4/24/2025

Provider Manual

Medical Management

Appeal Process for Medical Determinations and Expedited Appeals

If a member or provider disagrees with a coverage decision, an appeal may be made in writing within 180 days of the denial or adverse determination. An expedited appeal may also be requested. See Pre-authorization and Concurrent Review Guidelines or Your Right to Appeal.

Coverage

Certain services may be considered cosmetic, investigational, not medical (dental) or otherwise not covered under the plan. Any service for which coverage is in question must be submitted for predetermination before the service is provided.

Definitions for Levels of Care

QualChoice recognizes the following distinct levels of care.

Psychiatric Disorder Levels of Care

  • Acute inpatient: The highest intensity of medical and nursing services provided within a structured environment providing 24-hour skilled nursing and medical care. Full and immediate access to ancillary medical care must be available for those programs not housed within general medical centers.
  • Residential treatment: Care provided at a 24-hour, state-licensed sub-acute level with licensed healthcare professionals.
  • Partial hospital: An intensive non-residential level of service where multidisciplinary medical and nursing services are required. Care is provided in a structured setting, similar in intensity to inpatient, meeting for more than 4 hours and generally less than 8 hours daily.
  • Intensive outpatient: Multidisciplinary, structured services provided at a greater frequency and intensity than routine outpatient treatment. These are generally up to 4 hours per day, up to 5 days per week. Common treatment modalities include individual, family, and group psychotherapy and medication management.
  • Outpatient: The least intensive level of service, provided in an office setting. Individual psychotherapy sessions last for up to 60 minutes per day and group psychotherapy sessions for up to 90 minutes per day.

Substance Use Disorder Levels of Care

  • Inpatient detoxification:Services provided in an inpatient setting with full skilled nursing and medical care, generally on inpatient or sub-acute units. Can also be provided on a medical/surgical unit or other medical hospital unit when needed for safety or in the absence of adequate services elsewhere.
  • Inpatient rehabilitation: Care provided at an inpatient facility or sub-acute level with skilled nursing care after a member has fully or partially recovered from acute detoxification symptoms and no longer requires intensive medical monitoring.
  • Residential treatment: Care provided at a 24-hour, state-licensed sub-acute level with licensed healthcare professionals.
  • Outpatient/ambulatory detoxification: Services delivered within a structured program having medical and nursing supervision where physiological consequences of substance withdrawal are not life threatening. 
  • Partial hospital: An intensive, non-residential level of care where multidisciplinary medical and nursing services are required. Care is provided in a structured setting, similar in intensity to an inpatient setting, meeting for more than four hours and generally, less than 8 hours daily. Such care is appropriate for substance use disorder treatment when provided in conjunction with ambulatory detoxification or when medical co-morbidity or other complications make less intensive levels of care unsafe or inadequate. 

Pre-authorization

All elective inpatient admissions and designated outpatient services must be pre-authorized to determine medical necessity and appropriate site of care. The provider should submit a completed Pre-authorization Request Form according to the Pre-authorization and Concurrent Review Guidelines at least five (5) days prior to the proposed service date. The medical decision will be made on the information provided, so complete and accurate information is necessary. If the care management nurse cannot approve the request, it is referred to the Medical Director for a final decision. The provider and/or member will be notified in writing of the decision.

  • If the criteria are met, the nurse will evaluate for case management or discharge planning needs at the time of pre-authorization.
  • If the criteria are not met, the member and provider will be notified of the decision, why their request was not authorized and their right to appeal.
  • If the member or the provider disagrees with the pre-authorization decision, he/she may request an appeal in writing within 180 days of the denial. An expedited appeal may also be requested. See Your Right to Appeal.

Our decision only affects whether reimbursement is available under the plan. The decision to proceed with the service rests solely with the member and the physician.

Site-of-service medical necessity reviews are part of our pre-authorization process that supports member benefit plans, requiring care to be medically necessary as well as cost-effective. Ambulatory care centers frequently offer significant cost savings compared with a hospital setting, which can help many of our members save on out-of-pocket costs. Ambulatory care centers may provide more convenient care experiences for members, as well.

As healthcare continues to evolve and consumers increasingly demand a wider range of quality, cost effective options for their healthcare services, we anticipate a continued focus on place of service. We encourage you to review network ambulatory care centers in your area that best meet your needs and your patients’ needs.

