Contact information
For additional information on the following subjects, please refer to your
Annual Benefits Guide or Summary Plan Description. If you are a retiree and
Medicare is your primary carrier, coverage is provided only for services
approved by Medicare.
Eligibility and Enrollment
1. When can I enroll in the plan?
PSE (Public School Employee) open enrollment is in August for an effective date
of October 1.
ASE (Arkansas State Employee) open enrollment is in October for an effective
date of January 1.
ASE and PSE retirees will be moved to the retirement group upon their retirement
date. Thereafter, the open enrollment is in October for an effective date of
January 1.
Open enrollment period: A time-period annually for employees to
make changes to health-plan coverage.
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2. Can my dependents be added to my plan after it is in
effect?
Active employees may add eligible dependents during the group's open enrollment
period or during a specific enrollment period based on a qualifying event.
Please refer to your Summary Plan Description. Contact your agency
representative or school business official if you have a family status change
that meets the criteria for a special enrollment period.
Retirees cannot join the plan or add dependents after retirement unless there is
an approved family status change. You must be on the plan at the time of
retirement to be eligible to continue coverage.
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3. What is the age limit for dependent coverage?
Eligible dependents are the employee's:
Unmarried children, if, but only if, they fall into one or more of the following
categories:
- A child less than age 19 and living in the home;
- A child who is enrolled and regularly attending on-campus classes as a full-time
student at an accredited college or university, under age 24 and who is
financially dependent on the employee;
- A child of any age, who is medically certified as totally disabled due to mental
or physical incapacity and chiefly dependent on the employee for financial
support, provided the requirements below are met.
Proof of mental or physical incapacity: For dependent coverage to be
provided due to mental or physical incapacity, proof of the child's dependency
and incapacity must be submitted prior to the child's attainment of the
applicable limiting age referenced in section above. Subsequent evaluation for
continued incapacity and dependency may be required. Newly eligible employees
may enroll an incapacitated dependent child provided the disability commenced
before the limiting age, and the child has been continuously covered under a
health benefit plan as a dependent of the employee since before attaining the
limiting age.
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4. When is my newborn covered?
The change form requesting coverage for your newborn must be submitted through
your agency representative or school business official.
Coverage for an employee's newborn child shall become effective as of the date of
birth, placement for adoption, or filing date of petition for adoption of the
child if the employee gives notice of the child by submitting an application or
change form for the child within 30 days of the child's date of birth. This
deadline applies to members on all coverage tiers (employee only, employee +
child(ren), employee + spouse, and employee + family.
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5. What is a qualifying event for COBRA coverage?
- Termination of an enrolled employee's employment (other than for gross
misconduct) for any reason (layoff, resignation, retirement, etc.).
- Reduction of work hours.
Death of the covered employee.
- Divorce or legal separation from the covered employee.
- Dependent child ceasing to meet eligibility requirements.
Retiree or retiree's spouse or child loses coverage within one year before or
after the commencement of proceedings under Title 11.
- When dependent loses coverage due to covered employee becoming entitled to
Medicare.
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6. What is a Certificate of Credible Coverage (COC)?
A Certificate of Credible Coverage (COC) lists your coverage with Health
Advantage from the initial effective date to your termination date. This
certificate is generated after your policy is terminated. Insurance companies
use this certificate to reduce pre-existing time clauses and to verify insurance
coverage with other carriers. Contact Employee Benefits Division if you need a
COC.
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Health Plan Information
1. Do I need to take my member ID card each time I go to
the doctor?
We strongly recommend that you carry your ID card with you at all times, and
that your family members carry their ID cards with them as well. To ensure
prompt payment of claims, please make sure that the information on your ID card
is correct and that all providers have the correct date of birth and the
spelling of your name.
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2. What if I lose my ID card?
You may order cards online at
www.arbenefits.org or by contacting the Employee Benefits Division (EBD) at
1-877-815-1017 or 501-682-9656 or Health Advantage Customer Service at
1-800-482-8416.
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3. What is the difference between in-network and
out-of-network services?
In-network services are covered services or supplies a member receives from plan
physicians or plan providers. Out-of-network services are covered services or
supplies a member receives from non-plan physicians or other non-plan providers
that are not in the Health Advantage provider network chosen by your employer.
