Doctor's Note

Dear Colleagues and Office Staff,

This is the fourth issue of our newsletter where we have sought to communicate medical policies more effectively to you. I hope you have noticed these improvements and recognize the thorough work Arise does to stay on the leading edge of evaluating new technologies and treatments.

Not only do we regularly convene our Medical Policy committee which includes a number of your specialist colleagues, but we sit down with individual specialty practices seeking input and incorporating their valuable suggestions. As an example, we recently modified our Stereotactic Radiosurgery policy in relation to an in depth process of this nature.

I would also like to introduce you to Dr. Dan Wautlet, DC. His role at Arise Health Plan will be to dialogue with chiropractors around the state about back pain care guidelines and to reinforce the need for their documentation to follow the highest standards. As the program develops, Dr. Wautlet will also do outreach to primary care offices to talk about cost-effective coordination of care for members with back pain. Full-spectrum care could include the use of in-network chiropractors within the service area of each primary care practice. Our goal is to optimize early treatment pathways for people with acute back pain. More details will be forthcoming.  Please feel free to contact Dr. Wautlet at 
920-490-6995  or should you have any questions.

In January, please look to our website, , for our newly developed Prior Authorization tip sheet. It will provide helpful information regarding the prior authorization process.

As always, feel free to contact me with any questions.

Michael Ostrov MD MS

Genetics Corner

Arise Health Plan  requires prior authorization for Genetic Testing. We value the clinical information that is submitted from our ordering health care providers. Therefore, clinical documentation must come from the ordering provider and/or associated genetic counselor.
Because order forms direct from the genetic laboratory do not provide sufficient information regarding the ordering provider's clinical assessment, rationale for the specific requested test, or the plan of care, we are unable to accept that as sole documentation to the prior authorization request.

Documentation of the member's clinical history and genetic counseling evaluation will be required for all genetic tests. The documentation must include results of the pertinent family history (family pedigree), communication regarding the genetic risks, evaluation to confirm, diagnose, or exclude specific conditions, and information regarding the specific changes in management that would be made to the current treatment plan based on the findings of the genetic test being requested. The genetic counselor or provider performing the genetic history and evaluation must be free of commercial bias.
Please submit the required documentation through iExchange at for prompt review of your prior authorization request.
Pain Injection Update

Beginning Jan. 1, 2016, many of our member certificates will have changes in the calendar year limits applied to pain management procedures.
  • Epidural injections, including selective nerve root blocks will be limited to three injections per year regardless of location, type, or level.
  • Facet joint injections/medial branch nerve blocks will be limited to a maximum of four per year regardless of location, type, or level.
  • Neuroablation will be limited to one treatment per year regardless of location.
  • Sacroiliac joint injections are limited to one per year.
Please note that many pain management services are considered experimental/investigational/unproven and therefore not covered. 

Refer to the Non-Covered Services Medical Policy on our website for the list of non-covered services:    

Please contact Customer Service (as listed on your patient's insurance card) to verify your patient's specific coverage, and limitations, and provider and facility participation in the health plan.
Quarterly Medical Policy Updates

The Medical Policy Committee meets quarterly to approve medical policies due for annual review and revision.  
Click here  for the most recent updates to medical policies. 
Please be sure all doctors, other clinical staff, and office staff are aware of these changes before submitting requests for coverage. Please also share these policy changes with providers who may be ordering or performing services and clinicians who may be referring patients for services.
The complete library of our medical policies can be found at:
No password required!
If you have specific questions or comments regarding development of policy content, contact the Medical Policy Editor by email or call 1-800-333-5003 ext. 64133. 

Prescription Program Updates

The Arise Health Plan's Prescription Drug Program is reviewed on an annual basis. We've outlined changes below. More detailed information can be found on our website, Specifically, you can access:
  • Our Drug Program Policy which includes how the formulary is developed and maintained, the prior authorization program and how to pursue an exception, as well as information on generic substitution and quantity limits.
  • The Drug Prior Authorization List which identifies the applicable medications as well as who to contact to initiate the process.
  • Specialty drug approval policies (this is part of our website's Medical Policy section)
  • The Arise Formulary/Preferred Drug List
Please note the following Formulary changes effective Jan. 1, 2016:

Formulary Additions
Arnuity Ellipta
Flovent Diskus
Flovent HFA
Premarin Cream

Formulary Deletions
Formulary Alternatives for Deletions
Benzoyl peroxide, clindamycin phosphate topical, erythromycin topical
Ciprofloxacin hcl ophthalmic, gatifloxacin ophthalmic, levofloxacin ophthalmic, ofloxacin ophthalmic, MOXEGA, VIGAMOX
Acyclovir ointment
gavilyte f, peg 3350-electrolyte, trilyte with flavor packets, PREPOPIK, SUPREP
Nexium packets
Esomeprazole magnesium capsule
HC pramoxine cream
Naproxen sodium, sumatriptan succinate

