Frequently Asked Questions

Visitor & General Frequently Asked Questions

• Are there programs to help people with limited incomes?

  Arise Health Plan offers competitive rate plans. Work with your agent to find a program that fits your needs.
  If you need help to find an Arise Health Plan agent, please contact Arise Health Plan Member Services at
  888-711-1444.

• Can my costs change after I enroll in a plan?

  Complete applications that are medically underwritten receive final rates/offers unless additional information
  is received that changes the risk.

• How long will it take to process the application form?

  Complete applications received by Arise Health Plan are provided medically underwritten rates/offers within
  approximately 5-7 business days.

• If I apply for an insurance plan, am I obligated to buy it?

  Arise Health Plan provides underwritten group quotes, but there is no obligation to submit for enrollment. If
  you are not satisfied with your individual policy, and it is returned to Arise Health Plan within 10 days of your
  receipt of the policy, it will be treated as if it had never been issued, and we will return all your payments
  directly to you.

• What are pre-existing conditions, and will my insurance policy cover them?

  A pre-existing condition is an illness or injury for which medical advice, diagnosis, care, or treatment was
  recommended or received during the specified time period prior to the covered person’s effective date.

  Benefits for pre-existing conditions and any complications are not payable under the plan for 12 consecutive
  months (18 consecutive months for Late Enrollees) from the enrollment date. Charges incurred after this
  period are eligible for benefits as provided under this plan.

  Further questions regarding coverage for pre-existing conditions may be directed to Arise Health Plan
  Member Services at 888-711-1444.

• What is a deductible?

  A deductible is the amount of covered expenses that must be incurred before benefits are payable. The
  Schedule of Benefits in your certificate shows the amount of the deductible and the health care benefits to
  which it applies. The deductible starts over at the beginning of every plan year.

• What are exclusions?

  Exclusions are any service or supplies listed in the Exclusions and Limitations section of your certificate.
  Services or supplies listed as exclusions are not covered by the plan, regardless of their medical necessity,
  their approval, or prescription by a physician or other provider.

• Can I use my plan once I’ve registered but haven’t yet received my information in the mail?

  When an Arise Health Plan policy number and effective date is issued, members can access their health
  insurance plan benefits to coincide with their effective dates. You or your provider of service may contact
  Arise Health Plan Member Services at 888-711-1444, and a representative will be able to confirm your
  coverage and provide the necessary identification and coverage information.

• What information do I need to utilize my plan?

  You will receive an ID card when you enroll in Arise Health Plan. The card identifies you as a plan member.
  If your plan has an office visit copay, it will appear on your card, and you will be asked to pay that amount at
  the time of service. You show your Identification Card each time that you visit your doctor. Your doctor will
  send us a claim for services provided.

• Do I have to use in-network providers?

  The type of plan that you are covered under determines whether benefits are available for out-of-network
  providers. If you are covered by an HMO plan, you only have coverage for in-network providers, unless
  services are for emergency or urgent care.

  If you are covered by a POS plan, you have coverage for expenses received from both in-network and out-of-
  network providers. For covered expenses received from in-network providers, you pay a lower
  coinsurance, copays, deductible, and out-of-pocket maximum. For covered expenses received from out-of-network
  providers, you pay higher coinsurance, copays, deductible, and out-of-pocket maximum.

• Why am I required to provide information about my medical history?

  Arise Health Plan medically underwrites risk for final rates/offers for all of our medical health plans.

• What information do I need to apply for a plan?

  You may contact your Arise Health Plan agent for all quoting/enrollment assistance. If you need help to find
  an Arise Health Plan agent, please contact Arise Health Plan Member Services at 888-711-1444.

• If I apply for a plan, how soon will my coverage begin?

  Effective dates are usually the first of the month following underwriting approval of a complete application.

Member Frequently Asked Questions

• Are there restrictions on my prescription drug coverage?

   There are certain guidelines that will be followed for prescription coverage. You will find those in your policy
  certificate under the Prescription Drug Benefits section.

  
  The following types of drugs are commonly excluded from most plans:
  • Drugs to treat infertility
  • Compounded medications that do not contain at least one legend ingredient
  • Non-legend drugs (i.e., those available without a prescription)
  • Investigational drugs
  • Drugs not obtained from a plan pharmacy
  • Replacement medications resulting from loss, theft, or damage
  • Any drug used for weight control
  • Drugs used for cosmetic purposes
  • Drugs to treat nail fungus

  
  The following are in place to ensure your prescription drug claims are processed correctly with regard to
  your benefit:

  
  • Quantity Level Limits—some drugs are not taken every day (e.g., migraine medications). Therefore, the
  amount you can get per copay is limited to what would be typically needed for that condition.