Emergency care and urgent care services that are covered are paid at the
in-network benefit level up to the allowable charge. The member may be billed
the difference between billed charges and allowable charges for services
received from non-plan providers.
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4. Does Health Advantage provide online services for
members?
Yes. You may access
www.HealthAdvantage-hmo.com for the following:
- Health plan information: General information about the health plan,
referral information, preventive health information, BlueCard Program, and
My Blueprint which allows you to view claim information is also
available.
- Provider Directory: A listing of all Network PCPs, Specialists,
Hospitals, Pharmacies and other providers contracted by Health Advantage. Click
on the directory specifically for your employer group.
- Eligibility/claim information: By registering for
My Blueprint, you may check membership eligibility and claims status,
print an Explanation of Benefits, and review primary care physician information.
- Health-Care Cost & Quality Health Information Guide: Allows you to search
for information on a wide range of health topics.
- Select Quality Care: A hospital quality guide that provides information
on health-care procedures, mortality rates and complications.
- Cost-of-Care Estimator: Access information that helps you to know how
much treatment for a condition might cost based on your location.
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5. What does my health plan cover and what will I need to
pay?
Your health plan covers preventive and medical services as defined in your
Summary Plan Description. You may be responsible for any applicable copayments,
deductibles and/or coinsurance. Usually, you will be responsible for any
applicable copayments and/or deductibles at the time of service and may receive
a bill at a later date for your coinsurance responsibility. Depending on the
type of benefit, prior approval may be required for certain specialty services.
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6. What is a deductible?
The deductible is the amount of allowable charges for out-of-network covered
services for which the member is responsible before the member pays the
coinsurance and Health Advantage makes payment for a service received.
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7. What services are subject to the deductible?
All covered services received from non-plan providers except for emergency care
are subject to the out-of-network deductible. Copayments and coinsurance do not
count toward the deductible.
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8. What is a copayment?
A copayment is the predetermined fixed dollar amount a member must pay to
receive a specific service. Copayment may mean a defined percentage of charges a
member must pay to receive specific services. Copayments do not apply to the
annual coinsurance maximum (out of pocket limit).
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9. What is coinsurance?
Coinsurance is a defined percentage of the allowable that a member pays for a
service after the copayment is applied. Once the annual coinsurance maximum is
met for each member or for the family, no further coinsurance will be charged
for the current contract year.
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10. What is applied to the annual coinsurance maximum?
The annual coinsurance maximum is the maximum amount of coinsurance payments a
member is required to make in connection with covered services or supplies in a
contract year. The deductible, copayments, and amounts a member may have to pay
in excess of contract benefit limits and benefit exclusions do not contribute to
the annual coinsurance limit. Out-of-network deductible, copayments and
coinsurance are not applied to the in-network annual coinsurance limit.
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11. How can I make sure I receive covered services from
in-plan physicians or plan providers?
When you are within the state of Arkansas, you may find a participating
physician or provider by accessing the Health Advantage
provider directory or contact Customer Service to verify whether a specific
provider is in-network. Remember, click on the provider directory listed as
Arkansas State Employees or Public School Personnel.
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12. What can I do to reduce my out-of-pocket expenses?
Using participating providers and obtaining any required precertification prior
to the service will reduce your out-of-pocket expenses.
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13. Why would a health plan ask for additional information
such as medical records?
Additional information may be requested when a claim is pended for review.
For example, to ensure the specific medical criteria are met. There are specific
procedures that are only covered when specific criteria are met for coverage.
The Health Advantage coverage policies are located on the Web site under the
link “Coverage Policy”.
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14. What are my wellness benefits?
Your ARHealth Plan provides some services recommended for the prevention and
early detection of disease. Promotion of these services is accomplished through
direct communication with your physician. The preventive health guidelines
reflect recommendations from leading authorities and local practitioners and are
meant to be a guide. Treatment is at the clinical discretion of your physician.
You may also review the wellness benefit chart information in your Annual
Benefits Guide or online under the Members tab at
www.HealthAdvantage-hmo.com.
Routine vision and dental exams are not covered. If you are an active public
school employee with group dental benefits through Arkansas Blue Cross and Blue
Shield, please refer to benefit information from DentalBlue.
