Coverage Policy Bulletins/ Medical and Pharmacy Policies

Please read before continuing:

Medical Policies are developed to assist in making coverage determinations under our health policies or plans.

Medical Policies are for informational purposes only and do not constitute medical advice, plan authorization, an explanation of benefits, or a guarantee of payment. Benefit plans vary in coverage and some plans may not provide coverage for all services listed in these policies. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and federal law. Some benefit plans administered by the organization may not utilize Medical Affairs Medical Policies in all their coverage determinations. Contact Member Services as listed on the member card for specific plan, benefit, and network status information.

Medical Policies are based on constantly changing medical science and are reviewed annually and subject to change. The organization uses tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG Health, to assist in administering health benefits. These medical policies and MCG Health guidelines are intended to be used in conjunction with the independent professional medical judgment of a qualified health care provider.

For specific patient-related policy or medical coding inquiries, contact Arise Medical Management with the applicable patient name and member number, along with the procedure, service, or treatment in question.

Arise Health Plan
Attn: Medical Management Department
P.O. Box 11625
Green Bay, WI 54307-1625

Phone: 1-920-490-6901 or toll-free 1-888-711-1444, ext. 76901
Fax: 1-920-490-6943

We welcome your feedback regarding medical policies or MCG Health guidelines. 
For questions or comments regarding research and evidence development of a specific criteria, general medical policy, or MCG Health questions, contact the Medical Policy Committee at medical.policies@wpsic.comTo request an assessment of new technology or medical policy criteria by the Medical Policy Committee, please complete the New Technology and Medical Policy Assessment Request Form, attach supporting documentation from peer-reviewed high-level scientific literature, and email to the committee at medical.policies@wpsic.com.

For questions regarding medical coding related to policies, contact the Code Governance Committee at codegovernance@wpsic.com.

NOTE: The email addresses above should NOT be used to send personal health records or member identified information.

This disclaimer applies to all past and present medical and pharmacy policies.

Medical Policy Changes

Arise Medical Policy Update - May 2018
Arise Medical Policy Update - February 2018
Arise Medical Policy Update - November 2017
Arise Medical Policy Update - June 2017
Arise Medical Policy Update - March 2017
Arise Medical Policy Update - December 2016
Arise Medical Policy Update - November 2016
Arise Medical Policy Update - August 2016
Arise Medical Policy Update - May 2016
Arise Medical Policy Update - February 2016
Arise Medical Policy Update - November 2015

I Understand and Accept the Above Information