Benefit Inquiries

Date: 12/20/24

In accordance with the Arkansas State Prior Authorization Transparency Act effective December 2023, Ambetter from Arkansas Health & Wellness is providing physicians and other healthcare providers the option to request a benefit inquiry. Read on for more information and answers to frequently asked questions. 

What is a benefit inquiry? A benefit inquiry is an inquiry by an Arkansas licensed healthcare 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 healthcare plan of the applicable healthcare insurer for services or prescription drugs that are not subject to prior authorization requirements of the utilization review entity. 

When should a provider request a benefit inquiry? An in-network or out-of-network healthcare provider may submit a benefit inquiry to a healthcare insurer or utilization review entity for a healthcare service not yet provided to determine whether the healthcare service meets medical necessity and all other requirements for payment under a health benefit plan if the healthcare 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 healthcare providers from a health plan before a specific service is delivered to the patient to qualify for payment coverage. 

Where is the Benefit Inquiry Form located? The Benefit Inquiry Form is available on our Provider Resources page, under Medical Management/Behavioral Health. 

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 all the information required to make a decision.

How will providers 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, refer to Rule 115 Prior Authorization Transparency Act (PDF). You can also refer to AR Code § 23-99-1113. 

Thank you for your continued partnership in helping Arkansas live better. If you have any questions or concerns about this notice, please contact us at Providers@ARHealthWellness.com.