Pre-authorization Exemption

Who is exempt from pre-authorization requirements?

Healthcare providers who have requested more than five pre-authorizations and received an approval rate of 90% or more on those requests during the period January 1, 2022-June 30, 2022, will be exempt from QualChoice pre-authorization requirements through December 31, 2024.

If I am exempt, what are my requirements?

Exempt healthcare providers will not be required to obtain pre-authorizations from QualChoice for medical services. Exempt providers will still be required to obtain authorizations for any pharmacy services, including the administration of drugs in an outpatient clinic setting. Medical exemption status, as determined by the above 2022 pre-authorization metrics, is valid through December 31, 2024.

If I am non-exempt, what are my requirements?

Non-exempt healthcare providers will be required to obtain pre-authorizations from QualChoice, when necessary. You may review the pre-authorization requirements as well as QualChoice medical policies at qualchoice.com. If you wish to appeal your exemption status, you must submit your appeal within 30 days of the receipt of this letter. To submit an appeal, contact the QualChoice provider relations department at pr@qualchoice.com or 1-800-235-7111, extension 7004. You may also mail your appeal to PO Box 25610, Little Rock, AR 72221.

Am I able to update where I want communication to go for pre-authorization exemption?

QualChoice allows healthcare providers to designate an email address or a mailing address for communications regarding pre-authorization exemptions, denials, and recessions. QualChoice asks that providers send notification to pr@qualchoice.com with their preferred contact information and delivery methods on all communications and if they would like to make any changes to their delivery methods relating to pre-authorization exemptions.

Please note that your pre-authorization exemption will not apply to self-funded employer groups. Self-funded employer groups where QualChoice is the third-party administrator will have member ID cards with both the employer group logo, as well as the QualChoice logo and employer group name. If you have questions, please contact our provider relations department at the information listed above.

Pre-authorization Requirements

Elective Services

All elective inpatient admissions and designated outpatient services must be pre-authorized to determine medical necessity and appropriate site of care. Pre-authorization must be requested according to our Pre-authorization and Concurrent Review Guidelines at least five (5) business days prior to the proposed service by calling QualChoice or submitting a Pre-authorization Request Form.

Verbal Approvals for Authorization Requests

QualChoice network providers will receive a verbal approval when requesting an authorization by mail or fax. It is the responsibility of the network provider to inform the member at that time that the request has been approved.

Emergency Care

Requests for procedures/services needed on an emergency basis must be made within 48 hours of admission. All emergency care is subject to review by QualChoice for medical necessity. If medical necessity is not established, payment will be denied. If in an emergency a member goes to an out-of-network facility’s emergency room for treatment, and the member is admitted at that out-of-network facility, the member, a family member or the facility must notify QualChoice once the member is stabilized, but no more than 48 hours after initial treatment. Out of Network Emergency care may be subjected to the No Surprises Act. When members use emergency rooms for treatment, specific emergency cost sharing will apply. Please review Pre-authorization and Concurrent Review Guidelines.

Clinical Review

A nurse will review the request and may contact the provider for pertinent medical information. If the nurse cannot approve the request, it is referred to the Medical Director for a final decision. If criteria are not met, or if the provider does not provide the information necessary for review, the service will not be authorized. QualChoice will notify the facility and the physician verbally and in writing of the denial decision. See Pre-authorization and Concurrent Review Guidelines for complete information.

Pre-authorization Denials

All pre-authorization denials undergo a physician review and are denied by a physician. If the member and/or the attending physician disagree with the denial, he/she may contact our Care Management Department and request an appeal. Specific details are noted in Pre-authorization and Concurrent Review Guidelines.

Pre-authorization Tool

To help check whether pre-authorization is needed, use our online Pre-authorization tool.

Pre-authorization for Genetic/Genomic Testing

QualChoice covers genetic/genomic testing when medically necessary with pre-authorization and clinical documentation. We do not cover genetic/genomic testing for conditions that treatment cannot alter or that specific interventions cannot prevent.

In all instances, genetic/genomic testing must be pre-authorized unless otherwise stated in a medical policy. An in-network laboratory must be used when available.

If genetic/genomic tests are not pre-authorized, the member may be responsible for the full cost. Additionally, if genetic/genomic testing is ordered and performed by an out-of-network lab and QualChoice determines the test was not medically necessary, the liability for all charges will revert to the member.

