HEALTHSMART PARTICIPATING PROVIDER PROGRAM GUIDE

Transcription

1 C-8 (PFOA) Medical Monitoring Program HEALTHSMART PARTICIPATING PROVIDER PROGRAM GUIDE 1 P a g e

2 TABLE OF CONTENTS C-8 (PFOA) Program Guide Introduction & Definitions Page 3 C-8 (PFOA) Medical Monitoring Program Description Page 4 C-8 (PFOA) Medical Monitoring Program Introduction Page 5 All Participating Provider Responsibilities Pages 6 Screening Provider Responsibilities Pages 7-10 Follow Up Testing & Services Provider Responsibilities Pages Provider FAQs Pages C-8 (PFOA) Provider Resources Enclosures LabCorp C-8 Requisition Form LabCorp Standard Requisition Form Program CPT Coding Quick Reference Guide Customer Service P a g e

3 PROGRAM GUIDE INTRODUCTION This Program Guide is intended to be instructional and descriptive. It is designed to assist HealthSmart Participating Providers and their staff to comply with and navigate the C-8 (PFOA) Medical Monitoring Program. Your patients (Eligible Class Members) will need you and your staff to have a complete understanding of the Program requirements throughout the entire monitoring process. HealthSmart, in conjunction with the Program Administrator, has organized a comprehensive support structure to be readily available to you the provider. Please familiarize yourself and your practice staff with the contents of this Program Guide and the Eligible Class Member packet. PROGRAM GUIDE DEFINITIONS For the purposes of the Program and this Program Guide the following definitions apply: HealthSmart Participating Provider: means those health care providers, including but not limited to any physician, hospital, hospital-based physician, skilled nursing facility, persons employed by such provider, entities that provide Covered Services under such provider s tax identification number(s), or any other health care provider, which have entered into an agreement directly or indirectly with HealthSmart to participate in certain health care provider networks established by HealthSmart. Screening Provider: means those HealthSmart Participating Providers that are performing the medical monitoring screening tests as defined by the Program. A HealthSmart Participating Provider may be both a Screening Provider and a Follow Up Services Provider (as defined herein). Follow Up Services Provider: means those HealthSmart Participating Providers that are performing the recommended Follow Up tests and/or procedures as defined by the Program. A HealthSmart Participating Provider may be both a Screening Provider and a Follow Up Services Provider (as defined herein). 3 P a g e

4 C-8 (PFOA) MEDICAL MONITORING PROGRAM DESCRIPTION In February 2005, The Wood County Circuit Court in West Virginia approved a class action settlement ( the Settlement ) between the Plaintiffs and E.I. du Pont de Nemours and Co. ( DuPont ), the defendant, in a civil class action lawsuit styled Jack Leach, et al. v. E.I. du Pont de Nemours and Co., Civil Action No. 01-C-608 pending in the Circuit Court of Wood County, West Virginia ( the Litigation ). The Litigation involves claims arising from alleged contamination of human drinking water supplies with a chemical known as ammonium perfluorooctanoate (hereinafter C-8 ) attributable to releases from DuPont s Washington Works Plant in Wood County, West Virginia. As part of the Settlement, Class Counsel and DuPont selected an independent panel of three epidemiologists ( the Science Panel ) to conduct and evaluate studies to answer the question whether a Probable Link exists between exposure to C-8 among Eligible Class Members and serious human disease ( Human Disease ). After lengthy studies, in which many Eligible Class Members participated, the Science Panel found that there is a Probable Link between exposure to C-8 and the following Human Diseases: (1) pregnancy-induced hypertension (including preeclampsia), (2) kidney cancer, (3) testicular cancer, (4) thyroid disease, (5) ulcerative colitis, and (6) diagnosed high cholesterol (hypercholesterolemia). The Settlement Agreement defines a Probable Link to mean that, based upon the weight of the available scientific evidence; it is more likely than not that there is a link between exposure to C-8 and these Human Diseases. The Science Panel did not find that a Probable Link exists for any other Human Diseases. 4 P a g e

5 C-8 (PFOA) MEDICAL MONITORING PROGRAM INTRODUCTION HealthSmart has been chosen as an independent contractor to arrange provider network and other administrative services for the C-8 (PFOA) Medical Monitoring Program ( Program ). As a participating provider in the HealthSmart networks, you may be contacted by a HealthSmart Customer Service Representative and Eligible Class Member to schedule an appointment for C-8 (PFOA) screening appointment and/or follow up services. Services that are covered under the Program will be reimbursed in accordance with the rate structure in your HealthSmart Participating Provider Agreements. Eligible Class Members will not present with the standard member identification card. In its place, they will bring an Eligible Class Member packet which will include all of the information needed to perform recommended screening and follow up tests and submit a provider claim. As a Participating Provider you are expected to review, complete and submit all of the required Program documents to the Program Administrator, in accordance with the Eligible Class Member packet and this Program Guide. On or about September 2, 2014 the Program Administrator will issue thousands of notices to potential Class Members. The highest concentration of potential Class Members reside in West Virginia and Ohio, however, potential Class Members are located across the United States. The notices will instruct the recipients to submit a Class Member Registration and Eligibility Form to the Program Administrator to determine the Class Member s eligibility for the Program. Upon the Program Administrator s determination of eligibility, those Eligible Class Members will be instructed to contact a HealthSmart Customer Service Representative to help them identify a HealthSmart Participating Provider and also call those Participating Provider offices to schedule the Eligible Class Member screening appointments. 5 P a g e

6 Step 1: Educate yourself ALL PARTICIPATING PROVIDER RESPONSIBILITIES PRIOR TO THE APPOINTMENTS The C-8 (PFOA) Medical Monitoring Program requires a good deal of physician and patient interaction. It mandates specific requirements of the Screening and Follow Up Services Providers. Please read the contents of this Program Guide at your earliest convenience to ensure compliance with the Program requirements. Step 2: Educate your staff It is possible your practice will experience a significant volume of Eligible Class Members scheduling appointments. For that reason, it is critical that you schedule time, prior to September 2nd, to review the contents of this Program Guide in detail with your staff. We invite you to reach out to HealthSmart with any questions or concerns you may have. We have established a call center, dedicated to the Program, for your convenience. HealthSmart can be reached at SCHEDULING THE APPOINTMENTS It is important that your staff understand the Eligible Class Member will be instructed to contact the HealthSmart call center to identify a local HealthSmart Participating Provider and to schedule their appointment. In most cases the Eligible Class Member will be on the line while the appointment is being scheduled. As an added convenience, the Customer Service Representative can provide helpful information about the Program during the scheduling call. We recommend that you schedule enough time with your Eligible Class Members to allow you to perform your clinical tasks and also have the opportunity to review the Class Member Screening Questionnaire, Diagnosis Form, the HIPAA Authorization Form and the other required documents Eligible Class Members will bring with them. The HealthSmart Customer Service Representatives may provide the following information at the time of appointment scheduling: Eligible Class Member Name Eligible Class Member DOB Eligible Class Member Program Identification Number (an 11 digit Registration Number beginning with 8888 found on the Eligible Class member documents) Information regarding the C-8 (PFOA) Medical Monitoring Program Eligible Class Member s Other Insurance Information (when available) All Other Eligible Class Member Information Required to Schedule Appointments 6 P a g e

7 Step 1: Screening Appointment SCREENING PROVIDER RESPONSIBILITIES DURING THE SCREENING APPOINTMENT Screening Providers are required to review, complete and sign all of the applicable Program documents that the Eligible Class Member will bring to their screening appointment. The Eligible Class Member packet has detailed instructions for the Eligible Class Member and Participating Provider (Instructions for Physicians) with regard to the Program requirements. Upon the conclusion of the Eligible Class Member Screening Appointment, you must submit the completed and signed forms listed below to the Program Administrator, and please retain copies of these documents for your records. INSTRUCTIONS FOR PHYSICIANS o Complete and sign page 5 o Return the completed form to the Program Administrator MEMBER SCREENING QUESTIONNAIRE FORM FOR PROBABLE LINK CONDITIONS o Sign page 5 titled Screening Doctor Information and Signature o Return the completed form to the Program Administrator SCREENING AND FOLLOW UP TESTING FORM o Complete, sign and provide a copy to the Eligible Class Member o Return the completed form to the Program Administrator LABCORP C-8 (PFOA) REQUISITION FORM o This form is to use exclusively for the C-8 (PFOA) lab tests o Complete, sign and provide a copy of this requisition to the Eligible Class Member o Refer patient to LabCorp with this requisition form LABCORP STANDARD REQUISITION FORM o This form is to use for all other screening tests other than the C-8 (PFOA) test o Complete, sign and provide a copy of this requisition to the Eligible Class Member, if applicable o Refer patient to LabCorp with this requisition form, if applicable HIPAA AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION o Ensure Eligible Class Member has completed and signed this form o Return this form to the Program Administrator DIAGNOSIS FORM o This form should be completed upon receipt of test results o Complete, sign and return the form to the Program Administrator 7 P a g e

8 Step 2: C-8 (PFOA) Screening Lab Test At the conclusion of the Screening Appointment and upon completion of the Program forms (i: Instructions for Physicians, ii: Member Screening Questionnaire, iii: Screening and Follow Up Testing Form, iv: Applicable LabCorp Requisition Forms, v: HIPAA Authorization Form) the Eligible Class Members should be referred to LabCorp for the C-8 (PFOA) screening test. A customized LabCorp requisition form is included in the Eligible Class Members information packet, in this Program Guide and on our website at The requisition form should be completed by you, the Screening Provider, and a copy given to the Eligible Class Member to present to LabCorp. Step 3: Other Screening Lab Tests, if applicable If Follow Up testing is recommended after the Eligible Class Member screening appointment; please use LabCorp s standard requisition form for ordering lab tests recommended under the C-8 (PFOA) Medical Monitoring Program. The standard LabCorp requisition form should be completed by the Screening Provider and a copy given to the Eligible Class Member to present to LabCorp. A LabCorp standard requisition form is included in this Program Guide and on our website at Step 4: Refer Eligible Class Member to HealthSmart Specialist, if applicable Screening Providers may refer the Eligible Class Member to a specialist if the screening exam warrants that the recommended Follow Up tests and/or procedures are performed. The specialist (Follow Up Provider) must also be a HealthSmart Participating Provider. You can visit or for a complete listing of HealthSmart Participating Providers. 8 P a g e

9 UPON RECEIPT OF TEST RESULTS Step 1: Share the Test Results and Complete Diagnosis Form(s) In accordance with the Screening Provider s standard of care, the screening test results should be communicated to the Eligible Class Member as well as the Program Administrator. The instructions and necessary forms for communicating the results with the Program Administrator can be found on Page 6 of the Instructions for Physicians Packet. Step 2: Submit Completed and Signed Program Forms to the Program Administrator INSTRUCTIONS FOR PHYSICIANS o Complete and sign page 5 o Return the completed form to the Program Administrator MEMBER SCREENING QUESTIONNAIRE FORM FOR PROBABLE LINK CONDITIONS o Sign page 5 titled Screening Doctor Information and Signature o Return the completed form to the Program Administrator SCREENING AND FOLLOW UP TESTING FORM o Complete, sign and provide a copy to the Eligible Class Member o Return the completed form to the Program Administrator LABCORP C-8 (PFOA) REQUISITION FORM o This form is to use exclusively for the C-8 (PFOA) lab tests o Complete, sign and provide a copy of this requisition to the Eligible Class Member o Refer patient to LabCorp with this requisition form LABCORP STANDARD REQUISITION FORM o This form is to use for all other screening tests other than the C-8 (PFOA) test o Complete, sign and provide a copy of this requisition to the Eligible Class Member, if applicable o Refer patient to LabCorp with this requisition form, if applicable HIPAA AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION o Ensure Eligible Class Member has completed and signed this form o Return this form to the Program Administrator DIAGNOSIS FORM o This form can now be completed as you have obtained test results o Complete, sign and return the form to the Program Administrator Step 3: Refer Eligible Class Member to HealthSmart Specialist, if applicable Screening Providers may refer the Eligible Class Member to a specialist if an Eligible Class Member s screening exam and/or the test results warrant that the recommended Follow Up tests and/or procedures are performed. The specialist (Follow Up Provider) must be a HealthSmart Participating Provider. You can visit or for a complete listing of HealthSmart Participating Providers. 9 P a g e

10 Step 4: Submit Your Provider Claims We recommend provider claims be submitted electronically. Electronic Provider Claims should be sent to: HealthSmart Benefit Solutions Electronic Payor ID: Member Program ID: 8888xxxxxxx (An 11 digit number that is the Eligible Class Member s registration number included in the Eligible Class Member program documents) Paper Provider Claims should be sent to: Administrator C-8 (PFOA) Medical Monitoring Program c/o GCG PO Box Dublin, OH Fax: For questions related to provider claims you may contact customer service at Note: The address listed above is only to be used for Provider Claims submitted to the C-8 (PFOA) Medical Monitoring Program. All other provider claims for HealthSmart members with a standard member ID card should be submitted to the claim address listed on the ID card. 10 P a g e

11 FOLLOW UP SERVICES PROVIDER RESPONSIBILITIES Step 1: Follow Up Appointment DURING THE FOLLOW UP APPOINTMENT Follow Up Providers are required to review, complete and sign all of the applicable Program documents that the Eligible Class Member will bring to their Follow Up appointment. The Eligible Class Member packet has detailed instructions for the Eligible Class Member and Participating Provider (Instructions for Physicians) with regard to the Program requirements. Upon the conclusion of the Eligible Class Member Follow Up Appointment, you must submit the completed and signed forms listed below to the Program Administrator, and please retain copies of these documents for your records. INSTRUCTIONS FOR PHYSICIANS o Complete and sign page 5 o Return the completed form to the Program Administrator SCREENING AND FOLLOW UP TESTING FORM o Complete, sign and provide a copy to the Eligible Class Member o Return the completed form to the Program Administrator LABCORP STANDARD REQUISITION FORM o This form is to use for all other screening tests other than the C-8 (PFOA) test o Complete, sign and provide a copy of this requisition to the Eligible Class Member, if applicable o Refer patient to LabCorp with this requisition form, if applicable HIPAA AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION o Ensure Eligible Class Member has completed and signed this form o Return this form to the Program Administrator DIAGNOSIS FORM o This form should be completed upon receipt of test results Step 2: Other Follow Up Lab Tests, if applicable The standard LabCorp requisition form should be completed by the Follow Up Provider, as needed, and a copy given to the Eligible Class Member to present to LabCorp. A LabCorp standard requisition form is included in this Program Guide and on our website at 11 P a g e

12 UPON RECEIPT OF TEST RESULTS Step 1: Share the Test Results and Complete Diagnosis Form(s) In accordance with the Follow Up Provider s standard of care, the Follow Up test results should be communicated to the Eligible Class Member as well as the Program Administrator. The instructions and necessary forms for communicating the results with the Program Administrator can be found on Page 6 of the Instructions for Physicians Packet. Step 2: Submit Completed and Signed Program Forms to the Program Administrator INSTRUCTIONS FOR PHYSICIANS o Complete and sign page 5 o Return the completed form to the Program Administrator SCREENING AND FOLLOW UP TESTING FORM o Complete, sign and provide a copy to the Eligible Class Member o Return the completed form to the Program Administrator LABCORP STANDARD REQUISITION FORM o This form is to use for all other screening tests other than the C-8 (PFOA) test o Complete, sign and provide a copy of this requisition to the Eligible Class Member, if applicable o Refer patient to LabCorp with this requisition form, if applicable HIPAA AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION o Ensure Eligible Class Member has completed and signed this form o Return this form to the Program Administrator DIAGNOSIS FORM o This form can now be completed as you have obtained test results o Return this form to the Program Administrator Step 3: Refer Eligible Class Member to HealthSmart Specialist, if applicable If additional treatment or tests are required, the Follow Up Provider may continue to monitor the Eligible Class Member or refer the Eligible Class Member to another specialist when an Eligible Class Member s exam and/or test results warrant that the recommended Follow Up tests and/or procedures are performed. The other specialist (Follow Up Provider) must also be a HealthSmart Participating Provider. You can visit or for a complete listing of HealthSmart Participating Providers. 12 P a g e

13 Step 4: Submit Your Provider Claims We recommend provider claims be submitted electronically. Electronic Provider Claims should be sent to: HealthSmart Benefit Solutions Electronic Payor ID: Member Program ID: 8888xxxxxxx (An 11 digit number that is the Eligible Class Member s registration number included in the Eligible Class Member program documents) Paper Provider Claims should be sent to: Administrator C-8 (PFOA) Medical Monitoring Program c/o GCG PO Box Dublin, OH Fax: For questions related to provider claims you may contact customer service at Note: The address listed above is only to be used for Provider Claims submitted to the C-8 (PFOA) Medical Monitoring Program. All other provider claims for HealthSmart members with a standard member ID card should be submitted to the claim address listed on the ID card. 13 P a g e

14 HealthSmart C-8 (PFOA) Medical Monitoring Program General Information PROVIDER FREQUENTLY ASKED QUESTIONS Q1 What is the C-8 (PFOA) Medical Monitoring Program? In February 2005, The Wood County Circuit Court in West Virginia approved a class action settlement ( the Settlement ) between the Plaintiffs and E.I. du Pont de Nemours and Co. ( DuPont ), the defendant, in a civil class action lawsuit styled Jack Leach, et al. v. E.I. du Pont de Nemours and Co., Civil Action No. 01-C- 608 pending in the Circuit Court of Wood County, West Virginia ( the Litigation ). The Litigation involves claims arising from alleged contamination of human drinking water supplies with a chemical known as ammonium perfluorooctanoate (hereinafter C-8 ) attributable to releases from DuPont s Washington Works Plant in Wood County, West Virginia. As part of the Settlement, Class Counsel and DuPont selected an independent panel of three epidemiologists ( the Science Panel ) to conduct and evaluate studies to answer the question whether a Probable Link exists between exposure to C-8 among Class Members and serious human disease ( Human Disease ). After lengthy studies, in which many class members participated, the Science Panel found that there is a Probable Link between exposure to C-8 and the following Human Diseases: (1) pregnancy-induced hypertension (including preeclampsia), (2) kidney cancer, (3) testicular cancer, (4) thyroid disease, (5) ulcerative colitis, and (6) diagnosed high cholesterol (hypercholesterolemia). The Settlement Agreement defines a Probable Link to mean that, based upon the weight of the available scientific evidence; it is more likely than not that there is a link between exposure to C-8 and these Human Diseases. The Science Panel did not find that a Probable Link exists for any other Human Diseases. This Settlement does not pertain to The Elk River contamination of 4-methylcyclohexane methanol, or MCHM, and polyglycol ethers, known as PPH, discovered on January 9, 2014 in Charleston, West Virginia. Q2 Does an Eligible Class Member have to be seen by a participating HealthSmart Provider? Yes. For covered tests/services to be paid for by the C-8 (PFOA) Medical Monitoring Program, Eligible Class Members must be seen by a participating provider in the HealthSmart network. Upon the Program Administrator s determination of eligibility, those Eligible Class Members will be instructed to contact a HealthSmart Customer Service Representative to help them identify a HealthSmart Participating Provider and also call those Participating Provider offices to schedule the Eligible Class Member screening appointments. For assistance identifying a participating network provider, you may visit or call P a g e

15 PROVIDER FREQUENTLY ASKED QUESTIONS Q3 Q4 Are fees for missed appointments covered under the Program? When Eligible Class Members schedule an appointment with a participating provider and are not able to make the appointment, they must provide 24-hours advanced notice to cancel or reschedule the appointment. If the appointment is not canceled or rescheduled with 24-hours advanced notice and participating provider charges a missed appointment or a No Show fee, this fee is NOT covered by the Program. The Eligible Class Member is expected to pay this fee. Refer to C-8 (PFOA) Medical Monitoring Program Coding for covered services. What is the process for scheduling the screening appointment with a Provider? Upon the Program Administrator s determination of eligibility, those Eligible Class Members will be instructed to contact a HealthSmart Customer Service Representative to help them identify a HealthSmart Participating Provider and also call those Participating Provider offices to schedule the Eligible Class Member screening appointments. In most cases, the Eligible Class Member will be on the line with the customer service representative when the appointment is being scheduled. The customer service representative will be able to provide the following information that is typically required in order for the appointment to be scheduled. Eligible Class Member Name Eligible Class Member DOB Eligible Class Member Program Identification Number (an 11 digit Registration Number beginning with 8888 found on the Eligible Class member documents) Information regarding the Program Eligible Class Member s Other Insurance Information (when available) All Other Eligible Class Member Information Required to Schedule Appointments Please note that an Eligible Class Member may contact your office directly to schedule an appointment. In this event, please remind the Eligible Class Member to bring the required documents to the screening appointment. 15 P a g e

16 PROVIDER FREQUENTLY ASKED QUESTIONS Member Identification Q5 How will a Provider identify an Eligible Class Member? Eligible Class Members will arrive to their scheduled appointments with C-8 Medical Monitoring Forms that include on each page the Eligible Class Member s unique identifying number and HealthSmart network logos (referred to as registrants ID number on all Program documents, where 8888xxxxxxx number is the member s registration number listed on all Program documents) The three Forms which must be filled out and signed include: (1) a Class Member Screening Questionnaire which the Class Member must complete and sign; (2) a HIPAA Authorization Form allowing the provider to disclose health information to the Administrator of the C-8 Medical Monitoring Program which the Class Member must sign; (3) the Diagnosis Form; (4) the Instructions for Physicians Form that includes information for the provider including screening and follow up tests and referral form. This Form must be completed and signed by the Physician. As stated in the Instructions for Physicians Form, all of these forms must be returned to the Administrator of the C-8 (PFOA) Medical Monitoring Program at the following address/fax: Administrator C-8 (PFOA) Medical Monitoring Program c/o GCG PO Box Dublin, OH Fax: Referrals for Screening and Diagnostic Testing Q6 Q7 Am I required to send member to a specific lab within the HealthSmart provider network for the C-8 Screening and other recommended tests? Yes. Laboratory Corporation of America (Lab Corp) is the clinical reference laboratory established to perform the C-8 (PFOA) Blood Test for the Program. The Eligible Class Member will bring two LabCorp requisition forms to the appointment for your convenience. You may also obtain copies of the Lab Corp requisition forms at In addition, Eligible Class Members can visit to locate the nearest patient service center. If there are no convenient LabCorp patient service centers in your area, please contact Lab Corp directly to make arrangements for courier service from your office. I normally draw certain lab specimens in my office and send them to lab for testing. Can I continue this practice or am I required to send member to a patient service center of a participating lab? You may continue to practice as usual and draw lab specimens in your office. The lab requisition for the C-8 Blood Test provides detailed instructions that must be followed for handling. The requisition can be found in the packet that the Eligible Class Member brings to the appointment or at Specimens for other covered tests should be sent to LabCorp as stated above. 16 P a g e

