HealthSmart Reference Guide for HealthSmart Providers

I. Contact Quick List

This section provides essential contact information for various HealthSmart services and inquiries.

General Inquiries & Online Access:

• Visit: healthsmart.com
• 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

Credentialing & Provider Relations:

• Email: networkinfo@healthsmart.com
• To check Credentialing status
• Speak with a Provider Relations Representative
• Inquire about fee schedules
• Request an orientation or in-service

Provider Data Updates:

• HealthSmart Preferred Care: Email: external.updates@healthsmart.com
• Interplan Health Group: Email: cgc.data@healthsmart.com
• Emerald Health Network: Email: ehndata@healthsmart.com
• For these networks, submit additions, changes, & terminations to provider data information or panel.

Member Information Verification:

• See phone numbers on the member's ID card.
• To verify member information, including: Eligibility, Benefits, Precertification requirements, Claim payment status.

II. About HealthSmart

Comprehensive & Innovative Healthcare Solutions

HealthSmart Holdings is a holding company comprising several healthcare-related subsidiaries. The HealthSmart companies are dedicated to providing comprehensive and innovative healthcare solutions to meet client needs. Their goal is to improve health and reduce costs by leveraging technology, a dedicated team of professionals, and a fully-integrated inventory of wholly-owned products and services. HealthSmart aims to custom-fit services to meet the needs of any organization, providing smarter healthcare solutions.

As a healthcare solutions company, HealthSmart focuses on delivering services and tools that reduce costs and improve member health and well-being. They emphasize a partnership approach to understand member needs and deliver valuable solutions. HealthSmart believes its integrated healthcare solution delivers necessary results.

Well-developed Services Provide Nearly Endless Savings Options

HealthSmart has acquired companies, developed technologies, and utilized professionals to become a comprehensive healthcare solutions provider. They serve over 1 million member lives through distinct, synergistically linked business units. Key offerings include:

• THE HEALTHSMART PREFERRED PROVIDER NETWORKS: Includes PPO networks like HealthSmart Preferred Care Network, Interplan Group Health Network, and Emerald Health Network.
• 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: Manages on-site employer-sponsored healthcare clinics.
• HEALTHSMART INFORMATION SYSTEMS INC.: An information technology provider experienced with over 100 million EDI transactions.

HealthSmart guarantees forward-thinking, high-quality products and services, secure networks, credentialed providers, seamless administration, and a commitment to making a positive impact on customers and their members.

Vision, Mission and Values

Our Vision: To be the healthcare industry's leading provider of innovative solutions.

Our Mission: To provide clients with the highest quality healthcare solutions using the latest technology and a resourceful team of professionals, focused on reducing costs and improving member health.

Core Values:

• QUALITY: Commitment to superior healthcare products and services for customers, clients, brokers, and consultants.
• PRODUCTIVITY: Striving for a winning approach that yields excellent results and continued growth.
• FULFILLMENT: Maintaining a positive work environment and promoting personal values for a successful career.
• VALUE: Creating ongoing value and growth for shareholders through a corporate culture that delivers positive financial results.
• COMMUNITY: Dedication to communities and charities shared with associates and clients.

III. Provider Data Update Process

Provider Data Update Process

This section details the process for making additions, terminations, and changes to provider data.

Making Additions, Terminations and Changes

HealthSmart Preferred Care:

• Email: external.updates@healthsmart.com
• Fax: 806.473.2525, Attention: Data Management
• Mail: HealthSmart Preferred Care, Attn: Data Management, 2002 W. Loop 289, Ste 121, Lubbock, TX 79407
• Verify information received: 800.687.0500

Interplan Health Group:

• Email: cgc.data@healthsmart.com
• Fax: 806.473.2525, Attention: Data Management
• Mail: Interplan Health Group, Attn: Data Management, 2002 W. Loop 289, Ste 121, Lubbock, TX 79407
• Verify information received: 800.613.1124 or 866.511.4757

Emerald Health Network:

• Email: ehndata@healthsmart.com
• Fax: 216.479.2039, Attention: Data Management
• Mail: Emerald Health Network, Attn: Data Management, Tower at Erieview, 1301 E. 9th Street, Suite 2400, Cleveland, OH 44114
• Verify information received: 800.613.1124 or 866.511.4757

Update Provider Data

To update provider data, navigate to: http://www.healthsmart.com/HealthSmartCustomers/Providers.aspx. Look for the option to 'Click Here to Update Provider Information'.