  
  • Generic Substitution—when an FDA-approved generic is available, the health plan may limit coverage to
  the generic form of a drug. If the member requests the brand, he/she will be responsible for the appropriate
  brand copay plus the difference in cost between the brand and the generic.

  
  • Pre-Authorization—a limited number of drugs must meet specific criteria for use before they will be
  considered a covered benefit. Your practitioner may be required to send us certain medical information to
  help us make that decision. The practitioner’s office and member are notified as to whether or not the drug
  is approved.

  
  If a drug pre-authorization request has not been submitted, or the authorization has been denied, your
  pharmacy will not be able to file the drug claim under your prescription benefit, and you will be responsible
  for the entire cost of the prescription.

  
  If a member would like to initiate the pre-authorization process, you may print this form and give it to your
  provider.

• Who do I contact for benefits questions?

  Please direct your questions to Arise Health Plan Member Services at 888-711-1444.

• When do I need pre-service authorization?

  A pre-service authorization must be obtained prior to the patient being seen by a specialist outside of the
  network, and before being seen at all in-patient facilities. The authorization must be approved by the
  medical director or his/her designated agent prior to the date(s) of service requested.

  
  Pre-service authorization IS required for:
  • In-patient stay in a hospital, skilled nursing facility (nursing home) or birthing center
  • Transplants
  • Home health care
  • Hospice care
  • Durable medical equipment over $500 or any durable medical equipment rentals
  • Home infusion
  • Prosthetics over $1,000
  • New medical or biomedical technology
  • New surgical methods or techniques
  • Non-emergency ambulance transportation
  • Genetic counseling, studies, and testing

• Who do I contact for billing?

  Please direct your questions to Arise Health Plan Member Services at 888-711-1444.

• What does preferred allowance mean?

  Preferred allowance is the contracted rate that Arise Health Plan has negotiated with the participating
  providers in plan.

• What is the difference between in-network and out-of-network providers?

  An in-network provider is a person, entity, or institution that is part of the Arise Health Plan network. This
  may include any practitioner, hospital, pharmacy, clinic, skilled nursing facility, surgical center, or other
  health care provider. Covered services performed by an in-network provider are generally paid at a higher
  level of benefit than if the same services are provided by an out-of-network provider. An in-network provider
  may provide a discount on services for which the member is not responsible.

  
  An out-of-network provider is a person, entity, or institution that is not part of the Arise Health Plan
  network. Depending on the type of plan under which you are covered, services by an out-of-network
  provider may not be covered or, if covered, they will be paid at a lower level of benefits than an in-network
  provider may be. Additionally, the allowance for covered services by an out-of-network provider is limited to
  what we determine to be usual and customary for the service. You would be responsible for any amount in
  excess of the usual and customary amount.

• What are pre-existing conditions, and will my insurance policy cover them?

  A pre-existing condition is an illness or injury for which medical advice, diagnosis, care, or treatment was
  recommended or received during the specified time period prior to the covered person’s effective date.

  
  Benefits for pre-existing conditions and any complications are not payable under the plan for 12 consecutive
  months (18 consecutive months for Late Enrollees) from the enrollment date. Charges incurred after this
  period are eligible for benefits as provided under this plan.

  
  Further questions regarding coverage for pre-existing conditions may be directed to Arise Health Plan
  Member Services at 888-711-1444.

• What are exclusions?

  Exclusions are any service or supplies listed in the Exclusions and Limitations section of your certificate.
  Services or supplies listed as exclusions are not covered by the plan, regardless of their medical necessity,
  their approval, or prescription by a physician or other provider.

• What is my coverage period?

  Generally, policies last one calendar year and are renewed annually. For verification of your coverage
  period, contact Arise Health Plan Member Services at 888-711-1444.

• What do copayment and coinsurance mean?

  A copayment (or copay) is an amount shown in your Schedule of Benefits that you must pay directly to your
  provider each time a covered service is received. Copayments do not apply to any deductibles or out-of-pocket
  maximums.

  
  Coinsurance is the amount of covered expenses that you must pay toward the total expenses incurred for
  services. The amount is shown in the Schedule of Benefits. Charges that you pay as coinsurance do not
  apply to any deductible or copayment for which you are responsible. The participating coinsurance applies
  to the participating out-of-pocket maximum and non-participating coinsurance applies to the nonparticipating
  out-of-pocket maximum.

