PROVIDER REFERENCE INFORMATION

HealthSmart appreciates your participation in its network of preferred providers. In an effort to assist your business office and staff, HealthSmart has summarized the most frequently asked questions on claims administration and pre-certification.

Who is HealthSmart?

HealthSmart is a national healthcare management services company dedicated to promoting cost-effective quality care to participating clients, employers, insurance companies, their members and patients. Through creative PPO plan designs and benefit incentives, employers offer their employees and covered dependents the opportunity to reduce their out-of-pocket medical cost(s) by utilizing providers on our networks. HealthSmart is always a benefit option; therefore the member/patient always has a choice in selecting their health care provider.

How to Identify a Member of a HealthSmart Network

HealthSmart makes every effort to identify participating PPO members. Most members have an ID card that contains our name and/or logo.

Eligibility and Benefit Information

HealthSmart does not verify membershipp eligibility or determine which healthcare services or benefits are covered. Always refer to the member ID card and call the telephone number printed on the card to verify benefits and eligibility.

Copayments

Only copayments and/or verified deductibles should be collected from the member at the time of service. Copayments and deductible levels may vary by employer. These amounts may be listed on the member ID card, or obtained by calling the benefit plan telephone number listed on the card.

Precertification

Most employer groups require precertification for inpatient and outpatient hospital services. Refer to the member ID card for the telephone number for precertification.

Billing Procedures

Submit claims for payment on the standard UB-92 or CMS 1500. Provide the following information when submitting a claim:

  • Patient Name
  • Patient Date of Birth
  • Group Plan Number
  • Covered Member’s ID Number
  • Covered Member’s Employer Name
  • Date of Service
  • CPT Code(s) and Description
  • ICD-9 Code(s)
  • Provider Name and Tax ID Number

The member should complete and sign an Assignment of Benefit Form. Mail claims to the address listed on the member ID card.
Upon receipt of payment, an Explanation of Benefits (EOB) from the Payor will identify the contract adjustments and any amounts due from the covered member. PLEASE NOTE: the member should not be billed for the contract adjustment amount.

Claim Status / Claim Appeals

To determine the status of a submitted claim, contact the Customer Service Department of the Payor listed on the member ID card.
Questions regarding the specific contract adjustment amounts of a processed claim can be directed to the appropriate Customer Service location.

Medical Referrals

Use of non-PPO providers is always an option to the member. However, members are encouraged through their benefit plan designs to use providers within the their network. HealthSmart encourages our providers to refer members to other participating providers and facilities.

Contact Customer Service

HealthSmart has customer service professionals designated specifically for provider relations:

Phone: 800.266.5896
Fax: 330.686.7087