The HealthLink HMO Classic network program is offered to employers, labor organizations, school districts and certain state and municipal governmental subdivisions that self-fund their group health plans. Typically, these health plan payors desire to offer HMO plan design (either in combination with a HealthLink PPO network program or an indemnity plan) while preserving their self-funding arrangement. The HealthLink HMO Classic network program also may 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.
Payor plans that use the HealthLink HMO Classic network program 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 the HealthLink HMO Classic network program. With the exception of OB-GYN care, behavioral health treatment and emergency care, payor plans using the HealthLink HMO Classic program 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.
HealthLink HMO administers benefits, pays claims and issues remittance advice and enrollee explanations of benefits for health plans enrolled in the HealthLink HMO Classic program.
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 portions of Missouri, Illinois, Indiana and Arkansas. Generally, physicians and facilities that participate in the HealthLink HMO program 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 using the 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.
Reimbursement Models
HealthLink HMO issues to each primary care physician a monthly list of the HealthLink HMO Classic health plan enrollees who have selected the primary care physician under a capitation arrangement agreed to by HealthLink HMO and the primary care physician. For these enrollees, the primary care physician receives a monthly capitation payment for the delivery of all basic health care services. Non-capitated services are reimbursed based on a discounted fee-for-service methodology. Laboratory services, routine vision care and behavioral health services may be subject to special service arrangements with designated providers, as indicated on the patient’s enrollee ID card.
Claim Coordination
In most instances, HealthLink HMO processes claims and administers the payment of claims for health plans that access the HealthLink HMO Classic network program, and may
administer claims on behalf of health plans for certain other programs that access HealthLink HMO. HealthLink HMO’s claim and Utilization Management systems are integrated to verify that charges are consistent with Utilization Management certifications and primary care physician authorizations. HealthLink HMO works with regional and national electronic claim vendors.
Preventive Care Benefits
Health plans that use the HealthLink HMO Classic network program typically provide coverage for preventive care, including routine exams, immunizations, mammography, prenatal care and annual routine OB-GYN services. HealthLink HMO-contracted physicians, hospitals, laboratories, radiology centers and health care professionals must provide the services in order for services to be considered for benefit coverage.
Flexible Plan Design
Health plans that use the HealthLink HMO Classic network program include a standard set of covered preventive care and medical benefits. Co-payments, deductibles, pharmacy
coverage, behavioral health arrangements and various other benefits and exclusions may vary. Please refer to your patient’s enrollee ID card or call HealthLink HMO Customer Service for information.
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Verifying Eligibility
Payor plans that use the HealthLink HMO Classic network program provide HealthLink HMO with initial plan enrollment information. They update this information regularly to reflect current data related to their plan enrollees’ eligibility for coverage. This information is necessary for HealthLink HMO to administer benefits and pay claims on the payor plan’s behalf.
HEALTHLINK HMO CLASSIC NETWORK PROGRAM FEATURES 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
Utilization Management
Specialty Care Referrals by Primary Care Physician Pre-Admission Certification of Planned Admissions
Emergency Admission Notification Concurrent Stay Review Discharge Planning Assistance
Major Case Management Outpatient/Ambulatory Review
Ancillary Services Review
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
To determine coverage and eligibility for a patient and/or service to be provided, please call HealthLink Customer Service at the number listed on the patient’s enrollee ID card. Please be prepared to:
• Identify yourself as a HealthLink HMO participating physician.
• Provide patient’s name, enrollee’s name (if different), the name of the employer and group certificate number.
• When requesting a patient’s coverage information and eligibility, please verify effective date, pre-existing conditions, co-payment, co-insurance and deductible amounts. Also, check for limitations, exclusions and Utilization Management requirements. Reimbursement for services performed may be reduced if you do not follow applicable Utilization Management procedures.
• Obtain the name and extension number of the person providing you with this information for your records.
Remember – Verification of benefits does not guarantee that services are covered.
Benefits are subject to the patient’s eligibility at the time charges are actually incurred, and to all other terms, conditions and exclusions of the applicable health plan.