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15. Which services need pre-certification?
The Arkansas Employee Benefits Division (EBD) has contracted with a third-party
vendor, American Health Holding (AHH), not affiliated with Arkansas Blue Cross
and Blue Shield or Health Advantage, effective Oct. 1, 2007, for the Arkansas
State and Public School employees, to provide utilization management services
that include pre-certification, pre-determination and concurrent review.
Services that require pre-certification from AHH include but are not limited to
are:
| Inpatient admissions |
Cognitive rehab |
Home infusion therapy |
| Sub-acute admissions |
Specific therapy |
Home nursing visits |
| Inpatient rehabilitation |
Skilled nursing facilities |
Pet scan |
| Residential treatment |
Transplants |
|
| CT scan |
MRI/MRA |
|
| Limited out-patient hospital surgical procedures and specific
surgeries |
Please refer to your Summary Plan Description for specific information. It is
your responsibility to ensure that your provider contacts AHH at 1-800-592-0358
for pre-certification for you to receive these types of services.
If the Arkansas State or Public School member has Medicare primary,
pre-certification by AHH is not required.
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16. Do I need a referral to receive medical care from a
plan specialist?
No. Members may receive in-network covered services at the in-network benefit
level from plan physicians and plan providers without a referral. Remember:
Specific services require authorization from American Health Holding (AHH).
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17. If I am out of the Health Advantage service area and
have an unexpected illness or injury, what should I do?
If it is an emergency, go to the nearest medical facility. Health Advantage will
cover emergency care and urgent care outside the service area (state of
Arkansas). Urgent care is an unexpected illness or injury that cannot wait until
the member returns to the service area. The member may limit expenses to
copayment/coinsurance for emergency care and urgent care by using PPO providers
in the BlueCard program. The member may be billed the difference between the
billed charges and allowable charges for services received from out-of-plan
providers that do not participate in the BlueCard program. Note: All emergency
hospital admissions should be reported to American Health Holding (AHH) within
24 hours.
If this is not an emergency, please call the BlueCard number on the front of your
ID card to locate the nearest PPO BlueCard provider.
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18. What medical conditions are considered an emergency?
Conditions that are so severe as to cause serious disability if not treated are
considered emergencies. Some examples of emergencies that require immediate
attention include:
| *Heart attack or severe chest pain |
*Serious burns |
*Acute abdominal pain |
| *Uncontrollable bleeding |
*Poisoning |
*High fever |
| *Broken bones |
*Unconsciousness |
*Severe shortness of breath |
| *Convulsions or choking |
|
|
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19. Are weight-loss programs covered?
We suggest that you work with your physician to develop a healthy lifestyle for
you and your family. Weight-loss programs and treatments designed to assist
weight loss, such as health club memberships, dietary supplements, surgical
procedures or complications resulting from surgical procedures, are not covered
by Health Advantage. Contact LifeSynch at 1-866-378-1645 to inquire about weight
loss and life style change programs.
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20. I am pregnant; what should I do concerning my
health-care benefits?
You should schedule an appointment with a participating obstetrician as soon as
possible (no referral required). Contact the Employee Benefits Division at
501-683-0260 or 866-451-8194 to enroll in the ‘Mommy 2 B’ program. Upon
satisfactory completion of the program, the member will receive a one-time
credit (per pregnancy) of the $250 inpatient copayment.
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21. Are FluMist and flu shots covered?
Yes. When in-plan providers are used, the member may not be billed the
difference in the billed and allowed amount.
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22. Are diabetic supplies covered?
Yes. There is coverage for items and supplies such as insulin pumps and supplies, glucometers
and supplies, and diabetic self-management training. Applicable charges may apply such as copayments
and coinsurance. Payment for diabetic supplies does not apply towards the DME contract maximum. There
is no contract maximum amount or limit for diabetic supplies. You may purchase your insulin and supplies
at the pharmacy-all covered for just one copayment. Please refer to your Summary Plan Description for
coverage details.
Other supplies or durable medical equipment (DME) items
Items must be obtained from an in-plan provider in order for the claim to be
paid on the in-network benefit level. If an out-of-plan provider is used, the
claim will be processed on the out-of-network benefit level. DME examples are
crutches, wheel chairs, walkers, etc. Pre-certification by American Health
Holding (AHH) is required for four categories of DME – spinal cord stimulators,
continuous glucose monitoring devices, defibrillator vests, and power mobility devices.
Hospital services:
Inpatient hospital services are covered at the
semiprivate room rate. The member is responsible for the difference between a
private room and semiprivate room rate except when a private room is medically
necessary or when a hospital has only private rooms. Pre-certification is
required for all inpatient admissions and specific outpatient services. Please
call American Health Holding (AHH) at 1-800-592-0358 and refer to your Annual
Benefits Guide for utilization management information.
Ambulance services:
Emergency transportation by ambulancEmergency
transportation by ambulance is covered up to a $2000 benefit maximum per member
per plan year ($2000 does not include charges for emergency medications
administered during transport). In addition to the member’s coinsurance (if
applicable), the member is responsible for the difference in the billed and
allowed charge when a non-participating provider is utilized.
Behavioral/mental health and substance abuse services:
These services are coordinated through LifeSynch. Please contact LifeSynch at
1-866-378-1645 for a list of participating providers and instructions on
accessing these services.
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23. What is case management?
A case management program is a personalized, multidisciplinary process to assist
patients and family members of patients who face catastrophic illnesses and
long-term recoveries in meeting health needs. Case management promotes
individual health-care management while facilitating appropriate health-care
measures within the most cost-effective environment. For case management and
health education needs, call the Employee Benefits Division (EBD) at
877-815-1017.
For other benefit coverage and limitation information, please refer to your
Annual Benefits Guide or Summary Plan Description.
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PCP Selection
1. Am I required to select a primary care physician (PCP)?
ARHealth members are not required to select a PCP; however, Health Advantage
does encourage members to see a PCP for routine medical care and preventive
health services and to coordinate health care.
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2. If I decide to select a PCP, must I select the same PCP
for all family members?
ARHealth members do not need to select a PCP, and can see any participating PCP
for medical care and pay the $25 PCP copayment.
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3. What is the proper procedure for seeing my PCP?
If you are a new member, we recommend that you contact your PCP office to
schedule an appointment. You should also have your medical records transferred
to your new PCP.
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4. What if I become ill or am injured and my PCP office is
not open?
Contact your PCP or the physician on call. He or she will instruct you on what
to do. Since you are on the ARHealth plan, you may see any PCP you want to see.
However, if your problem is so severe that immediate medical care is needed, get
help first at the nearest medical facility. Your PCP should be notified of any
emergency care within 24 hours.
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BlueCard Program
ARHealth retirees with Medicare as their primary insurance may utilize any
provider within the Medicare coverage area. Please note that Medicare does not
cover services outside the United States or United States’ territories. Your
ARHealth plan only coordinates with Medicare for approved services.
As an ARHealth Health Advantage plan member, you have more freedom to choose the
doctors and hospitals that best suit you and your family. Your coverage gives
you a world of choices. Within the United States, you have access to more than
815,000 PPO doctors and hospitals. Outside the United States, access is
available in more than 200 countries and territories around the world through
the BlueCard Worldwide program. The BlueCard program gives you access to PPO
doctors and hospitals almost everywhere, giving you the peace of mind that
you’ll be able to find the health-care provider you need.
With the BlueCard program, there are two methods to locate doctors and hospitals
within the United States quickly and easily — the BlueCard number is located on
the front of your ARHealth ID card.
- Call BlueCard Access® at 1-800-810-BLUE (2583) for the names and addresses of
providers in the area where you or a covered dependent need care.
- Visit the BlueCard Doctor and Hospital Finder at
www.BCBS.com to locate PPO providers, maps and directions.
Always use a BlueCard PPO doctor or hospital to ensure you receive in-network
benefits.
Designed to save you money… In most cases, when you travel or live outside
your local service area, you can take advantage of savings the local Blue plan
has negotiated with doctors and hospitals in that state or country. For covered
services, you should not have to pay any amount above the negotiated rates.
Take charge of your health wherever you are…
Within the United States:
- Always carry your ARHealth ID card.