• How can I find a provider?

  You may use the Find A Doctor option on the website, or you may contact Arise Health Plan Member
  Services at 888-711-1444 for assistance.

• Where do I send my claims?

  You or your provider may send your claims to:

  
  Arise Health Plan
  PO Box 11625
  Green Bay, WI 54307-1625

  
  Please include your identification number to assist in processing.

• Is my prescription covered?

  Please refer to your plan documents. For specific questions, call Arise Health Plan Member Services at 888-
  711-1444, option #1.

• How do I renew my insurance?

  Arise Health Plan provides all active policies/groups with an automatic renewal notification and assumes
  that the policy will remain in force unless the policy is being terminated in accordance with the termination
  provisions outlined in your policy or certificate.

• How do I view my current benefit plan?

  You may view your benefit plan online by creating an account on our website.

• How do I check the status of a claim?

  You may view your claims through the Arise Health Plan website by creating a user account, or you may
  contact Arise Health Plan Member Services at 888-711-1444.

• How do I update my information?

  A member should notify us of any change in name, address, other insurance, and primary care physician.
  This can be done by submitting a change form or by contacting Arise Health Plan Member Services at 888-
  711-1444.

  
  Arise Health Plan
  Billing & Enrollment Dept.
  PO Box 11625
  Green Bay, WI 54307-1625

  
  Email: BillingandEnrollment@arisehealthplan.com

Provider Frequently Asked Questions

• Who can make a pre-service authorization?

  A participating practitioner can submit a pre-service authorization form to Arise Health Plan. Services or
  products can be rendered after receiving written approval from Arise Health Plan. Services will be subject to
  all plan provisions including, but not limited to, medical necessity and plan exclusions.

• When must a pre-service authorization be obtained?

  Pre-service authorization is required for all non-participating practitioners/providers and tertiary care
  specialists/facilities.

  
  Pre-service authorization is required for specialized services including:
  • In-patient stay in a hospital, skilled nursing facility (nursing home) or birthing center
  • Transplants
  • Home health care
  • Hospice care
  • Durable medical equipment over $500 or any durable medical equipment rentals
  • Home infusion
  • Prosthetics over $1,000
  • New medical or biomedical technology
  • New surgical methods or techniques
  • Non-emergency ambulance transportation
  • Genetic counseling, studies, and testing

  
  Before seeking medical services, members should call Arise Health Plan Member Services at (920) 490-
  6900 or toll-free at 888-711-1444, option 1, to verify that the pre-service authorization request has been
  approved.

  
  Services that do not require pre-service authorization:
  • Services performed by a participating practitioner/provider
  • Emergency care or urgent care at an emergency or urgent care facility
  • Covered radiologist, pathologist, and anesthesiologist services at a participating facility
  • Services for mental and nervous disorders or substance abuse

   

  The employer may require the member to access behavioral health care through an employee assistance
  program (EAP). If this is the case, a pre-service authorization may be required for behavioral health care.

• How do we add/delete a new Tax ID number?

  Any changes to existing provider status should be reported to Network Management on a completed
  Provider Update Datasheet, which is located in the Provider Forms section of the website.

Employer Frequently Asked Questions

• Where will my employees need to file a claim?

  Your employees, or their providers, may send claims to:

  
  Arise Health Plan
  PO Box 11625
  Green Bay, WI 54307-1625

  
  Please include the identification number to assist in processing.

• What should an employee do if a claim is denied?

  If a claim is denied, in whole or in part, an employee will receive written notice of the denial and the reasons
  for the denial. The notice will also inform them of the right to file a grievance and the procedure to follow.
  Pre-service authorization denials will be considered claim denials and will follow the same notification
  process. If they have a complaint or want to file a grievance, please contact Arise Health Plan Member
  Services locally at (920) 490-6900 or toll-free at 888-711-1444.

• How are claims handled for employees with more than one health insurance plan?

  Standard COB will apply. Refer to language specified within the certificate, policy, or summary plan
  description.

• How do I change the probationary period on a group’s policy?

  Simply complete a written request.

• Do my employees receive coverage if they are out of the area?

  For both HMO and POS plans, employees have coverage for emergency room care when they are out of
  the area (covered at the in-network level of benefits). For POS plans, employees out of the area would have
  coverage at the out-of-network level of benefits for non-emergency care. For HMO plans, there is no
  coverage out-of-network for non-emergency care.

• Is payment required at the time of application?

