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For additional information on the following subjects, please refer to your Summary Plan Description.
Arkansas State Employees Open Enrollment period was October 1 to October 31, 2018, for changes for the 2019 plan year. Public School Employees Open Enrollment was October 1 through October 31, 2018, for changes effective January 1, 2019.
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 Employee Benefits Division if you have a family status change that meets the criteria for a special enrollment period.
If your dependent is a child, they may join the Plan as long as they are your child, stepchild, or you have permanent legal guardianship for them and you can answer yes to one of the following questions:
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.
Contact the Employee Benefits Division at 877-815-1017 for more information.
Newborn children can be added within 60 days of the date of birth. The Election form requesting coverage for your newborn must be submitted through the Employee Benefits Division.
A Certificate of Credible Coverage (COCC) lists your coverage with ARBenefits the initial effective date to your termination date. This certificate is generated after your policy is terminated. Contact Employee Benefits Division if you need a COCC.
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, make sure the information on your ID card is correct and that all providers have the correct date of birth and the spelling of your name as it appears on your card.
Contact the Employee Benefits Division (EBD) at 877-815-1017 to order a replacement card.
In-network services are covered services or supplies a member receives from a contracted physician/provider. Out-of-network services are covered services or supplies a member receives from a non-contracted physician or provider. Non-contracted providers may balance bill the difference between the billed charges and the allowable charges.
Yes. HealthAdvantage-hmo.com provides:
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.
A deductible is a specific amount that a member must pay out of pocket each year before the plan begins to pay its portion.
A copayment is the predetermined fixed dollar amount a member must pay to receive a specific service. Copayments will apply to the True Out-Of-Pocket (TrOOP) limit.
Coinsurance is defined as a percentage of the allowable charge that a member pays for a service after any deductible and copays are applied.
Eligible coinsurance for medical services.
When you are within the state of Arkansas, you may find a participating physician or provider by accessing the Health Advantage provider directory or contacting Customer Service to verify whether a specific provider is in-network. Remember, click on the provider directory listed as ARBenefits. If traveling or living out of state, call 1-800-810-BLUE or use the find a doctor tool to find participating providers.
Some procedures are only covered when specific criteria are met for coverage. Medical records can be requested for the review of coverage criteria.
Your ARBenefits Plan provides some services recommended for the prevention and early detection of disease. You may review the Preventive Services or the Immunization Benefit Coverage policies at arbenefits.org under Coverage Policies for services received prior to June 1, 2014, and see Health Advantage coverage policy for services beginning June 1, 2014, to the present.
Services that require precertification for School & State members include but are not limited to:
Refer to your Summary Plan Description for specific information. It is your responsibility to ensure your provider contacts us at 1-800-482-8416 for School & State members for precertification to receive these types of services.
For high-tech radiology precertification, learn more about AIM Specialty Health or call 1-866-688-1449.
For behavioral or mental health precertification, call New Directions at 1-877-982-8295.
For transplants precertification, call 1-800-482-8416.
No. Members may receive covered services without a referral. For in-network benefits, members will need to stay in the Health Advantage network of participating hospitals and doctors.
ARBenefits plans cover emergency care as in network regardless of the facility's participation status. If you are having an emergency, seek medical attention at the nearest facility. If you are in another state and need non-emergent medical care, and are concerned about a doctor or hospital's network status, be assured that Health Advantage covers you anywhere in the United States. Your doctor or hospital needs to be in the PPO network of their local state's provider network. To find a BlueCard healthcare provider outside Arkansas, visit the National Doctor & Hospital Finder.
Yes. When in-plan providers are used, they are covered 100%. The member may not be billed the difference in the billed and allowed amount. FluMist and flu shots are also covered at a participating pharmacy, and may be billed to the prescription card, with no copayment or coinsurance due.
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:
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, wheelchairs, walkers, etc. Prior approval by ActiveHealth for School & State members is required for four categories of DME: spinal cord stimulators, continuous glucose monitoring devices, defibrillator vests, and power mobility devices.
