- Contact information
For additional information on the following subjects, please refer to your Annual Benefits Guide or Summary Plan Description. If 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. (If a COC is generated prior to a termination date, the end date will appear as 12/31/9999.)
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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 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 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 Evidence of Coverage/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 plan chosen by your employer, a referral or 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 copayment/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.
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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 paid. 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 at www.HealthAdvantage-hmo.com 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?
If you are on a specific plan that requires referrals, using participating providers and obtaining the required referrals prior to the service will reduce your out-of-pocket expenses. If you are on a point-of-service or open-access plan, using participating providers will result in fewer out-of-pocket expenses to you since there are no (or lower) deductibles and lower coinsurance responsibilities.
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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. Some examples of this would be:
- 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”.
- When a policy has a pre-existing clause, the medical records are requested during the look-back period (This is the six-month timeframe prior to your effective date with Health Advantage or from the first date of your waiting period, whichever is earlier) to determine if the claims that have been submitted are related to a pre-existing condition.
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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 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 |
Pain management |
Skilled nursing facilities |
| Residential treatment |
TMJ |
Transplants |
| CT scan |
MRI/MRA |
Pet scan |
| 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 CorpHealth 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). Please refer to your Summary Plan Description for maternity benefits.
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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. Items and repairs in excess of $1,000 require pre-certification by American Health Holding (AHH).
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 ambulance is covered up to a $1000 benefit maximum per member per plan year ($1000 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 Corphealth. Please contact Corphealth 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 1-800-482-8416.
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)?
Members are not required to select a PCP; however, Health Advantage does encourage selection of a PCP to provide routine medical care and preventive health services and to coordinate health care. The PCP must be listed as a PCP in the Health Advantage provider directory (specific for your employer group). Members may call Customer Service to select or change a PCP. All PCP changes are effective on the first day of the next month.
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2. If I decide to select a PCP, must I select the same PCP for all family members?
You may select the same PCP for all family members, or you may select a different PCP for each family member.
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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 provide within the Medicare coverage area. Please note that Medicare does not cover services outside the United States or Unite States’ territories.
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:
- Verify your international benefits with Health Advantage before leaving the country. Members with Medicare as their primary coverage do not have out-of-country benefits.
- Always carry your ARHealth ID card.
- In an emergency, go directly to the nearest hospital.
- Call the BlueCard World Wide Service Center at 1-800-810-BLUE (2583) or collect at 1-804-673-1177, 24 hours a day, seven days a week for information on doctors, hospitals, and other health-care professionals or to receive medical assistance services. An assistance coordinator, in conjunction with a medical professional, will help arrange a doctor’s appointment or hospitalization, if necessary.
- If you need to be hospitalized, call American Health Holding at 1-800-592-0358 for pre-certification.
- Call the BlueCard Worldwide Service Center when you need inpatient care. In most cases, you should only pay upfront the $250 copayment and 10 percent of the allowed charges. The hospital will submit the claim on your behalf.
- You will need to pay upfront for care received from a doctor and/or a non-participating hospital. Contact Health Advantage upon return for assistance with claims payment.
ARHealth retirees with Medicare as their primary insurance may utilize any provider within the Medicare coverage area. Medicare does not cover services outside the United States or United States’ territories.
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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 when you have a member responsibility of a deductible, copayment or coinsurance, or when a service is denied. 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. You also may call MyBlueLine – an interactive voice response system – toll free, 24/7, at 1-800-843-1329.
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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 1-800-843-1329.
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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 the plan administrator, Employee Benefits Division, within the number of days as identified within your Summary plan Description. 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 the number of days specific in your Summary Plan Description. 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
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P.O. Box 8069, Little Rock, AR 72203-8069
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| Customer Service
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1-800-482-8416.
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| Interactive Voice Response (available 24/7)
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1-800-482-8416
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| My Blueprint
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Click on “technical support” for system issues, ID, password, and registration issues. Call 1-800-482-8416 if you have other questions.
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| Trover (HealthCare Recoveries)
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Call 800-685-4013 to report a motor vehicle accident or injury that includes third-party liability.
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| COB information line
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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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