About HealthLink PPO
More than one million individuals are enrolled in health plans that access the HealthLink PPO networks. The HealthLink PPO service area includes Missouri, Illinois, Indiana, Iowa, Arkansas, West Virginia and Kentucky.
Multi-Payor System
HealthLink is not tied to any one payor organization. Rather, HealthLink provides network
access and administrative services to approximately 200 payors (contracted insurance
carriers, self-funded self-administered payor clients and third party administrators)
who administer benefits on behalf of self-funded clients who have contracted directly
with HealthLink.
HealthLink is not the insurer or claims administrator in these arrangements. In exchange for access to HealthLink's networks and certain related administrative services, these contracted payors and plan sponsors agree to provide benefit incentives to plan participants who use the HealthLink network, to administer claims promptly and to make payments, in accordance with HealthLink's negotiated rates and the plan's benefit provisions, to network physicians and facilities.
Reimbursement Model
HealthLink's negotiated rates with physicians and facilities are based on an agreed discounted
fee-for-service basis. 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.
Self-Referral to Health Care Services
Enrollees may self-refer to physicians and other health care services. Referrals are arranged
between the physician, patient and specialist. Please refer patients to other participating
physicians, hospitals and health care professionals in recognition of the enhanced
benefits that typically exist when enrollees utilize HealthLink PPO network services.
You may contact HealthLink's Customer Service Department or access HealthLink's
website 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 contract
agreements with physicians or facilities. Afterwards, we forward the claims and
worksheets to the claims administrator for benefit determination and payment. A
repricing worksheet is produced for every claim. The worksheet shows the applicable
contracted rate that corresponds to the billed service. HealthLink works with regional
and national electronic claim vendors.
HEALTHLINK PPO PROGRAMS AND SERVICES
Networks
Patient Self-Referral/Physician-Directed Care
Discounted Fee-for-Service Arrangements
Optional Pharmacy Network
Utilization Management
Pre-Admission Certification of Planned Admissions (standard)
Emergency Admission Notification (standard)
Concurrent Hospital Stay Review (standard)
Discharge Planning Assistance (standard)
Major Case Management (elective)
Outpatient/Ambulatory Review (elective)
Second Opinion Surgical Review (elective)
HealthLink-Provided Administrative Services
Claim Repricing
Claim Activity Confirmation Reports
Claim Investigation and Resolution
Payor and Network Contract Administration
Utilization Management (elective)
Toll-Free Customer Service
Network Service Representation
Centralized Credentialing
Network Directory Publication
Web-Based Resources and Promotion
HealthLink PPO 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.
Customer Service Call Center
For inquiries about referral resources, claim status, and inquiries about benefit administrator
phone numbers to verify patient eligibility or covered services, please call:
HealthLink Customer Service
Toll-free 1-800-624-2356
Hours: 7:30 a.m. to 5:30 p.m. CST
Open business days.
Please note: HealthLink PPO ID cards identify the office phone number of the benefit administrator. Questions regarding eligibility or benefit coverage may most efficiently be directed to the patient's benefit administrator.
You may also 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.
Utilization Management
Utilization Management components vary among health plans accessing the HealthLink PPO
program and network. 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 PPO program:
For pre-certification of inpatient and select 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:
Select insurance companies and third party administrators are allowed to provide Utilization Management services directly or through a vendor, provided they are URAC-accredited and suitably licensed. Please refer to your patient's enrollee ID card for verification.
Network Services
For general information about programs, contracts, administrative services and credentialing
information, please call your Network Services representative. If your representative
is out of the office, you may leave a voicemail message or contact HealthLink's Customer
Service Call Center for assistance and/or transcription of your inquiry:
HealthLink Network Services
Toll-free 1-800-624-2356
Hours: 8:00 a.m. to 5:00 p.m. CST
Open business days.
Messages to Network Services representatives will be returned within two business days.
Claims Submission
Submit electronic claims through your electronic clearinghouse vendor:
HealthLink Payor ID 90001
Submit paper claims to:
Specific PO Box and claim filing addresses listed on the patients' ID cards.
Office Visit Co-payment
The office visit co-payment varies by employer group and/or payor. Typically, a specific
dollar amount co-payment is indicated on the patient's enrollee ID card if the plan
coverage includes a flat co-payment. Collect this co-payment at the time of service.
If the plan has a coinsurance percentage and/or deductible, the amount payable by the
patient may vary as benefits are used during the plan benefit year. Coinsurance and
deductibles usually are not printed on the patient's enrollee ID card.
File your claim as directed on the patient's enrollee ID card. The explanation of benefits will advise you and your patient of the expense paid by the health plan and the amount payable by the patient, if any. Practices are responsible for collecting any monies due from patients.
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.