17 PROVIDER FREQUENTLY ASKED QUESTIONS Q8 What is the process for ordering a blood pressure monitoring device? If an Eligible Class Member that is pregnant expresses concern about gestational hypertension, medical care providers should recommend home monitoring of blood pressure in between prenatal visits beginning at the 20 th week of gestation. Member should be given a prescription for the digital blood pressure monitoring device. Once purchased, the Eligible Class Member should submit the receipt for purchase directly to the Program Administrator for reimbursement along with a physician s order. Claim Submission and Program Reimbursement Q9 Is authorization required for services covered by the C-8 (PFOA) Medical Monitoring Program? Authorization for covered services is not required. Please refer to C-8 (PFOA) Medical Monitoring Program Coding which provides a list of services and procedures that are covered under the C-8 (PFOA) Medical Monitoring Program. These documents can also be found at NOTE: Only the covered services and procedures are paid under the Program, however if an Eligible Class Member is diagnosed with any of the Human Diseases as defined by the Program, the Eligible Class Member is encouraged to comply with the prescribed treatment plan under a physician s care. Any services or procedures not covered by the Program should be billed to the Eligible Class Members personal insurance for consideration. Q10 What is the medical monitoring program reimbursement for covered services? Covered Services will be paid in accordance with your HealthSmart participating provider agreement. A complete list of covered CPT codes is provided in your Participating Provider Program Guide or can be found on our website at If you have any questions regarding the reimbursement amounts, you may contact provider relations by at providerrelations@healthsmart.com or by phone at Q11 NOTE: Only the covered services and procedures are paid under the Program, however if an Eligible Class Member is diagnosed with any of the Human Diseases as defined by the Program, the Eligible Class Member is encouraged to comply with the prescribed treatment plan under a physician s care. Any services or procedures not covered by the Program should be billed to the Eligible Class Members personal insurance for consideration. Is there Program documentation that is required in order for the Provider claim to be processed and eligible for reimbursement? To ensure that your provider claim is processed and paid timely, the following Program documents must be submitted to the Program Administrator. Instructions for Physicians Member Screening Questionnaire Form For Probable Link Conditions Screening and Follow Up Testing Form HIPAA Authorization for Disclosure of Protected Health Information 17 P a g e

18 PROVIDER FREQUENTLY ASKED QUESTIONS Q12 What is the process for submitting provider claims for services covered by the C-8 (PFOA) Medical Monitoring Program? For ease and efficiency, provider claims should be submitted electronically. Provider claims should be submitted as listed below. Electronic Provider Claim Submission should be sent to: HealthSmart Benefit Solutions Electronic Payor ID: Member Program ID: 8888xxxxxxx (where 8888xxxxxxx number is the member s registration number listed on all Program documents) Paper Provider Claims Submission should be sent to: Administrator C-8 (PFOA) Medical Monitoring Program c/o GCG PO Box Dublin, OH Fax: For additional questions related to provider claims, you may contact customer service at Note: The address listed above is only to be used for Provider Claims submitted to the C-8 (PFOA) Medical Monitoring Program. All other provider claims for HealthSmart members with a standard member ID Card should be submitted to the claim address listed on the ID card. Q13 Q14 Q15 What is the process for recommended follow-up tests for the C-8 (PFOA) Medical Monitoring Program? Recommended follow-up tests are to be ordered using the C-8 (PFOA) Medical Monitoring Program Follow-Up Testing Form which is included with the Physician Instructions that the Eligible Class Member will bring to the appointment. This form can also be found at Who do I contact for status of Provider claims? To get information regarding status of provider claims, you may contact customer service at Who do I contact to determine if a test/procedure is covered under the C-8 (PFOA) Medical Monitoring Program or private insurance? For details regarding services covered by the Medical Monitoring Plan, please see Probable Link Conditions and Medical Monitoring Program CPT Coding documents. These documents can be found at You may also contact customer service at P a g e

19 PROVIDER FREQUENTLY ASKED QUESTIONS Q16 Which follow-up visits will be reimbursed by the C-8 (PFOA) Medical Monitoring Program? The C-8 Medical Monitoring Program will reimburse the physician for a single office visit to cover the screening interface with an Eligible class member. All subsequent office visits will only be reimbursed under the C-8 (PFOA) Medical Monitoring Program when the recommended follow-up test or procedure requires an office visit to be billed in order to perform the specific follow up test/procedure. NOTE: Only the covered services and procedures are paid under the Program, however if an Eligible Class Member is diagnosed with any of the Human Diseases as defined by the Program, the Eligible Class Member is encouraged to comply with the prescribed treatment plan under a physician s care. Any services or procedures not covered by the Program should be billed to the Eligible Class Members personal insurance for consideration. Q17 What happens if the lab value is inconclusive and requires a repeat test? If a repeat test is needed, use the Lab Corp requisition form to order the follow up test. Once the lab results are received, you must submit the results along with a signed Follow Up Testing Form to the C-8 (PFOA) Medical Monitoring Program claims address noted above in Q P a g e

20 PARTICIPATING PROVIDER RESOURCES Please see enclosures or contact HealthSmart Customer Service at You may also visit for additional provider resources. 20 P a g e