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.
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
email@example.com or fax at
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.
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
http://www.healthsmart.com to view HealthSmart’s most up to date client list.