HealthSmart Provider Manual

HealthSmart Provider Manual

Table of Contents

Provider Quick Reference Guide .........................................................................................................2

About HealthSmart ............................................................................................................................2

Provider Data Submission Guide.........................................................................................................5

Utilization Review & Case Management Precertification .....................................................................7

Network Participation ......................................................................................................................10

Network Credentialing Guidelines .......................................................................................................... 10

Delegated Credentialing Requirements .................................................................................................. 11

Dispute and Complaint Resolution ......................................................................................................... 13

Network Products ............................................................................................................................14

HealthSmart Preferred Care ................................................................................................................... 15

HealthSmart Accel Network .................................................................................................................... 17

HealthSmart Payors Organization: An Out-of-Network Claims Solution ................................................ 19

HPO Highlights ........................................................................................................................................ 19

Workers Compensation Network ........................................................................................................... 20

Requirements for Being a HealthSmart Bureau of Workers¡¯ Compensation Provider in Ohio .............. 22

HealthSmart Dental Network.................................................................................................................. 24

HealthSmart Ancillary Solutions ............................................................................................................. 26

SmartNET and Ancillary Care Services (ACS)....................................................................................... 26

Auto Medical Program ............................................................................................................................ 28

World Trade Center Health Program ...................................................................................................... 29

C-8 (PFOA) Medical Monitoring Program ............................................................................................... 32

HealthSmart Patient Procedures & Services ......................................................................................42

Claims Submission and Reimbursement............................................................................................43

ICD10 Readiness and Compliance .....................................................................................................46

Electronic & Online Services .............................................................................................................50

Reference Materials .........................................................................................................................57

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Provider Quick Reference Guide

HEATHSMART QUICK REFERENCE GUIDE FOR PROVIDERS

Customer Service

800.687.0500

Verify Eligibility

Refer to the member ID card and call the telephone number printed on the

card to verify benefits and eligibility.

Pre-Certification

Refer to the member ID card for precertification instructions.

Refer to member ID card for claims filing instructions or mail to:

Claims Submission - Paper

HealthSmart Benefit Solutions

P.O. Box 53010

Lubbock, TX 79453-3010

Claim Submission ¨C Electronic

Refer to member ID card for claims filing instructions.

Electronic Data Interchange (EDI)

Refer to member ID card for claims filing instructions.

Phone: 800.687.0500

Claim Appeals

Client List

Email: priority.service@

Fax: 214.574.3992

Visit for the most current list of clients. (select

Providers, under Quick Links, select Client List)

Visit for the most current list of Payors. (From the home

EDI Payor List

page, go to Solutions & Services. Under Information Systems, click Payor

List[LS1])

E mail Co n ta c ts

Provider Relations

(listed by state in which provider practices)

Submit Provider Relations inquiries to the regional emails below[JG2][LS3].

IA, IL, IN, KS, MO, MN, ND, NE, SD, WI

pr.central@

CT, DE, KY, MA, MD, ME, MI, NH, NY, OH, PA,

TN, VA, VT, WV, RI, NJ

pr.east@

AL, AR, FL, GA, LA, MS, NC, NM, OK, SC, TX

pr.south@

AZ, CA, CO, ID, MT, NV, OR, UT, WA, WY, HI, AK

pr.west@

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HealthSmart

About HealthSmart

For more than 40 years, HealthSmart has offered a wide array of customizable and scalable health plan solutions for self-funded

employers. Our comprehensive suite of services address healthcare from all angles. We offer claims and benefits administration,

provider networks, pharmacy benefit management services, business intelligence, onsite employer clinics, care management,

wellness initiatives and web-based reporting.

We work closely with our clients and business partners to achieve better treatment outcomes. Our innovative strategies bring

balance back to healthcare plans. Although our solutions are offered on a standalone basis, HealthSmart is an industry leader

because of the ability to integrate services according to each client¡¯s needs.

We are headquartered in Irving, Texas, with service hubs throughout the country. Last year, our 1,600+ associates paid more than $6

billion in medical claims for more than 1,000,000 members, and we were ranked by the Business Insurance Journal as the largest

independent third party administrator in the nation. In addition, HealthSmart¡¯s ongoing expansion strategy has brought greater

economies of scale and additional capabilities to our clients. Our mission is to improve member health and reduce healthcare costs.

Vision and , Mission and Values

Our Vision. To be the healthcare industry¡¯s leading provider of innovative solutions

Our Mission. To lower the cost of healthcare and improve the health of our members

Core Values

Quality. We are committed to providing superior healthcare products and services to all our customers, clients and , brokers and

consultants.

Productivity. We strive for an approach that provides excellent results and continued growth.

Fulfillment. We maintain a positive work environment and work hard to develop the career paths of our team members.

Value. We create ongoing value and growth for our shareholders by maintaining a work culture that delivers positive financial

results.

Community. We are dedicated to the communities and charities we share with our associates and clients.

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