Data Submission Tips

All updates (adds for delegated providers only, terms, or changes) must be received in writing via fax, email, or mail.

If submitting electronically, please use Excel format. Ensure the submission includes:

• Provider 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

IV. 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. This notification includes the reason for non-certification and the appeal mechanism. Appeals can be initiated by phone but require written follow-up within 60 days of the original determination. Medical records may be requested. The Utilization Management Department handles appeals, involving physician consultants for review. Expedited appeals for emergency care non-certification are completed within one working day. Other appeals are completed within 30 days of request and documentation receipt.

Application

Application requests for participation can be obtained from the applicable state's insurance department website, at www.healthsmart.com, or by contacting HealthSmart.

Case Management

A service designed to identify Covered Individuals who can benefit from close review and management due to length, severity, complexity, or cost of health care services. Case Managers locate and assess medically appropriate settings and manage health care benefits cost-effectively. The goal is to ensure care is provided in the most appropriate and least costly setting without compromising quality. Case Managers work with hospitals, physicians, families, and ancillary providers. Early identification is key, with referrals from pre-certification and concurrent review processes.

Certification

The determination made by a licensed, registered, or certified health care professional engaged by the Utilization Management program, confirming that health care services rendered by a Preferred Provider meet the requirements of care, treatment, and supplies. This is also known as 'Precertification'.

Concurrent Review

After admission, the Utilization Management Department monitors services on a concurrent basis. If a Covered Individual is not discharged within the approved timeframe, Utilization Review personnel contact the attending physician for additional information. Both care and services are monitored, with further certification depending on medical necessity.

Confidentiality

All Covered Individuals have the right to Privacy and Confidentiality as provided by State and Federal Law. Confidentiality of records and information is maintained according to all applicable laws and shared only with authorized agencies.

Covered Individual or Person

Any person eligible to receive health services covered by a plan administered by HealthSmart or a HealthSmart Network Payor.

Discharge Planning

The process of assessing a Covered Individual's needs for post-hospitalization treatment to arrange for necessary services and resources for an appropriate and timely discharge. It also identifies individuals needing post-discharge care, such as home health or extended care facilities. Early identification ensures timely discharge and cost-effective quality care.

Emergency Admissions

Notification of Emergency Admission must occur within 48 hours of admission.

HealthSmart Network

A PPO network of facilities, physicians, and other healthcare providers who have agreed to provide service to a Covered Individual.

HealthSmart Network Payor

A self-insured employer, Third Party Administrator, insurance company, health services plan, trust, non-profit facility service plan, governmental unit, or other entity responsible for administering, processing, arranging, or securing access to covered health care services or benefits for Covered Persons.

Maternity Admissions

Covered Individuals should contact HealthSmart Care Management Solutions or the UM Services provider early in pregnancy. Utilization Review personnel work with physicians to monitor pregnancies for potential high risk. High-risk pregnancies are referred to a Case Management Nurse. The Utilization Management Department must be notified of admissions for labor and delivery, as well as any other admissions prior to delivery (e.g., complications) or if the baby is not discharged with the mother.

Medical Criteria

Established, nationally recognized criteria used by Utilization Management Department personnel to determine the appropriateness of medical services. Criteria are reviewed annually and may include length-of-stay parameters based on expected outcomes, utilizing national norms like PAS guidelines.

Outpatient Surgery

The Utilization Management provider reviews procedures for recommendation of an outpatient surgical setting. Medical information is checked against established criteria to determine if a procedure can be safely performed on an outpatient basis. The provider then discusses this possibility with the Covered Individual's physician.

Pre-Admission Testing

The Utilization Management provider may suggest pre-admission testing for necessary hospitalizations. This allows routine tests (X-rays, lab tests, EKGs) to be done on an outpatient basis before confinement, potentially saving a hospital night. The attending physician determines if testing can be performed outpatient.

Preferred Provider

A licensed facility or licensed registered or certified healthcare professional who agrees to provide health care services to Covered Individuals. May be referred to as 'Provider'.

Retrospective Review

Cases where precertification and concurrent review were not performed are reviewed retrospectively, focusing on admission day and continued hospital stay. Information is obtained from the hospital or attending physician, and medical necessity is determined using established criteria. If criteria are not met, denial and appeal procedures apply.

Review Guidelines

Reviews are conducted according to the 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, through pre-admission certification, concurrent review, retrospective review, discharge planning, and Case Management.

Utilization Review

A program by HealthSmart Care Management Solutions or a HealthSmart Network Payor to evaluate requests for care, treatment, or supplies against established clinical criteria for medical necessity, appropriateness, and efficiency.

V. Network Participation

Network Credentialing Guidelines

HealthSmart maintains a high-quality network by credentialing and recredentialing providers according to American Accreditation HealthCare Commission standards. Providers must complete a Provider Application and Agreement, available via HealthSmart or www.healthsmart.com. Information must be complete for processing.

A National Practitioners Data Bank query verifies state licenses. For providers with admitting privileges, a query checks clinical privileges at the primary network hospital/facility. Malpractice experience is verified, with cases reviewed by a peer committee. Malpractice information for the past five years (or three for recredentialing) is required. Provider liability insurance must meet state and industry standards, and employees must maintain applicable coverage. Applicants must not have participated in Medicare or Medicaid fraud. Highest educational status or current Board Certification must be verified. Active credentials include State License, DEA, Controlled Substance Certificate, and Malpractice Insurance Certificate.

HealthSmart offers delegated credentialing for groups meeting URAC or NCQA guidelines. Approved groups sign a Delegated Credentialing Agreement and agree to monthly reporting of provider actions, quarterly submission of updated rosters, compliance with URAC/NCQA standards, 15-day advance notice of program changes, 10-day notification of physician privilege revocation/suspension, and annual audits. HealthSmart reserves the right to terminate agreements for deficiencies if corrective action is not taken.

Participation Program Requirements

Subcontracts of Physician Agreement

Provider Agreements may be assigned only with Network consent. Network may assign agreements to affiliated entities with physician notification. Subcontracts are subject to agreement terms. Physicians must notify subcontracted providers where to find the HealthSmart Provider Manual, available at www.healthsmart.com.

Health Care Services

Physicians must provide Covered Services to Covered Persons in accordance with the Provider Reference Guide and applicable Agreement. Services must comply with federal and state laws, licensing requirements, and professional standards, be Medically Necessary, and rendered according to generally accepted medical practices. Services must be provided in the same manner as to other patients, without regard to race, age, religion, sex, national origin, marital status, sexual orientation, source of payment, or disability.

Medical Records

Physicians must maintain complete and professionally adequate medical records for at least four years (or longer if required by law) and make them available to Network, Group, and governmental agencies. Records must be readily available to verify charges and compliance with community standards. Records are accessible with reasonable notice during regular business hours.

Confidentiality and Covered Individuals' Rights

Covered Individuals have the right to Privacy and Confidentiality as required by State and Federal Laws. Medical information will only be released to authorized persons.

Patient Rights

• Be treated with respect and dignity by network physicians and personnel.
• Be assured privacy and confidentiality for treatments, tests, and procedures.
• Voice concerns about service and care received.
• Receive timely responses to concerns.
• Be provided access to healthcare, physicians, and facilities.
• Have coverage decisions and claims processed according to regulatory standards.
• Choose an advance directive for care wishes.

Patient Responsibilities, to the extent capable

• Know and confirm benefits before treatment.
• Contact an appropriate health care professional when a medical need arises.
• Show health care ID card before receiving services.
• Pay necessary copayments at the time of treatment.
• Use emergency room services only for injury or illness requiring immediate treatment to avoid jeopardy to life or health.
• Keep scheduled appointments.

Delegated Credentialing Requirements

HealthSmart offers delegated credentialing for groups meeting URAC or NCQA guidelines. Upon approval by the Medical Advisory Committee, groups are granted delegation status and sign a Delegated Credentialing Agreement. The delegated entity agrees to:

• Reporting: Submit monthly reports on provider actions (licensing status, additions, changes, terminations) and quarterly rosters highlighting changes.
• Compliance: Adhere to URAC/NCQA guidelines and HealthSmart standards.
• Program Change Notification: Provide 15 days advance notice of material changes.
• Physician Status Notification: Notify HealthSmart within 10 days of a hospital revoking or suspending a physician's privileges.
• Audit: HealthSmart reserves the right to annually monitor and audit delegated entities' performance.
• Corrective Action: Provide a written response within 15 days if deficiencies are identified, either disputing the deficiency or submitting a corrective action plan.

