Provider/Practice Information and QualChoice Procedures

Adding a Provider to an Existing Practice

If you have a new provider joining your clinic, please contact your Sr. Provider Relations Representative to ensure you complete the proper credentialing and provider demographic forms needed to participate in the QualChoice network.

Provider Changes and Updates

It is important that we maintain a current record of your demographic information to ensure:

  • Timely and accurate claims payment
  • IRS reporting accuracy
  • Distribution of email communications
  • Provider directory accuracy

To update your information:

Provider Search Directory

We make every effort to list providers correctly in our online directory. Each provider listing indicates:

  • Whether accepting new patients
  • Board certification
  • Hospital/facility affiliation
  • Clinic location
  • Hours of operation

Opening and Closing to New Patients

For a primary care provider to open or close his or her practice to new QualChoice members for any or all plans, use the Provider/Practice Change Form. QualChoice requires 60 days advance notice of closing to new patients. Opening a closed practice to new patients can be effective immediately once QualChoice receives the written request.

When an Established Patient Switches to a QualChoice Plan

When a patient covered by a different insurance company switches to QualChoice, the patient is considered to be an “established patient.” Even if your practice is closed to new patients, the member can designate the provider as their Primary Care Provider (PCP).

Out-of-Network Referrals

Network providers are contractually required to refer QualChoice members to in-network providers, including in-network facilities, labs and ancillary providers. Referrals to out-of-network providers require pre-authorization. Written referrals to in-network specialists are not required for QualChoice members. An Out-of-Network Authorization Request Form or a Letter of Medical Necessity must be completed by the ordering provider when referring to a non-participating provider (including facilities, labs and ancillary providers) for services that are not available in network.

Mail or fax the Out-of-Network Authorization Request Form or Letter of Medical Necessity and pertinent medical records at least five (5) business days prior to the anticipated date of service to allow time for review and notification of the approval or denial of the referral.

QualChoice
Attn:  Care Management Department
PO Box 25610
Little Rock, AR 72221
F:  501.228.9413 or 800.228.9413

QualChoice will notify the provider of the approval or denial. Providers can also call 501.228.7111 or 800.235.7111 to check the status of a referral. IMPORTANT:  Retroactive out-of-network referrals will not be accepted.

Reimbursement for Out-of-Network Providers

If an insured member receives medically necessary care from an out-of-network provider (even in an in-network setting) QualChoice may reimburse the member for the service rendered. Example:  An insured member goes to an outpatient facility and the in-network specialist uses an out-of-network laboratory during a procedure.

On-Call Arrangements

As stipulated in the Provider Agreement, participating providers shall provide Covered Services for members directly or through arrangements with other in-network providers, 24 hours, 7 days a week.

Medical Coverage Policy: BI109 Out-of-Network Referrals

QualChoice Medical Directors

Two full-time QualChoice Medical Directors partner with our provider community to review medical issues and help establish coverage policies.

Provider Relations Representative

We are committed to working with our network providers and their staff, to ensure that our members receive the right care at the right time, resulting in better health outcomes. A direct phone queue for providers means an immediate response to your questions and issues. Resources are also available 24/7 at QualChoice.com.

A Senior Provider Relations Representative will serve as your point of coordination for all network activities and ongoing operations, including contracting and information about QualChoice. Assigned regionally, the Provider Relations Rep can also assist you with specific inquiries or challenges.

QualChoice.com Provider Log-In

Registration is required to access member eligibility or claim status. Please call us at 501.228.7111 or 800.235.7111, ext. 7011 if you do not have an authorized user name and password.

Each individual user in your office, group or facility using the QualChoice web portal for daily transactions must have a separate secure account. A Portal Administrator (PA) must be designated for each practice or group via the Provider Portal Administrator Designation Form. Complete a form for each administrator needed. Only a PA may assign access to other users in the group by filling out a Provider Portal Access Form for each user.

Portal Designation and User Access Forms

My Account for Providers

Quality Results Provider Newsletter and Quick Alerts

We communicate with providers via targeted mailings, seminars and other educational materials as well as electronically via our quarterly newsletter, Quality Results and monthly Provider Quick Alerts. Updates to Medical Coverage Policies are communicated monthly and at least 60 days before becoming effective. Subscribe here for email communications.

Fraud, Waste and Abuse 

QualChoice takes the detection, investigation, and prosecution of fraud and abuse very seriously and has a Fraud, Waste, and Abuse (FWA) program that complies with federal and state laws. QualChoice, in conjunction with its parent company, Centene, operates an FWA unit. 

