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HMO POS PPO - Arkansas Blue Cross and Blue Shield

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<strong>Arkansas</strong> State Employees2006<strong>HMO</strong><strong>POS</strong><strong>PPO</strong>www.HealthAdvantage-hmo.comwww.<strong>Arkansas</strong><strong>Blue</strong><strong>Cross</strong>.com


We have dedicated Customer Service Representatives to serve the <strong>Arkansas</strong> State <strong>and</strong> Public School Employees <strong>and</strong> wehave three electronic features that you may prefer – e-mail, My <strong>Blue</strong>print <strong>and</strong> My <strong>Blue</strong>Line, interactive voice responsephone line. Also, we have staff in six Regional Offices throughout the state available to assist with your claims <strong>and</strong>benefits questions during normal business hours.Call one of our Regional OfficesJonesboro 1-800-299-4124Fayetteville 1-800-817-7726Fort Smith 1-800-299-4060Hot Springs 1-800-588-5733Texarkana 1-866-254-3969Pine Bluff 1-800-236-0369Health Advantage1-800-482-8416USAble Corporate Center320 W. Capitol, Suite 400PO Box 8069Little Rock, AR 72203-8069www.HealthAdvantage-hmo.comemail: customerservicease@Ark<strong>Blue</strong><strong>Cross</strong>.com<strong>Arkansas</strong> <strong>Blue</strong> <strong>Cross</strong> <strong>and</strong> <strong>Blue</strong> <strong>Shield</strong>1-800-482-8416USAble Corporate Center320 W. Capitol, Suite 400PO Box 2181Little Rock, AR 72203-2181www.<strong>Arkansas</strong><strong>Blue</strong><strong>Cross</strong>.comemail: customerservicease@Ark<strong>Blue</strong><strong>Cross</strong>.comTo determine when <strong>and</strong> if providers have joined the <strong>PPO</strong> or <strong>HMO</strong> network visit the provider directories(updated nightly) found at www.<strong>Arkansas</strong><strong>Blue</strong><strong>Cross</strong>.com or www.HealthAdvantage-hmo.com. By using theproviders listed in the directory, members will receive the highest level of benefits from their health plan.


SELF-SERVICE FEATURESIf your busy lifestyle dem<strong>and</strong>s all your time during the normal 8 to 5 customer service hours, we have two selfservicefeatures that are available 24 hours a day, seven days a week.My <strong>Blue</strong>print is an online, self-service center for members of Health Advantage <strong>and</strong> <strong>Arkansas</strong> <strong>Blue</strong> <strong>Cross</strong>.We strive to meet customer expectations by providing members with this convenient self-help access to theirhealth plan information 24 hours a day, seven days a week. For Health Advantage members, the self-servicecenter is available on www.HealthAdvantage-hmo.com. <strong>Arkansas</strong> <strong>Blue</strong> <strong>Cross</strong> members should go towww.Arkanasas<strong>Blue</strong><strong>Cross</strong>.com. Register today to access My <strong>Blue</strong>print. Click on the First-Time User link <strong>and</strong>follow the instructions to create your own log-on <strong>and</strong> password, giving you immediate secure access to yourinformation.What can I do by using My <strong>Blue</strong>print?o Check member eligibilityo Check status of claims <strong>and</strong> claim historyo Update My <strong>Blue</strong>print informationo Medical Cost & Quality Calculator (New)ooooOrder replacement ID cardView Explanation of BenefitsAccess HealthConnect <strong>Blue</strong>Generic Drug Calculator (New)My <strong>Blue</strong>Line, the interactive voice response system, recognizes speech patterns to answerquestions when you call the customer service telephone number 1-800-482-8416. If you are calling duringbusiness hours, at any time you can press “1” to use My <strong>Blue</strong>Line or press “2” to immediately be routed to thenext available customer service representative. If you choose to use My <strong>Blue</strong>Line, you simply respond to thequestions asked by the system – with no buttons to push – getting your questions answered quickly <strong>and</strong> easily.What information is available by using My <strong>Blue</strong>Line?o Get answers to benefit questionsoo Check status of claimsoOrder a new ID cardOrder a claim formWith HealthConnect <strong>Blue</strong>, you have access to a Health Coach day or night by calling 1-800-318-2384 orthrough the HealthConnect <strong>Blue</strong> link from My <strong>Blue</strong>print at www.<strong>Arkansas</strong><strong>Blue</strong><strong>Cross</strong>.com orwww.HealthAdvantage-hmo.com.When should you call?• When you’re looking for general health information• When you’re admitted to or discharged from the hospital• When you want more information about your disease or illnessA Health Coach can offer information, support <strong>and</strong> help you work with your doctor to make confident healthdecisions that are right for you. Being well informed is the first step in taking charge of your health. There’s nobetter place to start than with a HealthConnect <strong>Blue</strong> Health Coach.Call 1-800-318-2384 today!


