Coverage Policy Bulletins/ Medical and Pharmacy Policies

Please read before continuing:

Medical Policies are developed to assist in making coverage determinations under our health policies or plans.

Medical Policies are for informational purposes only and do not constitute medical advice, plan authorization, an explanation of benefits, or a guarantee of payment. Benefit plans vary in coverage and some plans may not provide coverage for all services listed in these policies. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and federal law. Some benefit plans administered by the organization may not utilize Medical Affairs Medical Policies in all their coverage determinations. Contact Member Services as listed on the member card for specific plan, benefit, and network status information.

Medical Policies are based on constantly changing medical science and are reviewed annually and subject to change. The organization uses tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG Health, to assist in administering health benefits. These medical policies and MCG Health guidelines are intended to be used in conjunction with the independent professional medical judgment of a qualified health care provider.

For specific patient-related policy or medical coding inquiries, contact Arise Medical Management with the applicable patient name and member number, along with the procedure, service, or treatment in question.

Arise Health Plan
Attn: Medical Management Department
P.O. Box 11625
Green Bay, WI 54307-1625

Phone: 1-920-490-6901 or toll-free 1-888-711-1444, ext. 76901
Fax: 1-920-490-6943

We welcome your feedback regarding criteria in the Medical Policies or MCG Health guidelines. Comments regarding research and evidence development of specific criteria should include supporting references from peer-reviewed high level scientific literature. Please send your comments to medical.policies@wpsic.com.

For general medical policy or MCG Health information, email the Medical Policy Committee: medical.policies@wpsic.com.

For questions regarding medical coding related to policies, contact the Code Governance Committee: codegovernance@wpsic.com.

NOTE: These addresses should NOT be used to send personal health records or member identified information.

This disclaimer applies to all present and past Medical Policies.

I Understand and Accept the Above Information