Dispute/Complaint Resolution

Participating providers can initiate a dispute resolution or appeal process for grievances related to network status or actions taken by HealthSmart concerning professional competency or conduct. Contact the HealthSmart Medical Director, Credentialing Manager, or Quality Management Coordinator. If informal resolution fails, a written grievance can be submitted within 30 days. Matters are discussed at Medical Advisory Committee meetings. Appeals can proceed to Ad Hoc Committees for review. HealthSmart may automatically remove providers posing an immediate threat.

Disputes regarding rights and obligations under the Agreement may be resolved through arbitration. Parties will appoint representatives, and if resolution fails, arbitration will proceed before a single arbitrator. The arbitrator's decision is final and binding.

Provider Responsibility for Complaint Resolution

Providers must cooperate with the network in investigating inquiries and complaints and notify HealthSmart of any complaints received against their practice. Providers will also cooperate in the development and verification of information regarding profiling patterns.

VI. Products

HealthSmart Network Solutions encompass various provider networks, bringing nationwide healthcare coverage, credentialed providers, and management services. Wholly-owned provider networks include:

Preferred Provider Organization (PPO)

• Covered Persons may receive medical care from any licensed healthcare provider.
• Receiving services outside the Network panel results in less benefit reimbursement.
• PPO Participating Providers should refer only to PPO Network Participating Providers.
• PCP selection and referrals are not required, but precertification may be needed. Contact the plan administrator for details.

HealthSmart PPOs Include: HealthSmart Preferred Care, Interplan Health Group, Emerald Health Network.

Exclusive Provider Organization (EPO)

• Covered Persons may receive medical care from any licensed healthcare provider.
• EPO products provide in-network coverage only, except for emergency services.
• EPO Participating Providers should refer only to Network Participating Providers.
• PCP selection and referrals are not required, but precertification may be needed. Contact the plan administrator for details.

HealthSmart EPOs Include: HealthSmart Preferred Care, Interplan Health Group.

Gated Exclusive Provider Organization (GEPO)

• Only providers participating in the Network's GEP product provide services to GEPO's Covered Persons within the Network Service Area.
• GEPO Participating Providers should refer only to GEPO Network Participating Providers.
• Benefits may not be available for services rendered outside the GEPO Network.
• Enrolled Covered Persons may be required to select a Primary Care Physician (PCP).
• The GEPO product encourages steerage to local GEPO providers and promotes member treatment coordination 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 the Covered Person's benefit design.
• Participating Providers are specified as Primary Care Physicians (PCP) or Specialists.

HealthSmart GEPOs Include: HealthSmart Preferred Care.

HealthSmart Accel Network

HealthSmart Accel is a superior managed care provider network designed for cost containment and excellent hospital/physician access. It offers an unparalleled solution for network management, pharmacy management, and other managed care services.

Accel Highlights

• Covered Persons may receive medical care from any licensed provider.
• PCP selection and referrals are not required.
• Accel Participating Providers should refer within the Accel Network. Benefits may be limited for out-of-network services, with reimbursement at an RBRVS-based fee schedule, resulting in higher member responsibility.
• Precertification is driven by the Covered Person's benefit design.

Accel Guidelines

• Accel product identified on member's ID card.
• Electronic claim processing, submission, remittance advice, and fund transfer are available, along with 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 align with Carrier Guidelines.
• Network and Payor adhere to predefined payment and service terms.

(Sample ID Card information is described textually in the original document, not included here as per instructions to exclude image-like content.)

HealthSmart Preferred Care

The HealthSmart Preferred Care Network, established in 1993, is a nationwide PPO focused on managing cost and quality in healthcare. It has a significant regional presence in the Southwest US but offers nationwide coverage. HealthSmart Preferred Care serves over three-quarters of a million covered lives. It aims to create a productive and effective business environment for employers, payors, administrators, and providers.