<strong>Arkansas</strong> State EmployeesPreventive Dental RiderThe <strong>Arkansas</strong> State Employees with medical insurance administered by Health Advantage have apreventive dental rider with their medical coverage: No referral is required for this benefit, which is a$25 copayment, limited to two (2) preventive visits per year per covered member. The dental networkavailable to State Employees for preventive services includes all dentists who are participating with<strong>Arkansas</strong> <strong>Blue</strong> <strong>Cross</strong> <strong>and</strong> <strong>Blue</strong> <strong>Shield</strong>’s Preferred Payment Plan (PPP).No reimbursement will be made for services provided by non-participating dentists or for servicesother than the codes listed below.CODE DESCRIPTION BENEFIT GUIDELINE0120 Periodic oral evaluation Two periodic exams per member per year0140 Limited oral evaluation –problem focusedLimited oral exam when done in conjunction with a procedure at thesame visit is considered part of the definitive procedure <strong>and</strong> a separatefee may not be charged.0150 Comprehensive oralevaluationIncludes a thorough examination <strong>and</strong> recording of the extraoral <strong>and</strong>intraoral hard <strong>and</strong> soft tissues.0210 Intraoral X-rays – Periapical A full mouth series is covered once every 3-5 years0220– first filmIntraoral X-rays – Periapical– each additional film0230 Intraoral X-rays – Periapicaleach additional film0240 Intraoral X-rays – Occlusalfilm0250 Extraoral – first film0260 Extraoral – each additionalfilm027002720274Bitewing – a filmBitewing – 2 filmsBitewing – 4 filmsRoutine working <strong>and</strong> final treatment x-rays are part of a completeprocedure <strong>and</strong> are not a separate benefit. A maximum of 8-10 films areallowed on the same date of service.Two occlusal films per 12 month period.One series of bitewing x-rays (2 or 4) allowed per calendar year.0330 Panoramic film 1 of either D0210 or D0330 in a 5 year period1110 Prophylaxis – Adult1120 Prophylaxis – Child1203 Topical application offluoride – child (prophylaxisnot included)1351 Sealant – to age 10 on 1 stmolars, age 15 on 2 nd molarsTwo topical applications of fluoride allowed per calendar year forcovered dependents up to their 19 th birthday.1 per tooth in a 3 year period.State Employees <strong>and</strong> their dependents do not have a separate dental identification card for this benefit.To receive reimbursement, claims should be filed using your Health Advantage identification number.Note: If you have a Dental<strong>Blue</strong> policy through ASEA/SEBCO, this rider is not related to thatdental policy. If you have services other than those listed above, please ensure your dentist hasboth identification numbers.


