Home > HSMSO Services > Claims


HealthSmart MSO claims department provides efficient and prompt claims processing services for our contracted IPA’s, Managed Hospitals and provides claims adjudication in contract agreements. Our experienced staff at HealthSmart MSO is familiar with Medicare (CMS), Medi-Cal, Healthy Families and Commercial regulatory requirements, including claims timeliness guidelines to ensure claims are processed accordingly. HealthSmart MSO is able to specifically customize clients payments based on the clients Health Plan contracts, provider contracts, member eligibility and member benefits.

Our state of the art claim system is able to log, adjudicate and pay claims. Our system automates most of the processing to allow greater accuracy and faster claim turnaround time. Our systems are able to read the information and automatically load it into our claims system.

HealthSmart MSO has the capability to receive claims electronically through our partnership with Office Ally or using an 837 electronic format for direct inloads from our FTP site. In addition, HealthSmart MSO uses its own remote access claim system (“HealthSmart Web”) and our Practice Management Module that allows Providers to submit claims electronically for even faster claims turnaround time.
HealthSmart MSO remote access system allows providers to review the status and history of their claims and payment online for quick and easy access. The integrated data loading capabilities of HealthSmart MSO claims systems allows our claims processors to manually enter only a minimal amount of data, which maximizes daily production.

Our claims staff actively pursues recoveries on behalf of our clients. Most importantly, our Claims Department is committed to providing timely and courteous Customer Service Responses. Our payment turnaround times consistently fall within accepted industry benchmarks, and we conduct back-end claims audits to avoid overpayment of claims and ensure that each claim is paid according to contracted rates. HealthSmart MSO supports in-house recovery procedures to identify and recover lost money on insured services, reinsurance, overpayments, Third-party liability, coordination of benefits, and retroactive terminations.
Submission of Claims

Providers may submit claims to HealthSmart MSO through the following methods:

  • Hard Copy of CMS 1500/UB04/PM160

                 Claims would be mailed to:
                 P.O.Box 6301
                 Cypress, CA 90630-6301

                 Payer ID Code:  HSM01
                 To Set up Office Ally Please contact (866) 575-4120

  • Electronic via 837 format to HealthSmart MSO:

                 Please contact your assigned Provider Service Representative at
                 714 947-8600 to set up your account.

  • Electronic via Web Portal to HealthSmart MSO Website:

                 Please click here to download your application for Web Portal use:

Fee Schedules

For a listing of the California Medi-Cal Rates, please refer to:
http://files.medi-cal.ca.gov/pubsdoco/rates/rateshome.asp

For a listing of the Medicare Rates, please refer to:
http://www.palmettogba.com/

ICD-10 Resources - Deadline October 1, 2014!

Appeals/PDRs

Medi-Cal and Commercial Providers

Please submit your PDR along with the ICE approved form, or click here to download the form (ICE approved).

 

 Medicare Providers

PDR Time Frame120 DAYs from the initial payment determination

Example of PDR:

Includes decisions where a non-contracted provider contends that the amount paid by the payer for a covered service is less than the amount that would have been paid under Original Medicare.

Provider payment disputes also include instances where there is a disagreement between a non-contracted provider and the payer about the MAO’s decision to make payment on a more appropriate code (down coding).

 

Appeal Time Frame 60 DAYS  from the MAO’s initial determination

Example of Provider Appeal:

   Items that can be appealed are those claims for services that result in zero payments.

·            Payment denials by payers that result in zero payments being made to a non-contracted provider.

·            Payment disputes for contracted providers

·            Local and National Coverage Determinations.

·            Medical Necessity determinations.

·            Payment disputes for which no initial determination has been made.

 

Medicare Non-Contracted providers:

Non-Contracted providers must include a signed Waiver of Liability form holding the enrollee harmless regardless of the outcome of the appeal.  Please click here to download the Waiver of Liability Form.

Please make sure to include additional documentation such as a copy of the original claim, remittance notification showing the denial, and any clinical records and other documentation that supports your argument for reimbursement.

If you appeal and we uphold the denial, in whole or in part, you will have additional appeal rights available to you including, but not limited to, reconsideration by a CMS contracted independent review entity.

To Appeal, please mail your request and completed Waiver of Liability Statement within 60 calendar days after the initial determination to:

Attn: Claims Appeals Department

PO Box 6301

Cypress, CA 90630-0018