QualChoice routinely conducts audits to ensure compliance with billing regulations. Our sophisticated code-editing software performs systematic audits during the claims payment process. To better understand this system, please review the billing and claims section of this manual. QualChoice’s Fraud, Waste, and Abuse Committee also performs retrospective audits, which may result in taking actions against providers who commit fraud, waste, and/or abuse. These actions include but are not limited to the following:

  • Remedial education and training to prevent the billing irregularity
  • More stringent utilization review
  • Recoupment of previously paid monies
  • Termination of provider agreement or other contractual arrangement
  • Civil and/or criminal prosecution
  • Announced or unannounced onsite audit investigations
  • Corrective action plan
  • Any other remedies available to rectify

Some of the most common FWA practices include:

  • Unbundling of codes
  • Upcoding services
  • Add-on codes billed without primary CPT®
  • Diagnosis and/or procedure code not consistent with the member’s age
  • Use of exclusion codes
  • Excessive use of units
  • Misuse of benefits
  • Claims for services not rendered

QualChoice auditors consider state and federal laws and regulations, provider contracts, billing histories, and fee schedules in making determinations of claims payment appropriateness. If necessary, a clinician of similar specialty may also review specific cases to determine if billing is appropriate. Auditors issue an audit results letter to each provider upon completion of the audit, which includes a claims report identifying all records reviewed during the audit. If the auditor determines that clinical documentation does not support the claims payment in some or all circumstances, QualChoice will seek recovery of all overpayments. Depending on the number of services provided during the review period, QualChoice may calculate the overpayment using an extrapolation methodology. Extrapolation is the use of statistical sampling to calculate and project overpayment amounts. It is used by Medicare Program Safeguard Contractors, CMS Recovery Audit Contractors, and Medicaid Fraud Control Units in calculating overpayments, and is recommended by the OIG in its Provider Self-Disclosure Protocol (63 Fed. Reg. 58,399; Oct. 30, 1998).

If you suspect or witness a provider inappropriately billing or a member receiving inappropriate services, please email fraud@QualChoice.com, call 1-800-235-7111 ext. 6740, or write to the following address:

QualChoice
P.O. Box 25610
Little Rock, AR 72221

QualChoice takes all reports of potential fraud, waste, and/or abuse very seriously and investigates all reported issues.

Post-Processing Claims Audit
A post-processing claims audit consists of a review of clinical documentation and claims submissions to determine whether the payment made was consistent with the services rendered. To start the audit, QualChoice auditors request medical records for a defined review period. Providers have 60 days to respond to the request; if no response is received, a second and final request for medical records is forwarded to the provider. If the provider fails to respond to the second and final request for medical records, or if services for which claims have been paid are not documented in the medical record, QualChoice will recover all amounts paid for the services in question.

QualChoice auditors review cases for common FWA practices, including:

  • Unbundling of codes
  • Upcoding services
  • Add-on codes billed without primary CPT®
  • Diagnosis and/or procedure code not consistent with the member’s age/gender
  • Use of exclusion codes
  • Excessive use of units
  • Misuse of benefits
  • Claims for services not rendered

False Claims Act
The False Claims Act establishes liability when any person or entity improperly receives or avoids payment to the federal government. The Act prohibits:

  • Knowingly presenting, or causing to be presented a false claim for payment or approval
  • Knowingly making, using, or causing to be made or used a false record or statement material to a false or fraudulent claim
  • Conspiring to commit any violation of the False Claims Act
  • Falsely certifying the type or amount of property to be used by the government
  • Certifying receipt of property on a document without completely knowing that the information is true
  • Knowingly buying government property from an unauthorized officer of the government
  • Knowingly making, using, or causing to be made or used a false record to avoid or decrease an obligation to pay or transmit property to the government
For more information regarding the False Claims act, please visit cms.gov.

Data Sharing to Prevent Fraud, Waste and Abuse

QualChoice submits claims data to LexisNexis® Risk Solutions on a quarterly basis to be reviewed for fraud, waste and abuse. Results from this review may be used to:

  • Inform a provider about proper billing practices
  • Modify a Medical Coverage Policy
  • Recoup overpayments from a provider
  • Initiate disciplinary action

For questions, contact your QualChoice Provider Relations Representative at 800.235.7111.

Treating Your Family Member or Yourself

QualChoice concurs with the recommendation of the American Medical Association (AMA) that practitioners should not treat themselves or their immediate family members in order to avoid the potential for ethical conflicts.

QualChoice policy statement on care provided by a relative by blood or marriage:

We will not cover care provided by an individual who normally resides in your household. We also will not cover care provided by you or by your parents, siblings, spouses, children, grandparents, aunts, uncles, nieces and nephews or other relatives by blood or marriage.

In addition, QualChoice practitioners must comply with HIPAA regulations protecting patient information, regardless of whether the patient is a family member.

Non-Discrimination/Language Help

QualChoice complies with applicable Federal civil rights laws and does not discriminate, exclude people or treat them differently on the basis of race, color, national origin, age, disability or sex.