Health Advantage <strong>HMO</strong> <strong>and</strong> <strong>POS</strong> Questions <strong>and</strong> AnswersHave you ever wondered if you have coverage outside <strong>Arkansas</strong>? What if yourchildren live or go to school in another state? Do you have a European vacation onthe horizon? <strong>Blue</strong>Card® can help.Q: What is <strong>Blue</strong>Card?A: <strong>Blue</strong>Card links participating health-careproviders <strong>and</strong> the independent <strong>Blue</strong> <strong>Cross</strong> <strong>and</strong> <strong>Blue</strong><strong>Shield</strong> Plans across the country through a singleelectronic network for professional, outpatient, <strong>and</strong>inpatient claims processing reimbursement. Theprogram allows participating <strong>Blue</strong> <strong>Cross</strong> <strong>and</strong> <strong>Blue</strong><strong>Shield</strong> providers in every state to submit claims forpatients who are enrolled through another <strong>Blue</strong> Planto their local <strong>Blue</strong> <strong>Cross</strong> <strong>and</strong> <strong>Blue</strong> <strong>Shield</strong> Plan. Thethree-character alpha prefix (XCH) at the beginningof the member’s identification number is the keyelement used to identify <strong>and</strong> correctly route out-ofareaclaims. The alpha prefix identifies the Plan ornational account to which the member belongs.Q: How does <strong>Blue</strong>Card work?A: When you need urgent or emergency care out ofthe service area, you can call 1-800-810-2583(BLUE) located on the back of the IdentificationCard to locate a <strong>Blue</strong> <strong>Cross</strong> <strong>and</strong> <strong>Blue</strong> <strong>Shield</strong>provider. You should ask for the traditionalnetwork. The call center is open 24 hours a day,seven days a week. You may also access <strong>Blue</strong>Cardproviders online at www.bcbs.com. The claim isfiled with the local <strong>Blue</strong> Plan <strong>and</strong> the alpha prefixlets the local Plan know where to route the claim.Members using the <strong>Blue</strong>Card Access have innetworkbenefits for care outside the service area.Q: My child will be attending college out of state.How will he/she be covered?A: Contact Customer Service at 1-800-482-8416<strong>and</strong> request an Out of Area application or go towww.HealthAdvantage-hmo.com to print a form.Your child will be listed as an Out of Area collegestudent <strong>and</strong> your normal benefits will apply to <strong>Blue</strong><strong>Cross</strong> providers in that state.Q: I am required to carry insurance on my childrenwho reside with their other parent out of state. Arethey eligible for coverage?A: Yes. You should contact Customer Service at 1-800-482-8416 <strong>and</strong> request an Out of Areaapplication or go to www.HealthAdvantagehmo.comto print a form.. Your dependents will belisted as Out of Area dependents <strong>and</strong> your normalbenefits will apply if they see <strong>Blue</strong> <strong>Cross</strong>participating providers in that state.Q: If we’re on vacation out of state <strong>and</strong> one of usbecomes ill, how can we get urgent or emergencycare?A: If it’s a true emergency, seek medical assistanceat the nearest facility. Emergency care is covered asin-network no matter where you receive it. If it’snot an emergency, but is an illness that requiresmedical attention, you should call the <strong>Blue</strong>Cardnumber (located on the back of your identificationcard) at 1-800-810-2583 (BLUE). This is aprovider locator service which will give you namesof <strong>Blue</strong> <strong>Cross</strong> <strong>Blue</strong> <strong>Shield</strong> providers in your travelarea.Q: What do I need to do if I need urgent oremergency care <strong>and</strong> I’m outside the United States?A: Members traveling abroad should contact the<strong>Blue</strong>Card helpline at 1-800-810-2583 (BLUE) <strong>and</strong>ask for <strong>Blue</strong>Card Worldwide. This is a providerlocator service open 24 hours a day, 365 days ayear. We also recommend that you visit the Website at www.bcbs.com to locate providers in advance<strong>and</strong> take advantage of the valuable health <strong>and</strong> travelinformation listed there.Q: I am going on COBRA <strong>and</strong> will be moving outof state. Am I eligible to continue coverage?A: Yes. Contact Customer Service at 1-800-482-8416 <strong>and</strong> request an Out of Area application or goto www.HealthAdvantage-hmo.com to print a form.You will be listed as an Out of Area member <strong>and</strong>your normal benefits will apply if you see <strong>Blue</strong><strong>Cross</strong> providers in that state.


General Questions <strong>and</strong> AnswersQ: Do I need a referral for my annual gynecologistvisit <strong>and</strong> mammogram?A: No. Both are covered without a referral. Noreferral is ever required to an in-networkgynecologist.Q: What is covered under the Enhanced WellnessBenefit?A: For a complete list of preventive services thatare now covered 100%, visit www.arbenefits.org<strong>and</strong> look under the “Benefits Library” for theSummary Plan Description or you may callCustomer Service at 1-800-482-8416.Q: Do I need referrals if I’m under the <strong>POS</strong> plan?A: <strong>POS</strong> members, you have a choice. You canchoose to seek care in-network <strong>and</strong> follow the sameguidelines as the <strong>HMO</strong> members or you have theoption to go out-of-network or seek specialty carewithout a referral <strong>and</strong> pay an additional cost. Whenmedical care is obtained out-of-network, you areresponsible for the out-of-network deductible,copayment, coinsurance, <strong>and</strong> may also beresponsible for the difference between billedcharges <strong>and</strong> the Health Advantage allowed amount.Q: Does Health Advantage require preauthorizationfor services?A: Health Advantage only requires preauthorizationfor the following services:• Breast reduction (not related to cancer)• Enteral feeding• IDET• Out-of-network services• Swing bed care (pre-authorization fromCase Management)• Transplant (excluding kidney <strong>and</strong> cornea)Q: Are pre-existing conditions excluded?A: No. The State of <strong>Arkansas</strong> does not exclude preexistingconditions.Q: My Emergency Room (ER) claim was deniedfor not being an emergency. What is an emergency?A: An emergency is defined as traumatic bodilyinjury or sudden, unexpected onset of an illnesswhich requires immediate care <strong>and</strong> attention from aqualified physician, or when the condition, if nottreated immediately, could reasonably be expectedby a prudent layperson to result in serious physicalimpairment. When emergency services are needed,the member is to proceed as follows:1. Seek emergency care immediately at thenearest emergency facility.2. As soon as possible, notify your PCP ofyour emergency care, so that follow-up caremay be arranged.3. All follow-up care must be authorized by thePCP <strong>and</strong> rendered by an in-network providerin order for in-network benefits to apply.Q: How will the Any Willing Provider (AWP) lawaffect my coverage?A: AWP is an <strong>Arkansas</strong> law, so providers outside<strong>Arkansas</strong> will not be affected. In <strong>Arkansas</strong>, if aprovider applies to be a participating provider, <strong>and</strong>completes our credentialing process, then thatprovider will be part of the Health Advantagenetwork, <strong>and</strong> normal in-network benefits will apply.Providers will still have the choice whether or not toparticipate, so there may still be some providerswho will not be in-network. For the most accurate<strong>and</strong> up-to-date provider directory, please visitwww.HealthAdvantage-hmo.com.Q: May I remain with Health Advantage after myretirement? How will my coverage change?A: Yes, as a retiree under age 65 <strong>and</strong> not Medicareprimary, you may remain on this Health Advantageplan. Your copays, out-of-pocket maximums <strong>and</strong>benefits (including a prescription drug card) willremain the same. Non-Medicare primary retireesalso have the option to move to the ARHealthbenefit plan. While the benefits will remain thesame, the premium amount, copays <strong>and</strong> out-ofpocketmaximums will change.Retirees over age 65 or Medicare primary retireeswill be automatically changed to the ARHealthbenefit plan administered by Health Advantage.More information is currently available on theHealth advantage Web site:www.HealthAdvantage-hmo.com


<strong>Arkansas</strong> State Employees 200IN-NETWORK<strong>HMO</strong> & <strong>POS</strong>OUT-OF-NETWORK<strong>POS</strong> ONLYDEDUCTIBLE$500 IndividualNOT APPLICABLE$1,000 FamilyANNUAL COINSURANCE LIMITCopays do not apply to coinsurance limit$1,000 Individual$1,500 Family$4,000 Individual$8,000 FamilyLIFETIME MAXIMUM Unlimited $1,000,000PHYSICIAN SERVICESPrimary Care Physician Office Visits $20 Copayment 30% after DeductibleSpecialist Office Visits $25 Copayment 30% after DeductibleInpatient <strong>and</strong> Outpatient Physician Services 10% Coinsurance 30% after DeductiblePREVENTIVE CARE SERVICES - *Please refer to SPDfor a complete list of covered preventive servicesHOSPITAL SERVICESInpatient Services (semi-private room)Maximum 