HealthSmart MPN Clients:

To meet Medical Provider Network (MPN) regulatory requirements pertaining to obtaining acknowledgements for all physicians and groups that were contracted with HealthSmart’s Workers’ Compensation Network prior to August 27, 2014, below you will find HealthSmart’s MPN Client listing for review.  Please note, HealthSmart is not a certified MPN in the State of California and this form is not intended to be representative of HealthSmart acting in the capacity of an MPN.  HealthSmart, however, serves as a contracting agent/leased network for several MPN Clients/Applicants.  Below you will find a listing of HealthSmart MPN Client/Applicants.

·         By your participation in HealthSmart’s Workers’ Compensation network you are automatically eligible to be a participating provider in the MPNs listed below.  However, it is ultimately the decision of the MPN applicant to choose the physicians/groups that will participate in the MPN.

·         To check if the physician/group has been selected to participate in any of the below MPNs, where applicable, click on the hyperlinked MPN Applicant name and search for your practice name (may be listed by individual physician or group name).

·         If you would like to de-select participation eligibility for any of the MPNs listed below, please uncheck the box preceding the HealthSmart MPN Client name, certify at the bottom of the form, then click submit to have your election transmitted to HealthSmart; or print, sign and send the form to HealthSmart via email at west.region@healthsmart.com or fax at 214-574-2368.

·         HealthSmart will communicate your de-selection to the specific MPN client(s) and also send an email acknowledging and providing status of your request within thirty (30) days of receiving your de-selection request.

Certification:

By clicking submit, I hereby acknowledge and agree that I have read and understand my rights and obligations with HealthSmart’s MPN client list.  I understand that HealthSmart is not a certified MPN but by my participation in HealthSmart’s Workers’ Compensation PPO I am eligible to participate in HealthSmart’s Client affiliated MPN’s should I be elected by the MPN applicant to participate in the network.  I further understand, where applicable, that upon submitting a request to de-select participation in a specific HealthSmart Client MPN that HealthSmart shall communicate my request to the MPN Client and I shall be removed from the MPN within sixty (60) days of submitting my de-selection request to HealthSmart, and where applicable, I shall continue to treat any injured worker benefiting from the de-selected MPN that is in my care as an in-network physician/group until an appropriate coordination and transfer of care is complete. 

*HealthSmart’s MPN Client list may be updated from time to time.  At any time visit http://www.healthsmart.com to view HealthSmart’s most up to date client list.