IMPORTANT! Before rendering any genetic testing services, inform members that they are likely to be responsible for the cost of these services. Please ensure that ALL providers and ancillary facilities are in-network, as any referral to an out-of-network facility may result in full liability for all charges reverting to the member.

Pre-authorization Requirements for High Tech Radiology

Evolent manages our high tech imaging radiology requirements. See Evolent Radiology Requirements and information on the Utilization & Pre-authorization page at QualChoice.com.

Pre-authorization is required for the following:

  • Computed tomography (CT) scans
  • Nuclear medicine
  • Nuclear cardiology
  • Magnetic resonance imaging (MRI/MRA)
  • Positron emission tomography (PET) Scans
  • Stress echo and echocardiography

Rendering location exclusions:

  • Imaging studies performed in conjunction with emergency room services
  • Inpatient hospitalization
  • Outpatient surgery (hospitals and free standing surgery centers)
  • 23-hour observations

For Evolent pre-authorization, call 866-249-1587 (Monday to Friday 7:00 a.m. – 7:00 p.m.). Review the Evolent imaging criteria. Imaging criteria can also be found in the My Account portal.

Pre-notification, Pre-authorization and Eligibility Requirements

  • Members are required to call QualChoice prior to admission to an out-of-network facility. A determination will be made as to whether care management is an appropriate option for the member.
  • Pre-authorization for inpatient treatment, pre-notification or any “verification of benefits” or other eligibility inquiries made prior to, at, or after admission, or provision of any services to members, are not a guarantee of payment.
  • Pre-authorization means that based on information provided to QualChoice, coverage for the admission (and for the initial number of inpatient days authorized for reimbursement) will not be denied solely on the basis of lack of medical necessity (as defined by the member’s health plan).
  • QualChoice attempts in good faith to report member eligibility information available within its records or computer systems at the time of admission or provision of services. Provider acknowledges and agrees that it is not possible to guarantee accuracy of such records or computer entries.
  • Provider understands and agrees that the eligibility of all members and coverage for any services shall be governed by the terms, conditions and limitations of the member’s health plan, which shall take precedence over any inconsistent or contrary oral or written representations.
  • If, following inpatient treatment or other services, it is discovered or determined that premiums had not been paid for a member’s coverage, that a former member was no longer employed and eligible for participation in the health plan at the time of the admission, or that coverage had lapsed or terminated for any reason specified in the member’s health plan, no reimbursement shall be due from QualChoice (or the applicable payer) for such services.

Postoperative Global Period

A global period is a period of time starting with a surgical procedure and ending some period of time after the procedure. QualChoice follows the postoperative global periods used by the Centers for Medicare and Medicaid (CMS).

Each surgical and/or invasive procedure will have a global period of zero to 90 days. This means that all usual postoperative services occurring within that time frame are included in the QualChoice allowance and reimbursement of the surgical/invasive procedure. Providers will not receive additional payments. Only those postoperative services that are considered significant and separately identifiable should be billed; QualChoice retains sole discretion to determine whether such services are eligible for payment as separate services.

Care Management and Referrals

We use a proactive and positive relationship-building approach in working with members, their families and physicians to develop and monitor the most appropriate treatment plan. Care management review and intervention are triggered by complex conditions, terminal illness, and catastrophic illness. Members whose diseases do not fall into these specific categories, but are likely to use a high level of medical resources in a 12-month consecutive period are also identified and potentially enrolled.

Our QCARE health and wellness programs create an impact on both the quality and the cost of care received by our members through interventions, such as:

  1. Determination of the medical necessity of requested services
  2. Provision of referrals to network providers
  3. Negotiation for discounts and services when non-contracted providers are involved
  4. Recommendation of benefit alternatives designed to provide more appropriate and cost effective treatment
  5. Facilitation of referral to a specialist or medical consultant

Cases are assessed and evaluated in regard to the following:

  • Age
  • Type of illness
  • Secondary diagnosis
  • Special equipment needs
  • Current treatment plan
  • Type of treatment
  • Treatment location
  • Potential for complications
  • Physician specialty
  • Financial concerns
  • Family dynamics

 

Our QCARE programs may be targeted to specific conditions, such as our core care management programs, or designed to improve or maintain overall health, such as our health and wellness programs. Regardless of their focus, all QCARE programs are intended to supplement and reinforce the care and guidance you provide to our members.

