As a Preferred Provider, you agree to submit clean claims, in a timely manner, for services rendered to Covered Individuals. HealthSmart Accepts these Claim Forms •
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CMS‐1500 or successor form UB‐04 or successor form ANSI 837P ANSI 837I Submitting Claims by Mail Claims must be submitted to the address as identified on the Covered Individuals ID card. Submitting Claims Electronically If the network accessed has the ability to accept claims electronically, then the CMS‐1500 and UB‐04’s may be submitted electronically through transaction networks and clearinghouses in a process known as Electronic Data Interchange (EDI). This method is recommended as it is faster and more accurate. The following routing number must be used on all EDI Claims. HSPC1 Carevu and THIN 75250 Emdeon (Web MD) 34167 Emdeon (Web MD) Prompt processing and payment is contingent upon provider completing each claim form accurately and completely. In order for HealthSmart to identify and process the claim, we must have all the necessary patient and insured information. Claims must be submitted within industry standard time frames unless specified in contract. 06/01/2010 Reference Guide for HealthSmart Providers page ‐27‐ VIII. Claims Submission and Reimbursement Claim Reimbursement Preferred Providers should bill for services for a Covered Individual at the normal retail rate. The HealthSmart Payor will reimburse once benefits are applied. You will receive an Explanation of Payment (EOP) detailing payment. You may not charge a member for Covered Services beyond copayments, coinsurance or deductibles as described in their benefit plans. You may charge a member for services that are considered as Non Covered under the applicable benefit plan, provided you first obtain the member’s written consent. Such consent must be signed and dated by the member prior to rendering the specific service(s) in question. Retain a copy of this consent in the member’s medical record. Each HealthSmart Payor’s plan may exclude or reduce benefits for some types of medical care, again please verify a Covered Individuals plan design by calling the appropriate HealthSmart Payor. Covered Individuals should be billed directly for services which are not covered by the HealthSmart Payor’s health benefits plan design. If an error has been made in the adjudication of Covered Individual’s benefits, please contact the appropriate HealthSmart Payor listed on the Covered Individual’s ID card or EOP Multiple Procedures In a case where multiple surgical procedures are scheduled, please obtain benefit information from the HealthSmart Payor for each procedure. Coordination of Benefits Covered Individuals are sometimes covered by more than one insurance policy. Always obtain complete benefit information from each Payor when verifying a Covered Individuals health plan benefit. 06/01/2010 Reference Guide for HealthSmart Providers page ‐28‐ VIII. Claims Submission and Reimbursement Complaint & Appeal Procedures Complaints & appeals may be filed by contacting Customer Service at the following numbers: 800.687.0500 HealthSmart Preferred Care 866.511.4757 Interplan Health Group 800.613.1124 Emerald Health Network 877.212.2235 Accel Network Complaints & appeals may be filed by mail to the following address: HealthSmart Attn: Provider Relations 222 W. Las Colinas Blvd, Suite 600N Irving, Texas 75065 Complaints & appeals may be filed by email at [email protected]. Please contact the Provider Relations department if you encounter any problems or have any questions concerning the HealthSmart provider network or contract. Provider Relations The Provider Relations department may be reached: HealthSmart Preferred Care 800.687.0500 Interplan Health Group 866.511.4757 This team can provide: • Information regarding contract terms, reimbursement, & effective dates • Product details & payor information • Escalated issue resolution • Information about network participation or how to add a new provider • Onsite orientation and educational visits 06/01/2010 Reference Guide for HealthSmart Providers page ‐29‐ IX. Electronic & Online Services Electronic & Online Services Electronic Data Interchange (EDI) Clearinghouse HealthSmart offers a Full Service Healthcare EDI Clearinghouse, which is open to all providers in the healthcare community. Our goal at HealthSmart is to give our network providers the highest level of customer service possible. EDI Services •
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Commercial claims (Aetna, CIGNA, Humana, etc…) to providers Free government claims to participating carriers Eligibility verifications Claim status inquiry Electronic remittance advice (ERA) for auto payment posting Referral and authorization requests e‐Paper (Print‐Mail Services) Patient statements EDI Benefits By utilizing the above features, providers experience the following benefits: • Faster reimbursement • Reduce rejected claims (Clean Claims) • Decrease time‐intensive manual tasks • Increase productivity and efficiency • Improve cash flow EDI Frequently Asked Questions What are your EDI Routing Numbers? HSPC1 (CareVu & Availity) 75250 (Emdeon) 75237 Accel Network How can I contact HealthSmart Information Systems? • Email: [email protected] • Phone: 888.744.6638 • Fax: 806.473.2425 What is the mailing address for HealthSmart Information Systems? HealthSmart Information Systems 2002 West Loop 289, Suite 110 Lubbock, TX 79407 What type of claims do you receive? At this time, we receive HCFA‐1500s, UB‐92s and UB‐04s electronically. What other clearinghouses work with HealthSmart? Our list of clearinghouses is constantly changing. For the most accurate answer, please contact HealthSmart Information Systems at 888.744.6638. 06/01/2010 Reference Guide for HealthSmart Providers page ‐30‐ IX. Electronic & Online Services Online Services & Resources •
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Claim status (contracted providers only) Health Smart Provider Look Up Provider Manual Repricing Reason Codes Request Information (fee schedule, network access application, etc.) Update Demographic Information Search for participating providers Provider Links • Applications • Peer‐Review and Editorial Board • News Services • Decision Making Tools 06/01/2010 Reference Guide for HealthSmart Providers page ‐31‐ IX. Electronic & Online Services Online Claim Status Instructions The Online Claim Status is a service provided to Payors and Providers that participate in the following networks: • HealthSmart Preferred Provider Network • PPO Plus Network • Beech Street Networks Go to:
http://www.healthsmart.com/HealthSmartCustomers/Providers.aspx
Click Here to login
or to register.