If you would like a copy of this information, please contact Member Services at 1-888-711-1444.
Benefits of iExchange

Prior authorization requests should be submitted via iExchange whenever possible. Benefits of iExchange include:

Save paper!
  • Electronic submission
  • Ability to attach documents
Ease of tracking!
  • Assignment of a Request ID number
  • Monitoring the status of the request (i.e. Auto-approval; Pended for review)
  • Communication with our staff through iExchange
Save time!
  • Immediate feedback
  • Alerts when the case has been updated
  • Printable requests/approvals for the provider
If you'd like more information regarding iExchange, please contact us at or contact Jim Sarnosky at (608) 226-4159 or
Claims Timely Filing

The number of days to file a claim is counted from the date of service to the date of our receipt of a clean claim. If you receive a letter from Arise or Emdeon indicating claim was not accepted, resubmission is necessary; it refers to an unclean claim and is not considered a received claim. In this scenario, we suggest you address the issue of missing or invalid information and resubmit as soon as possible to meet the timely filing parameters outlined in your agreement with Arise Health Plan. 
Arise Provider Portal Coming Soon!

The Arise Provider Portal is launching in the first quarter of 2016. The portal is designed to provide real-time, 24/7 access to the following:
  • Claim status
  • Eligibility
  • Copayments and deductibles
  • Code Combination Simulation Tool
  • Secured messaging with Customer Service
As our launch date approaches, you will receive more information on how to use and register for this informative tool. 
Electronic Data Options

Want to save time, money & paper by filing electronic claims?
Complete our Arise Electronic Data Interchange (EDI) Claims Agreement form at: 
Electronic Remittance Advice (ERA) and Electronic Funds Transfer (EFT) are also available. There is no paperwork involved! All you have to do is complete and submit our online forms and we'll get you set up. These online forms can be found at:

Any questions? Please contact us at:
EDI (Electronic Data Interchange) Department
  • EDI Marketing: Call (toll-free) 1-800-782-2680 Option 4
    For questions about EDI enrollment for claims submission, electronic remittance and electronic funds transfer:
  • EDI Help Desk: Call (toll-free) 1-800-782-2680 Option 2
    For questions about online registration, password resets, how to login, missing files or any other technical concerns:
  • Hours: 7:55 AM - 4:30 PM Monday - Friday (CST)
  • Fax: 608-223-3824
  • Email: 
Thank you for choosing Arise as your trusted health insurance partner!

Utilization Management Timeliness Standards
As a health plan accredited by National Committee for Quality Assurance (NCQA), Arise Health Plan adheres to the timeliness standards specified by NCQA for review of requested services. The standards are outlined below:
  • Non-urgent pre-service decisions are determined within 15 calendar days of receipt of the request.
  • Urgent pre-service decisions are determined within 72 hours of receipt of the request.
  • Urgent concurrent review decisions are determined within 24 hours of receipt of the request.
  • Post service decisions are determined within 30 calendar days of receipt of the request.
These timeframes are dependent on the inclusion of necessary clinical information upon receipt of the request. Arise may request additional medical records if the information submitted to make a determination is lacking. Pre-service authorization requests and clinical information can be faxed (920) 490-6943 or mailed to Arise Health Plan, PO Box 11625, Green Bay, WI  54307-1625.
If Arise cannot make a decision by our standard deadlines, we notify the affected member and requesting provider that an extension is necessary. The date by which we expect to make a decision is included in that notice.
We consistently strive to exceed these standards and meet the needs of our members.
Affirmative Statement on Incentives

Utilization Management (UM) decision making at Arise Health Plan is based only on appropriateness of care and service and existence of coverage.  The organization does not specifically reward practitioners or other individuals for issuing denials of coverage.  Financial incentives for UM decision makers do not encourage decisions that result in underutilization.

Radiology Benefit Management

Arise Health Plan continues to use NIA Magellan (National Imaging Associates Magellan), an accredited leader in the management of outpatient radiology benefits in the utilization management (UM) process. The updated NIA Radiology guidelines will be available in January 2016. Check the Arise website and your RadMD portal for additional information coming soon.
Highlights of the guideline changes are as follows:
  • Global change to applicable guidelines: Specific cancer surveillance timeframes for lung cancer were added to the indication for combination studies for ongoing tumor/cancer surveillance.
  • PET Scan: Prostate cancer added as an approvable indication under Subsequent Treatment Strategy.
  • Musculoskeletal: Cervical and Thoracic Spine - added specific symptoms that define and may relate to myelopathy.
  • Neurological: Expanded on the indications within sections of the Brain CT with an emphasis on congenital abnormalities.
  • Breast: New indication added that covers screening under any condition for a member with no history of breast cancer.
Arise Health Plan| P.O. Box 11625 | Green Bay, WI |
See what's happening on our social sites: