April 09, 2019
As you know, you’ll receive the best SmartHealth network benefit coverage (and pricing) when you use an Ascension Network (Tier 1) provider. But sometimes that’s not possible.
The benefit elevation program was created to assist members that live in areas where there are no Tier 1 providers/facilities available, to have claims paid at the “in-network” coverage level. If a Tier 1 provider is not available where a member resides, the National Network of BCBS is suggested for Tier II coverage. Those Tier II services can be requested to be elevated to Tier I coverage level.
If neither a Tier 1 provider or National provider are available, an out-of-network physician/facility can be elevated but only to Tier II. Requests for benefit elevation authorization must be submitted and approved prior to services be rendered. Benefits already provided will not be authorized retrospectively. However, they may be approved going forward from date requested.
Members can request benefit elevation for episodic care or for dependents whose current mailing address is more than 50 miles from a Tier 1 provider/facility’s zip code on record. Forms can be found on www.mysmarthealth.org. Select the “Member Info Center” and view the “Benefit Elevation” section.
Please note that it takes a minimum of 10 business days to process all benefit elevation requests.
Once the request is approved, benefit elevation for episodic care is granted for 90 days. After which, an extension will need to be requested.
For dependents whose current mailing address is more than 50 miles for a Tier 1 provider/facility’s zip code, benefit elevation is granted for the entirety of the benefit enrollment year.
Automatic Benefit Elevation
Is your home address of record more than 50 miles from the nearest Tier 1 provider/facility’s zip code?
You may qualify for automatic benefit elevation. This mileage is calculated from a standard formula that determines the most direct path between your home’s zip code and a Tier 1 provider/facility’s zip code.
If you qualify for automatic benefit elevation, you will receive an email and letter notification from SmartHealth notifying you of your automatic status. If you have a question regarding your automatic status, please call 1 (844) 699-7573 or email email@example.com.
For additional questions, check out our FAQ document to help you navigate the program.