- In an emergency, go directly to the nearest hospital.
- Refer to the BlueCard access number on the front of your card or the web address
to locate a provider.
- Call American Health Holding for pre-certification.
- When you arrive at the PPO physician’s office or hospital, show your ID card.
Around the World:
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Claims Processing
1. What is the time limit for filing a claim for benefits
to Health Advantage?
A notice of claim must be made to Health Advantage by the member or the
provider within 180 days of the date on which covered services were first
incurred.
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2. When will I receive an EOB and how will I know what
amount I need to pay?
You will receive an EOB every time Health Advantage processes a claim for you or
somebody on your contract. You should keep your EOB to compare it with the bill
that you receive from the provider. Your minimum responsibility should match the
amount requested from the provider. This may differ if the service is denied as
a non-covered service or as a benefit limitation. If the amount indicated on
your EOB does not match the amount billed by the provider, you may call the
provider or Customer Service at Health Advantage.
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3. How long should it take for me to receive an EOB from
the date of my service?
Once the provider submits a claim, it should be processed within 30 days. This
may be delayed if additional information is requested.
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4. How can I find out if Health Advantage has processed a
claim?
An EOB is mailed to your home each time a claim is processed. You may check the
status of a claim online by going to
My Blueprint and selecting "Check Claims Status." If the status shows
"complete," the claim has been processed. If the status shows "in process," the
claim has been received by Health Advantage, but final action has not been
taken. From My Blueprint, you can also sign up for e-mail notifications when there is an EOB available. You also may
call MyBlueLine – an interactive voice response system –
toll free, 24/7, at 1-800-482-8416.
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5. How can I find out my financial responsibility for a
claim?
An EOB is mailed to your home each time a claim is processed. Your copayment and
coinsurance responsibility (if you have one) will be shown on the EOB. You may
print a copy of the EOB for any claim that shows "complete" from
My Blueprint under "Check Claims Status." You also may call MyBlueLine –
an interactive voice response system – toll free, 24/7, at 1-800-482-8416.
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6. Why does my provider send me a billing statement?
If the statement date is less than 30 days old from the date of service, it is
possible that the billing statement may cross with the payment of the claim. If
adequate time has been allowed for the processing of the claim, you should
research the bill. If the claim has been processed and you received an EOB, the
amount that the provider is billing you should be matched with the amount on the
EOB that is listed as the member’s responsibility. If the amount the provider is
billing you is higher, or Health Advantage has not processed the claim, a call
should be made to the provider’s office. Explain the amounts shown on your EOB,
ask them to research your bill, and ask them to verify the information filed on
the claim. If the information filed doesn’t match your ID card, the provider
will need to file a corrected claim to Health Advantage. If you no longer have
the EOB, you may view your claim information by using our online tools at
www.HealthAdvantage-hmo.com. If the issue cannot be resolved, you or the
provider can call the Customer Service Department at Health Advantage.
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7. What do I need to look at closest when I receive an EOB?
The provider name and date of service should match a service that you received.
If you did not receive this service, please call the provider. They may have
filed an incorrect claim. If the date of service and provider information are
correct, you should review the amount shown as your responsibility such as a
copayment, coinsurance, deductible or denied charge. If you have questions or
feel the amount is incorrect, you should call the Customer Service Department.
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8. What if I receive an Explanation of Benefits (EOB) and
the claim has not been paid?
If your claim has not been paid and has been put in a "hold" status awaiting
additional information or payment, your EOB will have a description of any
additional information necessary for the claim to be processed and an
explanation of why such information is necessary. If your claim has been denied,
your EOB will have a reference to a specific plan provision on which the
determination is based and a description of your plan's appeal process.
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9. What should I do if any of my services were denied?
Review the service that was denied and reference the Exclusions or Benefit
Limitations in your Evidence of Coverage/Summary Plan Description. If the
service was denied correctly, you are responsible to pay the billed charge to
the provider. If you feel the claim was denied in error, you may call the
Customer Service Department. If you wish to appeal the denial of the claim,
please follow the appeal guidelines listed in your Evidence of Coverage/Summary
Plan Description.
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10. What if I have a question about an Explanation of
Benefits (EOB) determination?
