Providers Can Now Request a Benefit Inquiry
Date: 12/10/24
Per the Arkansas State Prior Authorization Transparency Act effective December 2023, Arkansas Total Care is providing physicians and other healthcare providers the option to request a benefit inquiry. Read on for more information about this option and how it impacts you.
What is a benefit inquiry? An inquiry by an Arkansas-licensed provider to a utilization review entity related to medical necessity, coverage, or payment for prospective healthcare services, including prescription drugs, for an enrolled member of a health plan of the applicable insurer for services or prescription drugs that are not subject to prior authorization requirements of the utilization review entity.
When should I request a benefit inquiry? An in-network or out-of-network provider may submit a benefit inquiry to an insurer or utilization review entity for a service not yet provided to determine whether the service meets medical necessity and all other requirements for payment under a health benefit plan if the service were to be provided to a specific subscriber.
What is the difference between a prior authorization request and a benefit inquiry? A benefit inquiry is only applicable to services or prescription drugs that are not subject to prior authorization requirements. A prior authorization must be obtained by physicians and other providers from a health plan before a specific service is delivered to the patient to qualify for payment coverage.
Where can I find a Benefit Inquiry Form? The request form is available on the Provider Resources section of our website, under Medical Management.
What is the turnaround time for a benefit inquiry? A healthcare insurer shall respond to a benefit inquiry authorized within 10 business days of receipt of information required to make a decision.
How will I receive final determination? Responses to a benefit inquiry shall be provided in the same form and manner as responses to requests for prior authorization.
For more details: Rule 115 Prior Authorization Transparency Act (PDF)