About HealthLink Open Access Programs
HealthLink Open Access programs offer payors access to HealthLink's network(s) of participating physicians, hospitals and other health care professionals. HealthLink Open Access programs are offered in Missouri, Illinois, Indiana and Arkansas. The program differs from the HealthLink POS program described in Chapter 5 in that it does not require primary care physician referral authorization/care coordination. In addition, preventive care and medical treatment are reimbursed on a negotiated fee-for-service basis. HealthLink HMO, Inc. may administer claims in accordance with the health plan's benefits or, more commonly, the health plan payor administers benefits.
Enrollees of payor plans using HealthLink Open Access programs may self-refer to the physician or facility of their choice. Please refer patients to other HealthLink participating physicians, hospitals and health care professionals in recognition of the enhanced benefits that typically exist (i.e., referrals to HealthLink HMO participating health care practitioners result in the enrollee's eligibility for the highest level of benefit for covered services).
Network Access and Benefit Plan
Payor plans using HealthLink Open Access have variable plan designs and access either HealthLink's
HMO network of participating health care practitioners or both the HMO and PPO
networks. Listed below are the four types of programs.
HealthLink OAI for Self-Funded Clients
Enrollees of plans using HealthLink OAI may self-refer to any physician or facility within
the HealthLink HMO network. Elective treatment by out-of-network physicians and
facilities is not a covered benefit. OAI includes Utilization Management services
and a pharmacy benefit management program. Behavioral health and routine vision
networks may be included as options.
HealthLink OAII for Self-Funded Clients
Enrollees of plans using HealthLink OAII have two levels of benefits for covered services.
The higher level of benefit coverage is available to enrollees who self-refer to
HealthLink HMO network physicians, hospitals and other health care professionals.
A second, lower level of benefits for covered services is available to enrollees
who self-refer to out-of-network physicians and facilities. OAII includes Utilization
Management services and a pharmacy benefit management program. Behavioral health
and routine vision networks may be included as options.
HealthLink OAIII for Self-Funded Clients
Enrollees of plans using HealthLink OAIII have three levels of benefits for covered services.
The highest level of benefits is available to enrollees who self-refer to HealthLink HMO
network physicians, hospitals and other health care professionals. A second, lower level
of benefits is available to enrollees who self-refer to HealthLink PPO network physicians,
hospitals and other health care professionals. The third, lowest level of benefits is available
to enrollees who self-refer to out-of-network practitioners and facilities. OAIII includes
Utilization Management services and a pharmacy benefit management program. Behavioral health
and routine vision networks may be included as options.
HealthLink OAIII for Affiliated Insurance Carriers
Enrollees of insurance carrier plans have three levels of benefits for covered services,
and have access to the same HealthLink HMO and HealthLink PPO networks of participating
physicians, hospitals and health care professionals. However, the carrier provides
benefit management, policy administration, Utilization Management services and
pharmacy or other specialty network benefit programs. HealthLink requires affiliated
carriers to utilize URAC-accredited medical management services. Please refer to
enrollee ID cards for Utilization Management contact information.
Specialty Networks
Each HealthLink Open Access program may include one or more of the following specialty
networks:
These specialty networks are determined by the health plan. Please refer to the patient's enrollee ID card for information and instructions.
Reimbursement Model
HealthLink's negotiated rates with physicians and facilities are based on an agreed discounted
fee-for-service arrangement. Participating physicians, hospitals and other health care
professionals may not balance bill patients in excess of the negotiated maximum allowance
(i.e., rate) for covered services.
Posting Contractual Allowances
If you participate in both HealthLink PPO and HMO networks:
Please post the contractual allowance at the HMO level.
If you participate in the PPO network only:
Please post the contractual allowance based on the PPO allowable amount.
If you participate in the HMO network only:
Please post the contractual allowance based on the HMO allowable amount.
Self-Referral to Health Care Services
Enrollees may self-refer to physicians and other health care service professionals and
facilities. Referrals are arranged between the physician, patient and specialist. Please
refer patients to other HealthLink participating physicians, hospitals and health care
professionals in recognition of the enhanced benefits that typically exist when enrollees
utilize HealthLink participating physicians, facilities and health care professionals.