If you have questions about an EOB determination, you may contact Customer
Service toll free at 1-800-482-8416 or write to: Health Advantage Customer
Service, P.O. Box 8069, Little Rock, AR 72203. This is an informal review is not
an appeal, nor a substitute for an appeal. Nor must you request an informal
review in order to request an appeal. Not all information reviews can be
processed by Health Advantage. In this case, the request will be forwarded to
the plan administrator, Employee Benefits Division, for an appeal review.
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Appeals
1. How do I appeal a claim or benefit determination?
If a claim for benefits is denied either in whole or in part, you may request a
review of a denial of benefits for any claim or portion of a claim by sending a
written appeal to Health Advantage, within 180 days of the denial. Your appeal
should include your name, identification number, and reference to the denied
claim. In preparing your request for review, you and your authorized
representative have the right to examine documents relevant to your claim. You
and your authorized representative may submit, with your request for review, any
additional information relevant to your claim and may also submit issues and
comments in writing. You will receive a final decision in writing within 30
days. If the appeal is related to a service that required pre-certification
from AHH, please call American Health Holding at 1-800-592-0358.
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2. What if I disagree with a determination but am not able
to file the appeal of a claim or benefit determination myself?
You may designate an authorized representative to represent you in filing an
appeal of a claim or benefit determination. For information on designation of an
authorized representative, please call Customer Service at 1-800-482-8416.
3. What if I have to pay for covered medical services or
medical supplies?
If you make payment other than required copayments or
coinsurance for services covered by Health Advantage, a claim for reimbursement
may be made by submitting a copy of your receipt for payment for services
received and a copy of the bill to Health Advantage. The request must include
the member's ID number and be made within 180 days from the date on which
expenses were first incurred. The request for reimbursement may be sent postage
paid to: Claims, Health Advantage, Post Office Box 8069, Little Rock, AR,
72203-8069.
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Other Insurance and Coordination of Benefits
1. Why do you want to know if I have other coverage?
A decision must be made as to which coverage is responsible for primary payment.
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2. Does Health Advantage coordinate benefits?
Yes. If you or any of your dependents have other insurance coverage that
provides benefits for hospital, medical, or other expenses, your benefit
payments may be subject to coordination of benefits. Unless the member has
Medicare primary, even if Health Advantage is not the primary carrier, you must
still follow the plan guidelines in order for Health Advantage to coordinate
benefits. It is the member’s responsibility to ensure Health Advantage has a
copy of the primary carrier’s Explanation of Benefits and all itemized bills,
and to inform Health Advantage of all changes in other insurance. If you
need to update other insurance information, you may submit the information in
writing, contact your employer benefits administrator, or call Customer Service.
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3. If I have secondary coverage, how can I get a copy of my
Explanation of Benefits from Health Advantage?
An Explanation of Benefits (EOB) is mailed to your home each time a claim is
processed. You may print a copy of the EOB for any claim that has been processed
from My
Blueprint under "Check Claims Status."
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4. How do I update other insurance information?
To update your Medicare information or other insurance information, you may
complete the Coordination of Benefits questionnaire (40 KB PDF) and mail to:
Health Advantage, Attn: Claims COB, P.O. Box 8069, Little Rock, AR 72203-8069.
You may also call toll free 1-800-969-3983. You also must provide your Medicare
information to the Employee Benefits Division. Obtaining Medicare may reduce
your monthly premium.
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5. Do I have coverage for prescriptions?
Please refer to your Summary Plan Description or Annual Benefits Guide to
reference your plan prescription coverage.
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Other Helpful Information
1. Contact Information
| Mailing address
|
P.O. Box 8069, Little Rock, AR 72203-8069
|
| Customer Service
|
1-800-482-8416.
|
| Interactive Voice Response (available 24/7)
|
1-800-482-8416
|
|
My Blueprint
|
Click on “technical support” for system issues, ID, password, and registration
issues. Call 1-800-482-8416 if you have other questions.
|
| Trover (HealthCare Recoveries)
|
Call 800-685-4013 to report a motor vehicle accident or injury
that includes third-party liability.
|
| COB information line
|
Call 800-969-3983 to report other medical or pharmacy insurance
coverage or changes related to the other insurance information we have on file.
|
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