State-Of-The-Art System Capabilities
System capabilities and plan design options are virtually unlimited with HealthSmart. HealthSmart utilizes RIMS, a self-adjudicating, online, real-time claim processing system. The software, RIMS QicLink Product Suite, was developed and is maintained by The TriZetto Group. The system’s flexible plan-building component allows us to accommodate a variety of benefit plans. Features of our state-of-the-art system include:
Benefit plan flexibility
Fully automated edits
Real-time, online processing
Fully integrated provider management
Experienced & Professional Personnel
Claim processing is a complicated business to most members. Our commitment is to provide the highest level of customer service during the settlement of members’ claims. Our members have access to our toll-free telephone number and also can submit inquiries via the web-based eServices. Our customer service representatives have full access to claims information and will respond to our members and providers quickly, within 72 hours of receiving a call or within 48 hours of receiving an email inquiry via eServices. Members are very important to us, and that is why our CSRs are carefully selected and monitored for quality.
Dedicated Claim Examiners are assigned to each client. Claim examiners meet with the client service team during the installation process so they understand the background of each client and their healthcare objectives. We hire experienced people with a background in claims and managed care administration. Our claim examiners are experienced in investigating eligibility, coordination of benefits, unreasonable charges and exclusions. New claim examiners, regardless of experience, receive extensive training. Our training consists of medical terminology and practices, HealthSmart’s policies, standard administrative procedures, claim system application and client-specific benefits.
Employer Service Representatives
Employer Service Representatives are senior members of the operations team and assigned to each client. Each employer service representative (ESR) interfaces directly with the client’s HR staff in regard to operational matters. ESRs can make adjustments while HR staff is on the line, they can research issues and have the expertise and skills to manage such situations. This service brings to the client a point person in operations who knows them and is accountable to them.
Customer Service Representatives
Customer/Member Service Representatives are sensitive to the many questions and concerns members have regarding often complex healthcare claims. Responding to those concerns and questions requires knowledge, professionalism and understanding. To meet these requirements, we have staffed our customer service department with individuals who possess excellent people skills and are knowledgeable about healthcare benefits. Customer service representatives (CSRs) are trained on HealthSmart’s policies and procedures, telephone courtesy, claim system as well as client-specific benefit information. In addition, HealthSmart CSRs participate in AchieveGlobal Customer Service Training. Our CSRs learn how to provide personalized service with consistently positive outcomes by developing a unique understanding of their customers' motivations and reactions.
Medical and Dental Consultants
Medical and Dental Consultants with board certified medical and psychiatric physicians in a variety of specialties are retained. As medical technology and practices become more complicated, claims for unique or unusual services or claims with questionable medical necessity are referred to our technical unit staff for review and determination. When necessary, claims are sent to one of our in-house nurses or a qualified independent consultant for review and recommendation.
Reasonable & Customary
Reasonable and Customary charges are automatically screened through Ingenix, formerly Medical Data Research. Ingenix’s system uses a sophisticated relative value system to accurately model claims experience in a given geographic area across a range of percentiles. It does this through a proprietary method of analysis where actual claims and fee information in each geographic area are used to generate conversion factors and unit values. The system provides more consistency by relating similar charges in the same area and the same charge in surrounding geographic areas. This is one of the most comprehensive and up-to-date R&C databases available. Having access to Ingenix’s data provides greater savings to our clients.
Provider Management is an important cost containment tool designed to analyze coded claims to ensure that correct CPT-4 codes are identified for reimbursement. CPT coding has become more complex over the years and inappropriate use of CPT codes has created “upcoding” or “code creep”. These terms are used to describe situations where a procedure could be identified with one code instead has several codes assigned to it. Our online editing capabilities are designed to detect the four most prevalent and expensive overbilling techniques. All unbundled claims of medically related services are rebundled and processed according to AMA guidelines.
Coordination of Benefits
Coordination of Benefits information is initially sought during the enrollment process. This information is loaded and maintained within the claim system and automatically indicates when COB is present, which family members are covered and identifies the other carrier. If COB is indicated, the system will not allow the examiner to complete a claim unless certain fields, such as what the primary carrier paid, are entered. The fully automated system then adjudicates the claim.
Subrogation Recoveries are pursued by International Subrogation Management (ISM). ISM has specialized in subrogation recoveries for over ten years and is dedicated solely to providing subrogation services. As a result, they developed the systems, procedures and staff expertise to pursue recoveries much more effectively than anyone in the industry. ISM has a dedicated staff located in HealthSmart’s claims office.
How We Work With You
There are specific attributes you need from a benefits partner. You need a company with proven strength to perform over the long-term. You need someone with the capability to offer the latest innovations and advancements in the industry, along with the knowledge and resources to effectively manage health care dollars. And, just as importantly, you need the reliability of professional support staff. You get it all, and more, with HealthSmart.
Long-standing stability - HealthSmart has been a trusted national TPA since 1967, with clients from coast to coast.
Maximizing technology - HealthSmart is committed to continuously investing in emerging technologies and systems, with the ultimate goal of providing convenient, reliable and cost-effective solutions.
Making a service difference - Whether you’re a benefits manager or a plan enrollee, you’ll have direct access to experienced, friendly staff professionals.
Success begins with ensuring client satisfaction. We strive to provide our clients with the very best administrative services. By maintaining flexibility and being responsive to new ideas, we adapt to the rapid changes in the benefits environment while retaining our position as an industry leader.