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. Please contact ActiveHealth for School & State members at 877-815-1017 to be directed to a case manager for your area.
Refer to your Summary Plan Description at arbenefits.org for complete prescription information, including formularies, prior approval and exclusions.
Public School retirees with Medicare coverage do not have a prescription drug benefit with this plan.
ARBenefits members are not required to select a PCP (General Practice, Family Practice, Internal Medicine, Pediatrician); however, Health Advantage does encourage members to see a PCP for routine medical care and preventive health services and to coordinate healthcare.
ARBenefits retirees with Medicare as their primary insurance may utilize any provider within the Medicare coverage area. As an ARBenefits Health Advantage plan member, you have more freedom to choose the doctors and hospitals that best suit you and your family. Within the United States, you have access to more than one million PPO doctors and hospitals. Outside the United States, access is available in more than 200 countries and territories around the world through the Blue Cross Blue Shield Global® Core 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 healthcare 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 ARBenefits ID card.
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.
Within the United States:
Around the World:
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.
You will receive a PHS every two weeks when claims are processed for you or your dependents/spouse on your contract. You should keep your PHS to compare it with the bill that you receive from the provider. If the amount indicated on your PHS does not match the amount billed by the provider, you may call the provider or Customer Service at Health Advantage.
If your medical service provider files the claim right after your service, and there are no delays in processing, you should receive a PHS in approximately 4 weeks. Once the medical service provider submits a claim, it should be processed within 30 days. This may be delayed if additional information is requested.
A PHS is mailed to your home every two weeks for the claims that have been processed. Your copayment, deductible and coinsurance responsibility (if you have one) will be shown on the PHS. You may print a copy of the PHS for any claim that shows "complete" from My Blueprint under "Check Claims Status." You also may call My BlueLine — an interactive voice response system toll free, 24/7, at 1-800-482-8416.
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 a PHS, the amount that the provider is billing you should be matched with the amount on the PHS that is listed as the member's responsibility. If the amount the provider bills 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 PHS, 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 PHS, you may view your claim information by using our online tools in My Blueprint. If the issue cannot be resolved, you or the provider can call the Customer Service Department at Health Advantage.
If your claim has not been paid, it is either denied, waiting for more information from you or the medical provider, or applied to your deductible. The reason for non-payment will be listed with the claim detail information on the PHS. If you are unsure how to read it, or question the reason for non-payment, contact customer service.
Review the service that was denied and reference the Exclusions or Benefit Limitations in the 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 at 1-800-482-8416. If you wish to appeal the denial of the claim, follow the appeal guidelines listed in the Summary Plan Description.
If you have questions about a claim determination on your PHS, you may contact Customer Service toll free at 1-800-482-8416 to discuss the claim. If the Customer Service Representative cannot resolve the issue to your satisfaction you may write to: Health Advantage Customer Service, P.O. Box 8069, Little Rock, AR 72203 to request a re-review of the claim. This informal review is not an appeal, nor a substitute for an appeal. Formal appeals must be submitted in writing to the plan administrator, Employee Benefits Division, Attn: Appeals, P.O. Box 15610, Little Rock, AR 72231.
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 1-877-815-1017.
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 the Employee Benefits Division at 877-815-1017.
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.
A review must be conducted to determine the order each carrier should process claims.
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. 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.
A Personal Health Statement (PHS) is mailed to your home every two weeks for the claims that have been processed. You may also sign up for My Blueprint to view/print your PHS or even elect to receive electronic notice when Health Advantage has finalized processing of a claim for you or a covered dependent.
To update your Medicare information or other insurance information, you may complete the coordination of benefits questionnaire [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.
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: Select need help for system issues, ID, password, and registration issues. Call 1-800-482-8416 for help with other questions.
Equian|Trover Solutions (HealthCare Recoveries): Call 1-800-945-0323 to report a motor vehicle accident or injury that includes third-party liability.
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