3 Copays per person per contract year$0 Copayment0% Coinsurance30% after Deductible$250 Copayment +10% Coinsurance30% after DeductibleOutpatient Surgery $100 Copayment 30% after DeductibleOutpatient diagnostic testing (lab, x-ray, tests performedoutside the doctor’s office)10% Coinsurance 30% after DeductibleEmergency Room Visit or Urgent Care Center- Copay waived $100 Copaymentif admitted to the same hospital as in-patient$100 CopaymentALLERGY SERVICESOffice Visit$20 PCP Copaymentor $25 SpecialistCopayment30% after DeductibleAllergy Injections 0% Coinsurance 30% after DeductibleAllergy Serum 0% Coinsurance 30% after DeductibleAMBULANCE SERVICES-$1,000 Maximum Per Member Per Contract YearREHABILITATIVE SERVICESInpatient Rehabilitation Services- Limited to 60 days perMember per Contract YearOutpatient Rehabilitation Services:Physical, Occupational, <strong>and</strong> Speech TherapyChiropractic Services <strong>and</strong> Cardiac RehabLimit of 60 aggregate visits per Member per contract year0% Coinsurance 10% Coinsurance$250 per admission +10% Coinsurance30% after Deductible20% Coinsurance 30% after DeductibleMATERNITY SERVICESInitial Specialist Visit $25 Copayment 30% after DeductibleOB Services $0 Copayment +10% CoinsuranceHospital Services (facility fee) $250 Copayment +10% CoinsuranceInpatient Physician Services $0 Copayment +10% CoinsuranceOutpatient Diagnostic Testing (lab <strong>and</strong> X-ray) 0% Copayment +10% Coinsurance30% after Deductible30% after Deductible30% after Deductible30% after Deductible


6 <strong>HMO</strong>/<strong>POS</strong> Benefit SummaryIN-NETWORK<strong>HMO</strong> & <strong>POS</strong>OUT-OF-NETWORK<strong>POS</strong> ONLYDURABLE MEDICAL EQUIPMENT-$10,000 MAX PER MEMBER PER CONTRACT20% Coinsurance 30% after DeductiblePROSTHETICS- $15,000 ANNUAL MAXIMUM 20% Coinsurance 30% after DeductibleDIABETIC EQUIPMENT AND INSULIN PUMPSUPPLIES (Diabetic supplies not for insulin pump are 20% Coinsurance 30% after Deductiblecovered by the prescription drug card)OSTOMY SUPPLIES 10% Coinsurance 30% after DeductibleHOME HEALTH SERVICES-120 VISITS PER MEMBERPER CONTRACT YEAR0% Coinsurance 30% after DeductibleHOME IV DRUGS/SOLUTIONS 10% Coinsurance 30% after DeductibleINJECTABLE MEDICATIONS-Medications when covered Office Visit Copayby Health Advantage-Subject to exclusions <strong>and</strong> limitations May Apply30% after DeductibleINFERTILITY SERVICES**Infertility Counseling $25 Copay 30% after DeductibleInfertility Testing10% Coinsurance(outpatient Surgery Copay may apply)30% after DeductibleSKILLED NURSING FACILITY-$250 Copay +Limited to 60 days Per Member Per Contract Year10% Coinsurance30% after DeductibleHospice Care (must be approved by Health Advantage) 20% 30% after DeductibleTMJ- Covered when diagnosed as medical condition Applicable CopayLimited to $500 Lifetime Maximum per Member10% Coinsurance30% after DeductibleOrgan Transplant Services- must be approved by Health$250 per admissionAdvantage (2 transplants per Member per Lifetime) – kidneyNOT COVERED<strong>and</strong> cornea transplants are not subject to prior approval.Routine Vision Exam 1 every 24 months $25 Copay NOT COVEREDPreventive Dental (cleanings <strong>and</strong> exam) 2 per person peryear (see page 5 for complete list of services)$25 Copay NOT COVERED*The Summary Plan Description (SPD) can be viewed online at www.arbenefits.org under the Benefits Librarysection, or you may contact Employee Benefits Division for a paper copy.**Treatment for infertility is not a covered benefit – benefits cover testing <strong>and</strong> counseling only.NOTE: Out-of-Network Deductible, Copayment <strong>and</strong> Coinsurance amounts do not apply to the In-Network AnnualCoinsurance Limit. Annual Coinsurance Limits are calculated on a fulfillment basis, not aggregate.Expenses incurred for services that exceed benefit limits are not applied to the Annual Coinsurance Limit.For In-Network benefits, services must be performed, arranged or authorized by the Primary Care Physician, exceptfor Emergency Care. The Member may be responsible for the difference between Billed Charges <strong>and</strong> AllowableCharges for services covered at the Out-of-Network benefit level if the provider does not participate with any<strong>Blue</strong> <strong>Cross</strong> plan nationwide.To determine when <strong>and</strong> if providers have joined the <strong>HMO</strong> network visit the provider directories (updated nightly)found at www.HealthAdvantage-hmo.com. By using the providers listed in the directory, members will receive thehighest level of benefits from their health plan.


