Transaction Processing Rules

Last updated: August 2022

Thank you for your interest in participating in the ProHealth Connect Network. As a participating retailer, you will bring important supplemental benefits to members and your communities.  Health plans that issue the ProHealth Connect Cards are an important community partner for your business as well as for the members.  Member and health plan satisfaction is of the utmost importance in the success of the ProHealth Connect Network.

We want to inform you that all ProHealth Connect Network cards are funded by the health plans and are generally government sponsored benefits.  As a result, retailers participating in the ProHealth Connect Network are considered providers under these Federal and State health care programs and are required to comply with all applicable laws and regulations relevant to the provision of services under a government contract, including, without limitation, the Federal False Claims Act.  

The following are rules and principles for processing the ProHealth Connect benefit (OTC, grocery, etc) cards. Participating retailers are required to adhere to these rules and principles. All retailer staff processing ProHealth Connect transactions MUST understand and follow these rules and principles:  

• ONLY eligible items can be deducted from the ProHealth Connect cards presented.  If a product does not scan as eligible, it cannot be paid for with the ProHealth Network card.  Each retailer must download their new UPCs/SKUs no later than the 5^th of every month for eligibility vetting. (Process for new items) This is required to stay in compliance with the ProHealth Connect Network, health plans and federal health care program rules and regulations. Failure to follow the process will limit item eligibility. Using ProHealth Connect Network cards to purchase ineligible items can lead to your retail location being suspended and/or  terminated from the ProHealth Connect Network.  

• Batch processing without using correct quantities is prohibited. Every item sold must be scanned separately or enter the quantity sold.

• Scanning an eligible item and replacing it with an ineligible item is prohibited and can lead to the retailer’s suspension and/or termination from the ProHealth Connect Network. ONLY eligible items can be deducted from the ProHealth Connect card presented.

• Retailers are prohibited from retaining ProHealth Connect Network cards or card numbers for use.  Each retailer is required to return the ProHealth Connect card at the close of the transaction and/or take appropriate steps to destroy the ProHealth Connect card information.   You cannot maintain possession of the member card to be charged each month. 

• Each retailer must issue a receipt both from the ProHealth Connect Terminal and the store register or POS system (as applicable)  following the completion of a member transaction.  The Retailer MUST maintain a copy on hand for your records.

• No retailer is permitted to charge the member a transaction fee or mark up prices on items in the store when the ProHealth Network card is presented. Marking up prices violates Medicare rules pertaining to benefits on the ProHealth Network Card.    Marking up prices may be grounds for retailer suspension and/or termination from the ProHealth Connect Network.

If during analysis we detect that any retailer is selling items at an average price in excess of prices charged across the ProHealth Connect Network in their area, for the same UPC, this may prompt an investigation and could result in the retailer’s suspension and/or termination from the ProHealth Connect Network.  

ProHealth Connect will analyze transaction data to identify suspicious activity and transactions in conjunction with complaints from members and plans.  Be aware that suspicious activity is monitored daily and will be investigated.  Any retailer found to have sufficient suspicious activity, may be suspended and/or terminated from the ProHealth Connect Network. ProHealth Connect may additionally choose to notify appropriate state and federal legal authorities regarding the suspicious activity.    

We thank you in advance for your cooperation and upholding these critical principles of participation in the ProHealth Connect Network.  We know your interests are in serving your customers and the community and upholding these guidelines support this commitment.