About HealthLink HMO Classic

HealthLink HMO Classic is offered to employers, labor organizations, school districts and certain state and municipal governmental subdivisions that self-fund their group health plans. Typically, these clients desire to offer a HMO plan design (either in combination with a HealthLink PPO program or an indemnity plan) while preserving their self-funding arrangement. HealthLink HMO Classic may also be offered on an insured basis in Missouri, Illinois and Arkansas service areas through HealthLink HMO's contractual relationships with certain insurance carriers. These carriers provide reinsurance, market the program directly and through their agent and broker relations, and report employer membership and enrollee eligibility to HealthLink HMO.

HealthLink HMO administers benefits, pays claims and issues remittance advice and enrollee explanations of benefits for health plans enrolled in HealthLink HMO. These plans may be employer or trust funded health plans, as well as fully insured health plans made available in conjunction with certain health carriers.

Payor plans that use HealthLink HMO Classic incorporate typical benefit features of a Health Maintenance Organization into their benefit plan design. Such features may include coverage for preventive services, diagnostic and medical care, behavioral health treatment and prescription coverage for eligible enrollees. Further, these payor plans generally prescribe that benefits are payable for covered services when plan enrollees use the HealthLink HMO network of participating physicians, hospitals and other health care professionals - as well as vision, behavioral health and pharmacy management specialty networks contracted with HealthLink HMO. With the exception of OB-GYN care, behavioral health treatment and emergency care, payor plans using HealthLink HMO must select a HealthLink HMO participating primary care physician to provide or coordinate the provision of all medical care in order for benefits to be payable for covered services.

Network Configuration - Primary Care Physician-Coordinated Care
The HealthLink HMO network consists of contracted primary care physicians, specialists, allied health care professionals and hospitals participating in a service area that includes Missouri, Illinois, Indiana and Arkansas. Generally, physicians and facilities that participate in HealthLink HMO are a subset of the physicians and facilities participating in HealthLink's PPO program.

Physicians contracting with HealthLink HMO are in private or academic practices. Hospitals include community as well as tertiary care facilities. At the time of enrollment, enrollees of a group health plan-sponsored HealthLink HMO Classic program select a HealthLink HMO participating primary care physician from the practice areas of Family Practice, General Medicine, Internal Medicine and Pediatrics. With few exceptions, the primary care physician delivers medically necessary covered services and/or authorizes all referrals to specialists for these services. Referrals are not necessary for OB-GYN services provided by HealthLink HMO participating OB-GYNs.

Patients may also self-refer for emergency care, and to participating behavioral health practitioners by contacting the care coordinator identified on the patient's enrollee ID card.

Claim Coordination
HealthLink HMO, Inc. processes claims, determines benefits and pays claims in accordance with the enrollee's plan. HealthLink HMO's claim and Utilization Management systems are integrated to verify that charges are consistent with Utilization Management findings and primary care physician authorizations. HealthLink works with regional and national electronic claim vendors.

Preventive Care Benefits
Payor plans that use HealthLink HMO Classic provide coverage for preventive care including routine exams, immunizations, mammography, prenatal care and annual routine OB-GYN services. Services must be delivered by participating HealthLink HMO physicians, hospitals, laboratories, radiology centers and health care professionals.

Flexible Plan Design
Payor plans that use HealthLink HMO Classic include a standard set of covered preventive care and medical benefits. Co-payments, deductibles, pharmacy coverage and behavioral health arrangements may vary. Please refer to your patient's enrollee ID card or call HealthLink Customer Service for information.

HEALTHLINK HMO CLASSIC PROGRAMS AND SERVICES

Provider Networks
Primary Care Physician-Directed Care
Capitation and Discounted Fee-for-Service Arrangements
Outpatient Laboratory Arrangements
Pharmacy Network and Benefit Management
Vision Care Network and Benefit Management
Behavioral Care Network and Benefit Management

Medical Management
Pre-Admission Certification of Planned Hospital Admission
Notification of Emergency Hospital Admission
Concurrent Hospital Stay Review
Discharge Planning
Case Management
Specialty Care Referral
Pre-Certification of Selected Ambulatory/Outpatient Services
Pre-Certification of Selected Ancillary Services
Medical Management Appeals Process

HealthLink-Provided Administrative Services
Full Claim Adjudication, Payment and Remittance Advice
Toll-Free Customer Service
Network Services
Enrollee ID Cards and Benefit Information
Claim Investigation and Resolution
Payor and Network Contract Administration
Utilization Management
Network Services Representatives
Centralized Credentialing
Enrollee Eligibility File Maintenance
Network Directory Publication (Web Availability)
Web-Based Resources and Promotion

HealthLink HMO Classic Quick Reference

Customer Service Call Center
To verify benefit coverage for health services or patient eligibility, please contact the benefit administrator identified on the patient's enrollee ID card. If you use Gateway EDI as a clearinghouse, you can verify patient eligibility through the Gateway system.

You may obtain claim status and payor information at the patient account level through HealthLink's IVR (Interactive Voice Recognition) system and by logging onto HealthLink's website, www.healthlink.com. Your PIN number (EDI claim filing and claim status authorization number) will allow you to access claim activity up to nine months old for multiple or single patient accounts specific to the practitioner or facility. IVR and web access for claims information are available from 5:00 a.m. to midnight CST.

If your request cannot be adequately addressed, you may call:

HealthLink Customer Service
Toll-free 1-800-624-2356
Hours: 7:30 a.m. to 5:30 p.m. CST
Open business days

Medical Management
HealthLink’s Medical Management program provides clinical review of the medical necessity for proposed or concurrent medical care to assist contracted payors in determining benefit eligibility in accordance with the health plan benefit provisions. The following Medical Necessity Review Components are included in the HealthLink HMO Classic program:

• Pre-Admission Certification of Planned Hospital Admission
• Notification of Emergency Hospital Admission
• Concurrent Hospital Stay Review
• Discharge Planning
• Case Management
• Specialty Care Referral
• Pre-Certification of Selected Ambulatory/Outpatient Services
• Pre-Certification of Selected Ancillary Services
• Medical Management Appeals Process

For specialist referral authorization, certification of hospitalizations and outpatient procedures, please call:

HealthLink Utilization Management
Toll-free 1-877-284-0102
Hours: 8:00 a.m. to 5:00 p.m. CST
Recorded messages after 5:00 p.m. CST

For pre-certification, please be prepared to provide the following information:

• Patient Name
• Diagnosis
• Patient ID Number (SSN)
• Procedure Required
• Hospital Name
• Date of Admission
• Admitting Physician Name and Tax ID Number

WellPoint NextRx
For inquiries about pharmacies, procedures and medications, please call:

Customer Service
1-888-820-0287
Hours: M-F 7:00 a.m. to 9:00 p.m. CST
Saturdays 8:00 a.m. to 7:00 p.m. CST

Vision Service Plan
For inquiries about routine vision examinations and vision care benefits, please call:

Customer Service
1-800-877-7195
1-800-428-4833 (for T.D.D.)
Hours: M-F 7:00 a.m. to 9:00 p.m. CST
Saturdays 8:00 a.m. to 4:30 p.m. CST

Co-payments
Co-payments vary by employer group. Please refer to the patient's enrollee ID card for applicable co-payment amounts or call HealthLink Customer Service to verify applicable co-payments. For inquiries regarding prescription co-pays, call WellPoint NextRx at 1-888-820-0287.

Claims Submission
Submit electronic claims through your electronic clearinghouse vendor:
HealthLink HMO Payor ID 96475

Submit paper claims to:
HealthLink HMO
P.O. Box 411580
St. Louis, MO 63141

Appeals Submission
Claim denials, payment reviews (not pertaining to fee allowances), claim status, lack of pre-certifications, etc. should be directed to the claims administrator listed on the patient's enrollee ID card.

For all other types of administrative, service and clinical appeals, please submit a typed explanation of the appeal consideration along with supporting information, and mail to:

HealthLink Appeals Division
P.O. Box 411424
St. Louis, MO 63141