Deductible (Annual)IndividualFamilyIn-Network$500At least two family members mustmeet the $500 deductible.<strong>Arkansas</strong> State EmployeesIndemnity <strong>PPO</strong> Benefit Summary 2006Out-of-Network$1,000At least two family members must meet the$1,500 deductible.Coinsurance (what you pay) 20% 30%Annual Out-of-Pocket LimitsIndividual $2,000 $2,500FamilyAt least two family members must At least two family members must meet themeet the individual out-of pocket limit. individual out-of-pocket limitLifetime Maximum None $1,000,000Preventive Care Services – for a complete list of services covered at 100%, please refer to your Summary PlanDescription which can be accessed at www.arbenefits.org.Immunizations, Mammograms,Physical Exams-Adults,Gynecological VisitsWell Baby CareWell Child CareNo deductible, 0% coinsurance30% coinsurance after deductiblePhysician Services 20% coinsurance after deductible 30% coinsurance after deductibleOutpatient Services 20% coinsurance after deductible 30% coinsurance after deductibleInpatient Hospital 20% coinsurance after deductible 30% coinsurance after deductibleEmergency Room Services 20% coinsurance after deductible 30% coinsurance after deductibleMaternity ServicesPhysician <strong>and</strong> Hospital Services20% coinsurance after deductible 30% coinsurance after deductibleTransplantsMost transplants require20% coinsurance after deductible 30% coinsurance after deductibleprior approvalDurable Medical Equipment$10,000 maximum per year20% coinsurance after deductible 30% coinsurance after deductibleProsthetics20% coinsurance after deductible$15,000 maximum per year30% coinsurance after deductibleTMJ $500 lifetime maximum 20% coinsurance after deductible 30% coinsurance after deductiblePhysical, Occupational, Speech Therapy, Cardiac Rehab, <strong>and</strong> Chiropractic Services60 visits per member per yearcombined20% coinsurance after deductible 30% coinsurance after deductibleAmbulance (L<strong>and</strong> or Air)$1,000 maximum per year for 20% coinsurance after deductible 30% coinsurance after deductibletransport servicesHome Nurse Visits 120 visits peryear20% coinsurance after deductible 30% coinsurance after deductibleHome Infusion IV Drugs &Solutions20% coinsurance after deductible 30% coinsurance after deductibleImportant Notice: If you use a hospital/physician who is a preferred provider, such hospital/physician has agreed to accept <strong>Arkansas</strong> <strong>Blue</strong> <strong>Cross</strong> <strong>and</strong><strong>Blue</strong> <strong>Shield</strong>'s payment for covered services as payment in full - except for your deductible <strong>and</strong> coinsurance, if applicable.If you use a hospital/physician who is a non-preferred provider, such hospital/physician is free to bill you charges for covered services in excess of<strong>Arkansas</strong> <strong>Blue</strong> <strong>Cross</strong> <strong>and</strong> <strong>Blue</strong> <strong>Shield</strong>'s payment. Before receiving services from any hospital/physician, please check your directory of participatingproviders. Member may be responsible for charges in excess of any dollar maximum.This benefit summary provides a brief description of your state employee benefits for the <strong>Arkansas</strong> <strong>Blue</strong> <strong>Cross</strong> <strong>and</strong> <strong>Blue</strong> <strong>Shield</strong> Indemnity <strong>PPO</strong> Plan.<strong>Arkansas</strong> <strong>Blue</strong> <strong>Cross</strong> <strong>and</strong> <strong>Blue</strong> <strong>Shield</strong> is a Claims Administrator under the direction of the Employee Benefits Division. For a complete descriptionof your benefits please refer to the Summary Plan Description (SPD) published by Employee Benefits, your Group Administrator.