(Sample ID Card information is described textually in the original document, not included here as per instructions to exclude image-like content.)

HealthSmart Preferred Care GEPO

The HealthSmart Preferred Care GEPO is a Gated Exclusive Provider Organization offering deep healthcare discounts in the Dallas-Fort Worth Metroplex. GEPO should be displayed on member ID cards. The DFW GEPO and the standard GEPO are distinct plans with different requirements.

(Sample ID Card information is described textually in the original document, not included here as per instructions to exclude image-like content.)

Emerald Health Network

Emerald Health Network (EHN), established in 1983, is a premier PPO network in Ohio, serving employers and providers. It comprises 225 hospitals, 2,500+ ancillary providers, and over 30,000 physician locations throughout Ohio and bordering states. EHN focuses on controlling healthcare costs without compromising quality and has expanded its coverage in the Midwest. EHN also manages the Accountable Health Plan of Ohio (AHPO), offering a robust provider network in south-central Ohio with competitive rates in the Columbus region.

(Sample ID Card information is described textually in the original document, not included here as per instructions to exclude image-like content.)

Interplan Health Group

Interplan Health Group (IHG) Network provides network coverage and state-of-the-art healthcare management services. IHG offers high-quality products, a secure network, credentialed providers, and seamless administration. With over 600,000 providers and 5,000 hospitals nationwide, IHG offers a full spectrum of services. Direct contracting with providers ensures efficient and personal relationships. Integrating IHG's Care Management program with the IHG PPO network leads to greater savings and care coordination.

(Sample ID Card information is described textually in the original document, not included here as per instructions to exclude image-like content.)

HealthSmart Payors Organization

The HealthSmart Payors Organization (HPO) is HealthSmart's national secondary preferred provider network, with over 260,000 directly contracted providers in over 476,000 locations, making it the second largest secondary/wrap network. HPO focuses on reducing medical expenses and claim processing time through a strategic national network build-out. It offers out-of-network discounts significantly above the national average by directly contracting with partner networks, optimizing cost savings in a provider-friendly manner. HPO's versatility accommodates diverse client healthcare needs.

(Sample ID Card information is described textually in the original document, not included here as per instructions to exclude image-like content.)

Workers Compensation Network

This network focuses on returning injured workers to the workplace quickly and cost-effectively. Its strength lies in savings that impact claim costs. The network includes over 38,000 directly contracted providers across a broad range of specialties, experienced in treating work-related injuries. Providers focus on addressing medical issues and facilitating return-to-work. Specialties include primary care, occupational health, behavioral health, ancillary providers, hospitals, diagnostic networks, neurologists, occupational specialists, chiropractors, physical therapy, alternative medicine practitioners, and pharmacy networks.

Relationships That Work: Direct contracts foster efficient and positive relationships, earning HealthSmart a reputation as a premier Workers Compensation Network in the western region. Facility contracts include provisions for cost-effective medical treatment, and pharmacy network partners provide savings.

Coverage That Covers The Map: Provides broad network coverage across the western region, with specialized networks for California, Washington, and Nevada. Coverage is expanding to Oregon, Arizona, the Southeast, Midwest, and Southwest.

High-Tech and High-Touch: Technology is key, with an adaptable infrastructure for easy network data delivery. Focus is on electronic provider and customer connectivity, with a web-based repricing system. Individual websites provide information based on geography and specialty.

IHG / Dentinex Dental Network

HealthSmart offers Dentinex, a dental network for self-insured and fully-insured plans. Dentinex is a premier dental PPO Network in California, providing access to over 10,000 dental office locations. Members benefit from expanded dental benefits and lower out-of-pocket costs due to predetermined fee schedules, offering average savings of 30% or more, including discounts on cosmetic and non-covered procedures.

Freedom of Choice: The network of credentialed dentists and specialists is growing, offering members a wide choice. Staff quickly credential potential providers not currently in the network.

Service Made Simple: The network is designed for simple administration and ease of use. Unparalleled customer service is provided for implementation and ongoing administration. Directories, toll-free lines, and Internet look-up capabilities help members find Dentinex providers. Networks can be customized for larger groups needing national PPO coverage.

(Sample ID Card information is described textually in the original document, not included here as per instructions to exclude image-like content.)