Identifying Members for Referral

Members are identified or referred for care management through a number of sources. Referrals may come from an internal department at QualChoice or from an external source, such as the member’s family, physician, or other healthcare professional or facility. Members may also self-refer.

To refer a QualChoice member for care or disease management, contact Customer Service at 501.228.7111 or 800.235.7111 (Monday-Friday, 8:00 a.m. to 5:00 p.m.) and ask to speak to a care manager, or submit a Care Management Referral Form.

Utilization Management

Affirmative Statement

QualChoice does not compensate individuals conducting utilization review for issuing denials of coverage, and it does not provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. Financial incentives for utilization review do not encourage decisions that result in underutilization. Utilization management decision making is based on medical necessity, applicable coverage guidelines and appropriateness of care and service.

Clinical and Payment Policies

To easily search for a policy, go to the Clinical and Payment Policies page and use the Ctrl+F (Command+F on Mac) function on your keyboard to search by keyword, policy number or effective date. 

QualChoice medical policies are based on research of current medical literature and review of common medical practices in the treatment and diagnosis of disease.

What are Clinical Policies?

Clinical policies are one set of guidelines used to assist in administering health plan benefits, either by prior authorization or payment rules. They include policies relating to evolving medical technologies and procedures as well as pharmacy policies. Clinical policies help identify whether services are medically necessary based on information found in generally accepted standards of medical practice, including peer-reviewed medical literature, government agency/program approval status, evidence-based guidelines, positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas affected by the policy, and other available clinical information.

All policies found on the QualChoice Clinical Policy page apply to QualChoice members. Policies on this QualChoice page may have either a “QualChoice” or a “Centene” heading. QualChoice follows care guidelines published by InterQual.
QualChoice may, from time to time, delegate utilization management of specific services. In such circumstances, the delegated vendor’s guidelines may also be used to support medical necessity and other coverage determinations. Other non-clinical policies (e.g., payment policies) or contract terms may further determine whether a technology, procedure, or treatment that is not addressed in the policies on this page or within the InterQual criteria is payable by QualChoice.

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

What are Payment Policies?

Healthcare claims payment policies are guidelines used to assist in administering payment rules based on generally accepted principles of correct coding. They are used to help identify whether healthcare services are correctly coded for reimbursement. Each payment rule is sourced by a generally accepted coding principle. They include claims processing guidelines referenced by the Centers for Medicare & Medicaid Services (CMS), Publication 100-04, Claims Processing Manual for physicians/non-physician practitioners, the CMS National Correct Coding Initiative policy manual (procedure-to-procedure coding combination edits and medically unlikely edits), CPT® guidance published by the American Medical Association (AMA) for reporting medical procedures and services, health plan clinical policies based on the appropriateness of healthcare and medical necessity, ClaimsXten™ review, and, at times, state-specific claims reimbursement guidance. More information about ClaimsXten and the way we utilize ClaimsXten with relation to claims payments can be found on our Claims and Payment Information page.

All policies found on this page apply with respect to QualChoice members. These payment policies may have either a “QualChoice” or a “Centene” heading. QualChoice may, from time-to-time, employ a vendor that applies payment policies to specific services. In such circumstances, the vendor’s guidelines may also be used to determine whether a service has been correctly coded. Other policies (e.g., clinical policies) or contract terms may further determine whether a technology, procedure, or treatment that is not addressed in these policies is payable by QualChoice.

Clinical Policies for CT/CTA/CCTA, MRI, MRA, and Pet scans can also be found at the Evolent website.

Medical Policy Dissemination

Medical policies are available to members, providers and the general public. Significant policy changes are communicated through our provider e-newsletter and email updates:  Quality Results and Provider Quick Alerts.

Benefit Inquiry or Pre-determination

Beginning December 1, 2017, written pre-determination requests must be submitted using the Predetermination Request Form. Please note that, as of January 1, 2018, paper requests that are received at QualChoice without the Predetermination Request Form will be returned to the submitting provider, along with instructions to resend the request using the appropriate form.

A medical benefit inquiry will assist you in obtaining a pre-determination as to whether a particular service or supply will be eligible under the QualChoice medical plan and if it meets the medical necessity guidelines.