06/01/2010 Reference Guide for HealthSmart Providers page ‐32‐ IX. Electronic & Online Services Logging In to Online Claim Status 06/01/2010 When you get to
the Online Claim
Status login page,
login here.
If you are not already
registered for the
Online Claim Status,
click here to register.
Reference Guide for HealthSmart Providers page ‐33‐ IX. Electronic & Online Services Registering for Online Claim Status When registering for Online Claim Status, make sure the contact information is complete and accurate • Email address must include : .com, .net, etc. • All Fields are required • After completion, the system will acknowledge your registration • Email confirmation will be sent in 3 business days • Fax back confirmation by Provider must be received prior to activation 06/01/2010 Reference Guide for HealthSmart Providers page ‐34‐ IX. Electronic & Online Services Selecting an Online Claim Once you enter Online Claim Status, do the following: 1. Click on the appropriate provider’s name 2. Enter Date of Service 3. For a quick search, we recommended that you do not enter the patient’s last name. 06/01/2010 Reference Guide for HealthSmart Providers page ‐35‐ IX. Electronic & Online Services Viewing an Online Claim Provider name, tax id
number and address
will be listed here.
If payor name is
underlined, click and
will be connected to
the web site.
06/01/2010 To obtain a
repricing sheet,
click on the R.
Reference Guide for HealthSmart Providers page ‐36‐ X. Frequently Asked Questions Frequently Asked Questions Question: Answer: Question: Answer: Question: Answer: Question: Answer: Question: Answer: Question: Answer: Question: Answer: Question: Answer: How do I confirm network participation of a provider? By calling the HealthSmart Customer Service Department. They may be reached at any of the following numbers: • 800.687.0500 Health Smart Preferred Care • 866.511.4757 Interplan Health Group • 800.613.1124 Emerald Health Network • 877.212.2235 Accel Network How do I update my Preferred Provider information: address, Tax ID number, etc. If you are contracted directly with HealthSmart, an update can be faxed, emailed, or mailed. If you are contracted through a provider group, then the update must come from said group. How do I verify benefits? Please contact the Plan Administrator or Payor on the member’s ID card. Where do I file a claim? Are claims always sent to HealthSmart first? In most cases, claims may be submitted to HealthSmart directly. However, since claim flow may vary by individual employer, please always consult the patient’s ID card. A claim mailing address should be located on it. Can claims be filed electronically? HealthSmart currently has networks that can accept claims electronically. • For HealthSmart Preferred Care, please submit using routing number HSPC1 or 75250 (WebMD/Emdeon). • For the Health Smart Accel Network please use the routing code of 75237 • For Emerald Health Network, please submit using routing number 34167(WebMD/Emdeon). How can I receive a copy of a repricing sheet? For HealthSmart Preferred Care, utilizing the Online Claim Status program is the best, www.healthsmart.com. How do I obtain payment status ? For payment status, please contact the Plan Administrator or Payor located on the patient’s ID card. How do I appeal a payment? Claim payment may be appealed directly through the Plan Administrator or Payor listed on the patient’s ID card or by submitting an email request to [email protected]. 06/01/2010 Reference Guide for HealthSmart Providers page ‐37‐ X. Frequently Asked Questions Question: Answer: Question: Answer: How can I obtain an Approved Payor Listing? An Approved Payor Listing may be obtained by visiting our web site www.healthsmart.com or by submitting a written request to: HealthSmart Network Solutions Attn: Provider Relations 222 W. Las Colinas Blvd., Suite 600 N Irving, Texas 75039 Why are claims returned to me or rejected by HealthSmart? In order to process a claim, please ensure that the information filed on the claim is complete and accurate (to the best of your ability). Some reasons for returned or rejected claims are listed below: • Unable to identify employer group listed on the claim. • Employer group is not effective for the date of service. • Employer group terminated prior to this date of service. • Patient no longer has access to the HealthSmart network. • Patient/Insured not valid for this date of service for this group. • Payor has requested that claims be submitted directly to them. • Missing claim elements. 06/01/2010 Reference Guide for HealthSmart Providers page ‐38‐ X. Frequently Asked Questions PRODUCT TYPE STATES SUBMIT PAPER CLAIMS EDI NUMBERS SAMPLE ID CARD 06/01/2010 Reference Guide for HealthSmart Providers page ‐39‐