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 since 2005. Ancillary services supplement or support care from hospitals and physicians, including laboratories, dialysis centers, diagnostic centers, surgery centers, and durable medical equipment (orthotics, prosthetics).

ACS offers cost-effective alternatives through a national network of approximately 2,500 providers at over 25,000 sites. It aims to lower ancillary healthcare costs and serve members with high-quality, cost-effective providers. The ACS network includes 26 primary specialties and over 30 subspecialties.

Primary services include:

High Performance Network

The HealthSmart High Performance Network provides plan members access to the most cost-effective providers in their service area, reducing healthcare costs by utilizing specific facilities and providers within a select geographic region.

Auto Liability Network

This network offers timely access to experienced providers for trauma-related injuries and special medical needs with maximum cost efficiency in the western region. Its strength lies in savings that impact claim costs, connecting members to over 51,000 direct providers. It offers a deep contract structure, broad coverage, and customer service that fosters efficient working relationships. Contracts specifically identify auto liability as a covered line of business.

HealthSmart National

HealthSmart National Network offers a single, easy-to-navigate point of contact for one of the largest national provider panels in the US, including over 5,000 hospitals, top-rated tertiary care facilities, and hundreds of thousands of respected physicians. The concept is a national network customized to needs, focusing on service, simplicity, and savings, with benefits like one point of contact, time/cost savings, deep discounts, effective repricing, quality networks, provider selection, and ease of billing.

VII. Patient Procedures & Services

Patient Identification (ID) Cards

HealthSmart Covered Individuals receive an identification card from the HealthSmart Payor. While cards may differ by Payor, the HealthSmart logo or name should be visible.

Eligibility

Always contact the HealthSmart Payor to obtain eligibility and benefit information before rendering services. Health Plan designs vary, and restrictions may apply. At the time of service, obtain estimates for patient's coinsurance, deductible, plan design, and copay information to determine payment responsibility.

Utilization Review

To achieve maximum reimbursement, proposed medical care must be certified by the HealthSmart Payor's Utilization Review (UR) service. This confirmation can be via telephone, written, or online communication. Notification requirements vary based on the urgency of care. Certification does not guarantee payment. If a determination is made not to approve or certify a service, written notification is sent to the physician, hospital, Covered Individual, and Payor, including reasons and appeal mechanisms. Appeals can be initiated by phone but require written follow-up within 60 days. Medical records may be requested. The Utilization Management Department handles appeals, involving physician consultants. Expedited appeals for emergency care non-certification are completed within one working day; others within 30 days.

Referrals

To help Covered Individuals avoid benefit reductions, refer them to Preferred Providers in the HealthSmart Network. Preferred Providers should admit Covered Individuals to participating facilities within the HealthSmart Network, except in emergencies. Contact HealthSmart Provider Customer Service at 800.687.0500.

VIII. Claims Submission and Reimbursement

Claims Submissions and Reimbursement

Claims Submissions

HealthSmart Provider Networks are not insurance companies, guarantors, or payors and are not liable for claim payments. As a Preferred Provider, you agree to submit clean claims promptly for services rendered to Covered Individuals.

HealthSmart Accepts these Claim Forms:

• 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 on the Covered Individual's ID card.

Submitting Claims Electronically: If the network supports electronic claims, CMS-1500 and UB-04 forms can be submitted via transaction networks and clearinghouses (Electronic Data Interchange - EDI). This method is faster and more accurate. Required routing numbers for EDI claims include:

• HSPC1 (CareVu & Availity)
• 75250 (Emdeon / Web MD)
• 34167 (Emdeon / Web MD)

Prompt processing and payment depend on accurate and complete claim forms, including all necessary patient and insured information. Claims must be submitted within industry standard time frames unless specified in contract.

Claim Reimbursement

Preferred Providers should bill at the normal retail rate. The HealthSmart Payor will reimburse after benefits are applied, providing an Explanation of Payment (EOP). Members cannot be charged for Covered Services beyond copayments, coinsurance, or deductibles. Members may be charged for Non-Covered services with prior written consent, which must be signed and dated by the member and retained in their medical record.

Verify each HealthSmart Payor's plan for exclusions or benefit reductions. Bill members directly for services not covered by their plan. If an adjudication error occurs, contact the appropriate HealthSmart Payor listed on the ID card or EOP.