QualChoice provides free aids and services to people with disabilities to help them communicate effectively with us, such as:

  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

QualChoice provides to people whose primary language is not English, free language services such as:

  • Qualified interpreters
  • Information written in other languages

If providers need these services, contact Customer Service at 501.228.7111. If you believe that QualChoice has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, then you may file a grievance with:

QualChoice Civil Rights Coordinator
QualChoice Health Insurance
P.O. Box 25610
Little Rock, AR 72221-5610
Phone: 501.228.7111
Fax: 501.707.6729
QCA_COE@qualchoice.com

You may file a grievance in person or by mail, fax or email. If you need help filing a grievance, the QualChoice Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue SW.
Room 509F, HHH Building
Washington, DC 20201
800.868.1019, 800.537.7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Notice of Discrimination Grievance Procedures

It is the policy of QualChoice not to discriminate on the basis of race, color, national origin, sex, age or disability. QualChoice has adopted an internal grievance procedure providing for prompt and equitable resolution of complaints alleging any action prohibited by Section 1557 of the Affordable Care Act (42 U.S.C. 18116) and its implementing regulations at 45 CFR part 92, issued by the U.S. Department of Health and Human Services. Section 1557 prohibits discrimination on the basis of race, color, national origin, sex, age or disability in certain health programs and activities. Section 1557 and its implementing regulations may be examined in the office of the QualChoice Civil Rights Coordinator, who has been designated to coordinate the efforts of QualChoice to comply with Section 1557 (the “Section 1557 Coordinator”):

QualChoice Civil Rights Coordinator
QualChoice Health Insurance
P.O. Box 25610
Little Rock, AR 72221-5610
Phone:  501.228.7111
Fax:  501.707.6729
QCA_COE@qualchoice.com

 

Any person who believes someone has been subjected to discrimination on the basis of race, color, national origin, sex age or disability may file a grievance under this procedure. It is against the law for QualChoice to retaliate against anyone who opposes discrimination, files a grievance or participates in the investigation of a grievance.

Procedure:

  • Grievances must be submitted to the Section 1557 Coordinator within sixty (60) days of the date the person filing the grievance becomes aware of the alleged discriminatory action.
  • A complaint must be in writing, containing the name and address of the person filing it. The complaint must state the problem or action alleged to be discriminatory and the remedy or relief sought.
  • The Section 1557 Coordinator (or her/his designee) shall conduct an investigation of the complaint. This investigation may be informal, but it will be thorough, affording all interested persons an opportunity to submit evidence relevant to the complaint. The Section 1557 Coordinator will maintain the files and records of QualChoice relating to such grievances. To the extent possible, and in accordance with applicable law, the Section 1557 Coordinator will take appropriate steps to preserve the confidentiality of files and records relating to grievances and will share them only with those who have a need to know.
  • The Section 1557 Coordinator will issue a written decision on the grievance, based on a preponderance of the evidence, no later than thirty (30) days after its filing, including a notice to the complainant of their right to pursue further administrative or legal remedies.
  • The person filing the grievance may appeal the decision of the Section 1557 Coordinator by writing to the Vice President Corporate Responsibility within fifteen (15) days of receiving the Section 1557 Coordinator’s decision. The Vice President Corporate Responsibility shall issue a written decision in response to the appeal no later than thirty (30) days after its filing.

The availability and use of this grievance procedure does not prevent a person from pursuing other legal or administrative remedies, including filing a complaint of discrimination on the basis of race, color, national origin, sex, age or disability in court or with the U.S. Department of Health and Human Services, Office for Civil Rights. A person can file a complaint of discrimination electronically through the Office for Civil Rights Complaint Portal at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: 

U.S. Department of Health and Human Services
200 Independence Avenue SW.
Room 509F, HHH Building
Washington, DC 20201

Complaint forms are available at:  http://www.hhs.gov/ocr/office/file/index.html.

Such complaints must be filed within 180 days of the date of the alleged discrimination. QualChoice will make appropriate arrangements to ensure that individuals with disabilities and individuals with limited English proficiency are provided auxiliary aids and services or language assistance services, respectively, if needed to participate in this grievance process. Such arrangements may include, but are not limited to, providing qualified interpreters, providing taped cassettes of material for individuals with low vision or assuring a barrier-free location for the proceedings. The Section 1557 Coordinator will be responsible for such arrangements.

QualChoice offers help for members with limited English proficiency (LEP). The following statement is printed in the top languages used in Arkansas, as required by the Federal government, and included with documents crucial to purchasing or using health benefits:

ATTENTION:  If you speak [insert language], language assistance services, free of charge, are available to you. Call 1.800.235.7111 (TTY: 711).

Non-discrimination and Language Help

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