<strong>PPO</strong> QUESTIONS AND ANSWERSQ: What is a <strong>PPO</strong> plan?A: A <strong>PPO</strong> (Preferred Provider Organization) isan Indemnity Plan. The <strong>Arkansas</strong> <strong>Blue</strong> <strong>Cross</strong> <strong>and</strong><strong>Blue</strong> <strong>Shield</strong> <strong>PPO</strong> Plan offers the largest networkof hospitals, physicians <strong>and</strong> other health-careproviders, which can be accessed without having toobtain a referral from a Primary Care Physician.Q: What if I receive care outside of the <strong>Blue</strong> <strong>Cross</strong>network?A: If you choose a hospital or physician who is aparticipating provider with any <strong>Blue</strong> <strong>Cross</strong> <strong>and</strong> <strong>Blue</strong><strong>Shield</strong> nationwide, that provider has agreed toaccept <strong>Blue</strong> <strong>Cross</strong>’ payment in full except for yourdeductible <strong>and</strong> appropriate coinsurance. If you usea hospital or physician who is not a participatingprovider with <strong>Blue</strong> <strong>Cross</strong>, that provider is free tobill you charges for covered services in excess ofthe company’s payment.Q: What is <strong>Blue</strong>Card® <strong>and</strong> how does it work?A: <strong>Blue</strong>Card links participating health-careproviders <strong>and</strong> the independent <strong>Blue</strong> <strong>Cross</strong> <strong>and</strong> <strong>Blue</strong><strong>Shield</strong> Plans across the country through a singleelectronic network for professional, outpatient, <strong>and</strong>inpatient claims processing reimbursement. Theprogram allows participating <strong>Blue</strong> <strong>Cross</strong> <strong>and</strong> <strong>Blue</strong><strong>Shield</strong> providers in every state to submit claims forpatients any <strong>Blue</strong> <strong>Cross</strong> <strong>Blue</strong> <strong>Shield</strong> member. Whenyou need medical assistance out of the service area,you can call 1-800-810-2583 (BLUE) located on theback of the Identification Card to locate a <strong>Blue</strong><strong>Cross</strong> <strong>and</strong> <strong>Blue</strong> <strong>Shield</strong> provider. You should ask forthe <strong>PPO</strong> Network. The call center is open 24 hoursa day, seven days a week. You may also access<strong>Blue</strong>Card providers online at www.bcbs.com. Theclaim is filed with the local <strong>Blue</strong> Plan <strong>and</strong> the alphaprefix lets the local Plan know where to route theclaim. Members using the <strong>Blue</strong>Card Access havein-network benefits for care outside the service area.Q: What do I need to do if I have a need formedical assistance <strong>and</strong> I’m outside the UnitedStates?A: Members traveling abroad should contact the<strong>Blue</strong>Card helpline at 1-800-810-2583 (BLUE) <strong>and</strong>ask for <strong>Blue</strong>Card Worldwide. This is a providerlocator service open 24 hours a day, 365 days ayear. We also recommend that you visit the Website at www.bcbs.com to locate providers in advance<strong>and</strong> take advantage of the valuable health <strong>and</strong> travelinformation listed there.Q: Are preventive care services covered by this<strong>PPO</strong> plan?A: Yes. For a complete list of preventive careservices, please refer to your Summary PlanDescription (SPD). You may access the SPD onlineat www.arbenefits.org <strong>and</strong> look in the BenefitsLibrary, or you may call Employee BenefitsDivision at 1-877-815-1017 <strong>and</strong> request a copy.Q: Are pre-existing conditions covered?A: Yes. All of the health plans offered cover preexistingconditions.Q: How will the Any Willing Provider (AWP) lawaffect my coverage?A: AWP is an <strong>Arkansas</strong> law, so providers outside<strong>Arkansas</strong> will not be affected. In <strong>Arkansas</strong>, if aprovider applies to be a participating provider, <strong>and</strong>completes our credentialing process, then thatprovider will be part of the <strong>Blue</strong> <strong>Cross</strong> <strong>PPO</strong>network, <strong>and</strong> normal in-network benefits will apply.Providers will still have the choice whether or not toparticipate, so there may still be some providerswho will not be in-network. For the most accurate<strong>and</strong> up-to-date provider directory, please visitwww.