Multiple Procedures

For multiple surgical procedures, obtain benefit information from the HealthSmart Payor for each procedure.

Coordination of Benefits

Covered Individuals may have multiple insurance policies. Always obtain complete benefit information from each Payor when verifying a Covered Individual's health plan benefit.

Complaint & Appeal Procedures

Complaints and appeals can 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 and appeals can also be filed by mail to: HealthSmart, Attn: Provider Relations, 222 W. Las Colinas Blvd, Suite 600N, Irving, Texas 75065. Email submissions can be sent to clientservices@healthsmart.com.

Contact the Provider Relations department for any problems or questions regarding the HealthSmart provider network or contract.

Provider Relations

The Provider Relations department can be reached:

• HealthSmart Preferred Care: 800.687.0500
• Interplan Health Group: 866.511.4757

This team provides:

• 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

IX. Electronic & Online Services

Electronic & Online Services

Electronic Data Interchange (EDI) Clearinghouse

HealthSmart offers a Full Service Healthcare EDI Clearinghouse open to all providers. The goal is to provide the highest level of customer service.

EDI Services

• 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

• Faster reimbursement
• Reduced rejected claims (Clean Claims)
• Decreased time-intensive manual tasks
• Increased productivity and efficiency
• Improved 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: support.his@healthsmart.com
• 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?

HCFA-1500s, UB-92s, and UB-04s are received electronically.

What other clearinghouses work with HealthSmart?

Contact HealthSmart Information Systems at 888.744.6638 for the most current list.

Online Services & Resources

• Claim status (contracted providers only)
• 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

Online Claim Status Instructions

Online Claim Status is a service for Payors and Providers participating in the following networks:

• HealthSmart Preferred Provider Network
• PPO Plus Network
• Beech Street Networks

Go to: http://www.healthsmart.com/HealthSmartCustomers/Providers.aspx

To log in or register, follow the instructions on the page.

Registering for Online Claim Status

Ensure contact information is complete and accurate. Email addresses must include .com, .net, etc. All fields are required. Registration acknowledgment and email confirmation will be sent within 3 business days. Fax back confirmation from the provider is required prior to activation.

Selecting an Online Claim

Once in Online Claim Status, click the provider's name, enter the Date of Service. Entering the patient's last name is optional for a quick search.

Viewing an Online Claim

The provider name, tax ID number, and address will be listed. If a payor name is underlined, clicking it connects to the payor's website. Click 'R' to obtain a repricing sheet.

X. Frequently Asked Questions

How do I confirm network participation of a provider?

Call the HealthSmart Customer Service Department 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)

How do I update my Preferred Provider information (address, Tax ID, etc.)?

If contracted directly with HealthSmart, updates can be faxed, emailed, or mailed. If contracted through a provider group, the update must come from that group.

How do I verify benefits?

Contact the Plan Administrator or Payor listed on the member's ID card.

Where do I file a claim? Are claims always sent to HealthSmart first?

In most cases, claims can be submitted directly to HealthSmart. However, claim flow varies by employer; always consult the patient's ID card for the correct mailing address.

Can claims be filed electronically?

HealthSmart networks accept electronic claims. Use routing number HSPC1 or 75250 (WebMD/Emdeon) for HealthSmart Preferred Care; 75237 for Health Smart Accel Network; and 34167 (WebMD/Emdeon) for Emerald Health Network.

How can I receive a copy of a repricing sheet?

For HealthSmart Preferred Care, utilize the Online Claim Status program at www.healthsmart.com.

How do I obtain payment status?

Contact the Plan Administrator or Payor located on the patient's ID card.

How do I appeal a payment?

Appeal payments directly through the Plan Administrator or Payor on the patient's ID card, or email clientservices@healthsmart.com.

How can I obtain an Approved Payor Listing?

Visit www.healthsmart.com or submit 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 or rejected?

Ensure claim information is complete and accurate. Reasons for returned/rejected claims include:

• Unable to identify employer group.
• Employer group not effective or terminated for the date of service.
• Patient no longer has access to the HealthSmart network.
• Patient/Insured not valid for the date of service for the group.
• Payor requested claims be submitted directly to them.
• Missing claim elements.