  Premium is not required to obtain a health insurance quote. However, a first month’s premium binder check
  is required once quote is accepted and in order to issue the policy.

• How do I obtain a group quote?

  Arise Health Plan works exclusively with agents. You must contact a licensed Arise Health Plan agent to
  obtain a quote. If you do not have an agent, please contact Arise Health Plan, and we will give you contact
  information for an agent in your area.

• What percentage of premium does the employer have to contribute?

  Arise Health Plan requires the employer contribute a minimum of 50% of a single contract.

• Can a group make a plan change off renewal anniversary?

  Yes, Arise Health Plan allows a group to make a plan change off renewal anniversary.

• What are the deadlines for a new group?

  All complete employer/employee required enrollment materials of an approved underwritten group must be
  received by Arise Health Plan before the requested effective date.

• What documentation is necessary for enrolling a group?

  Please contact your Arise Health Plan agent for a list of required enrollment materials.

• How long does it take to pay a benefits claim?

  Standard claim processing turnaround time is 30 days.

• How often is the prescription drug list updated?

  Our prescription drug list is reviewed and updated quarterly, or more often as needed.

• Who should employees call if they have questions?

  Your employees may contact our Member Services at 888-711-1444, option #1.

• How do I find the hospital options for each plan?

  The Find A Doctor option on the website also locates provider facilities. Using your group number, you can
  search for your hospital, or you may contact Arise Health Plan Member Services at 888-711-1444, option
  #1.

• What does “effective date” mean?

  Effective date means the first date on which all of the terms and provisions of this plan apply.

• How long is an employee eligible for group health insurance after leaving the job?

   If an employee leaves employment, coverage will be terminated based on your group’s termination
  provision, which is either end of the month or the last date of employment. All requests must be reported to
  us within 90 days of the last date of employment. The termination form can be sent to Billing & Enrollment.

  
  Arise Health Plan
  Billing & Enrollment Dept.
  PO Box 11625
  Green Bay, WI 54307-1625

  
  Fax (920) 490-6928

  
  Email: BillingandEnrollment@arisehealthplan.com

  
  If an employee is on disability, the coverage can be continued for up to three months. In addition, the
  employee can remain on the plan for two more months as a leave of absence.

• Who must be notified of a change of address or other administrative changes?

  An employee should notify us of any change in name, address, other insurance, and primary care
  physician. This can be done by submitting an employee change form or by contacting Arise Health Plan
  Member Services at 888-711-1444.

  If there are any changes to your company address or contact information, please notify our Billing &
  Enrollment Department. This may be done with a form that is included with your premium billing remittance
  slip, or you may send the changes to:

  
  Arise Health Plan
  Billing & Enrollment Dept.
  PO Box 11625
  Green Bay, WI 54307-1625

  
  Fax (920) 490-6928

  
  Email: BillingandEnrollment@arisehealthplan.com

• How long does it take to implement a plan?

  Once group is underwritten and all required employer and employee paperwork is received by Arise Health
  Plan and complete (no missing information), the plan will be implemented and ID cards and certificates will
  be sent out within 7-10 business days.

• Where do I send enrollment changes, additions, and terminations?

  Arise Health Plan
  Billing & Enrollment Dept.
  PO Box 11625
  Green Bay, WI 54307-1625
  Fax (920) 490-6928

  
  Email: BillingandEnrollment@arisehealthplan.com

• How do I find out if my doctor is in the network affiliated with a particular plan?

  You may use the Find A Doctor option on the website with your group number, or you may contact Arise
  Health Plan Member Services at 888-711-1444, option #1.

Agent Frequently Asked Questions

• How large is Arise Health Plan’s pharmacy network?

  Arise works with over 55,000 pharmacies nationwide.

• How often does Arise Health Plan update the prescription drug list?

  Our prescription drug list is reviewed and updated quarterly, or more often as needed.

• How long does it take to implement a plan?

  Once group is underwritten and all required employer and employee paperwork is received by Arise Health
  Plan and complete (no missing information), the plan will be implemented and ID cards and certificates will
  be sent out within 7-10 business days.

• Do I need special certifications to sell these products?

  Each Arise Health Plan agent must be licensed by the State of Wisconsin and held in good standing. We
  also require agents to have thorough knowledge of all of our products and provider base.

• What resources does Arise Health Plan have for members speaking foreign languages?

  Arise Health Plan provides language assistance for all members at no cost. For assistance, contact Arise
  Health Plan Member Services at 888-711-1444.