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Going to the Doctor

How can I get an estimate of my out-of-pocket expenses? (WI ACT 146)

At the written request of our customers, Arise Health Plan will provide a good faith estimate of the reimbursement that Arise will expect to pay and the customer’s responsibility (out-of-pocket costs) for a specified health care service that is being considered. This process does not take the place of a preauthorization, prior approval, or precertification.

Please be aware that any requested preservice estimate is a verification of benefits and not a guarantee of payment. Payment is based on the terms, conditions, and provisions of the policy/plan and is subject to the usual, customary, or contracted rates that are in effect at the time the service is preformed including, but not limited to:

  • Requirements for medical necessity
  • Prior authorizations
  • Precertifications
  • Exclusions for work-related injuries
  • Provider network affiliations
  • Pricing adjustments due to negotiated transplant coverage

Also, the estimate of out-of-pocket expenses that will be prepared are based on information submitted to Arise along with claims and benefits we have processed at the time of our inquiry response. Arise will assume no modifications or complications occur in the treatment plan.

To download and mail your estimation of out-of-pocket expenses form, choose one of the options below: