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:
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:
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
HealthLink®, Inc., is an Illinois corporation. HealthLink, Inc. is an organizer of independently contracted provider networks, which it makes available by contract to a variety of payors of health benefits, including insurers, third party administrators or employers. HealthLink has no control or right of control over the professional, medical judgment of contracted providers, and is not liable for any acts or failures to act, by contracted providers. HealthLink, Inc. is not an insurance company and has no liability for benefits under benefit plans offered or administered by payors. HealthLink® is a registered trademark of HealthLink, Inc. and a separately incorporated and capitalized subsidiary of WellPoint, Inc. Any reference in the material to other organizations or companies, including their Internet sites, is not an endorsement or warranty of the services, information or products provided by those organizations or companies. Discount offerings made available by third-party vendors.