You may contact HealthLink's Customer Service Department or access HealthLink's web
site at www.healthlink.com to verify other participants in your area, and/or request
a directory.
Claim Repricing/Processing Activity
As a network service, HealthLink receives and reprices claims in accordance with the contractual
agreement we have with the physician or facility. Typically, HealthLink then forwards
the claims and worksheets to the claims administrator for benefit determinations and
payment. In some instances, the self-funded client chooses to use HealthLink HMO, Inc.
as its third party claims administrator. In these instances, HealthLink HMO adjudicates
the plan participants' claims and makes payments in accordance with the plan's benefits.
Please refer to your patient's enrollee ID card for identification of the claims administrator.
Benefits may be administered by HealthLink HMO, Inc. or, more commonly, by a third party administrator or carrier contracted by the employer or trust fund accessing the HealthLink Open Access program and networks. Please refer to the Claims Procedures section of this chapter for more information.
Preventive Care Benefits
Payor plans using HealthLink Open Access programs 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 (OAI, OAII,
OAIII) or PPO (OAIII) physicians, hospitals, laboratories, radiology centers and health
care professionals.
Flexible Plan Design
Payor plans using HealthLink Open Access programs may vary in terms of co-payments, deductibles,
pharmacy coverage and behavioral health arrangements. Please refer to the claims administrator
identified on your patient's enrollee ID card.
HEALTHLINK OPEN ACCESS PROGRAMS AND SERVICES
Provider Networks
HealthLink HMO Network (OAI, OAII, OAIII)
HealthLink PPO Network (OAIII)
Benefits Provided for Out-of-Network Care (OAII, OAIII)
Discounted Fee-for-Service Arrangements
Pharmacy Network
Optional Vision Care Network
Optional Behavioral Care Network
Utilization Management
HealthLink-Provided Services Depending on Plan
Pre-Admission Certification of Planned Admissions
Emergency Admission Notification
Concurrent Stay Review
Discharge Planning Assistance
Major Case Management
Outpatient/Ambulatory Review
Optional Second Opinion Surgical Review
HealthLink Open Access 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 Open Access Quick Reference
Benefit Information
To verify benefit coverage for health services or patient eligibility, please contact the
benefit administrator identified on the patient's enrollee ID card.
Utilization Management
Utilization Management components may vary among health plans accessing the HealthLink
Open Access programs. Please refer to your patient's enrollee ID card for specific directions
and components of Utilization Management. The following Utilization Management components
may be included in the HealthLink Open Access programs:
For certification of hospitalizations and outpatient procedures, please refer to the patient's enrollee ID card or 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 certification, be prepared to provide the following information:
Claims Submission
Please reference the patient's enrollee ID card for instructions on filing paper and electronic
claims. For further information, please refer to the Claims Procedures section of this
chapter for detailed information, including electronic claim submission procedures.
Co-payments
Co-payments may vary by employer group. For verification of co-payments, please contact
the benefit administrator indicated on the patient's enrollee ID card.
Network Services
For inquiries about contracting with HealthLink for Open Access programs, program administration,
additional materials, information and problem resolution, please call:
HealthLink Network Services
Toll-free 1-800-624-2356
Hours: 8:00 a.m. to 5:00 p.m. CST
Open business days
You may also obtain claims status and payor information at the patient account level through HealthLink's IVR (Interactive Voice Recognition) system and by logging onto HealthLink's web site, 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.
Posting Contractual Allowances
If you participate in both HealthLink PPO and HMO Networks:
Please post the contractual allowance at the HMO level.
If you participate in HealthLink PPO only:
Please post the contractual allowance based on the PPO allowable amount.
If you participate in HealthLink HMO only:
Please post the contractual allowance based on the HMO allowable amount.
Pharmacy Management Program
Please refer to the patient's enrollee ID card to identify the name and phone number of
any designated pharmacy management program.
For inquiries about WellPoint Pharmacy Management 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
Your patient's Open Access program may include routine vision care benefits. Please refer
to the enrollee ID card for specialty network designation. For inquiries about routine
vision examinations, please call:
Customer Service
1-800-877-7195
Hours: M-F 7:00 a.m. to 9:00 p.m. CST
Saturdays 8:00 a.m. to 4:30 p.m. CST
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.