<strong>Arkansas</strong><strong>Blue</strong><strong>Cross</strong>.com.Q: I am about to retire. What do I need to do tocontinue my insurance, <strong>and</strong> what are my coverageoptions?A: If you are a non-Medicare primary retiree, youhave the option to remain on the <strong>Blue</strong> <strong>Cross</strong> <strong>PPO</strong>Plan or change to the new ARHealth Benefit Planadministered by Health Advantage.If you are age 65 or older, or Medicare is yourprimary insurer, you will be automatically changedto the ARHealth benefit plan administered byHealth Advantage. For specifics of this plan pleaseaccess the Health Advantage Web site at:www.HealthAdvantage-hmo.com.


Where do you go for help when you have questions?Use this chart to find the answers!COMMON QUESTIONSNeed a Health Insurance CardHow do I Add/Drop members from my contract?What do I do with Student Verification Forms?Need to change my address/telephone numberMy Social Security Number, name, or birthdate is wrongon my identification cardNeed to change my Primary Care Physician (PCP)Need to know if a provider is in your networkHow do I appeal a claim denial?Need to check claim status or have other claims relatedissueWho do I call if I'm admitted to a hospital that's not in thenetwork?Need a new prescription cardNeed to know why a prescription took a higher copay orwas not coveredHow do I get Prior-Approval for a prescription?What Mental Health providers are covered?How do I precertify a mental health service?WHO CAN HELPContact EBD (877)815-1017Contact your Agency Insurance RepresentativeX X XXXXXXXCall Customer Service(800)482-8416ARBenefits Web site www.arbenefits.orgHealth Advantage or <strong>Arkansas</strong> <strong>Blue</strong> <strong>Cross</strong> <strong>and</strong><strong>Blue</strong> <strong>Shield</strong> Web site *Email Customer Servicecustomerservicepse@arkbluecross.comX X XX X X XX X XX XX X XXCall NMHC Rx (800)880-1188Hospital Admission Prenotification **XXXXXCall Corphealth (866)378-1645* www.HealthAdvantage-hmo.com or www.<strong>Arkansas</strong><strong>Blue</strong><strong>Cross</strong>.com** <strong>Arkansas</strong> <strong>Blue</strong> <strong>Cross</strong> members call 1-800-451-7302 forhospital admissions outside of <strong>Arkansas</strong>**Health Advantage members call 1-800-299-4120 forhospital admissions out of the Health Advantage NetworkGoodNews!We offer a DiscountWellness Program.For health <strong>and</strong> fitnessdiscounts statewide,including Curves,Jenny Craig, <strong>and</strong> WeightWatchers,Please check out ourwebsites:www.HealthAdvantage-hmo.comwww.<strong>Arkansas</strong>bluecross.comA recent court decision reinstates an Any Willing Provider (AWP) law in <strong>Arkansas</strong>. Applications are being accepted from providers who wish tojoin the netwroks. Doctors <strong>and</strong> hospitals do not immediately <strong>and</strong> automatically become in-network providers, but must meet criteria outlined byHealth Advantage or <strong>Arkansas</strong> <strong>Blue</strong> <strong>Cross</strong> <strong>and</strong> <strong>Blue</strong> <strong>Shield</strong>. Due to the passage of this law <strong>and</strong> the provider interest in joining our networks, weare unable to print up-to-date provider directories. The best way to determine if a doctor or hospital has been included in the network is to checkthe online provider directories or call Customer Service at 1-800-482-8416.

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