Get the Most from Your Coverage
You deserve quality healthcare. And you also deserve to have the information you need to get the most from your coverage. Goals for quality are set and reviewed by your health plan to make sure you get the care you need.
This information is part of a Quality Program designed to improve the services and care you receive. It provides details about your coverage and services available to you.
Contact Customer Service to learn more about the Quality Program.
Know Your Rights
Being a member means there are things you should expect from your health plan. These are some of your rights:
- You should have access to all the services available to members.
- You should be treated with courtesy and respect.
- You should be able to get a copy of your medical record.
- You should know your medical data will be kept private. There are policies in place to guard your health records and protected health information.
It’s also important to know what you can do to get the most from your coverage:
- Ask questions if you don’t understand your rights.
- Be sure to keep your scheduled appointments.
- Keep your Member ID Card with you so you have it at appointments.
- Tell your doctor if you have gotten care in an emergency room.
The full list of rights and responsibilities is in your Member Handbook.
Getting the Care You Need
PRIMARY CARE PROVIDER (PCP)
Your PCP is the doctor you’ll see for routine checkups and care. Your PCP will help find other types of healthcare providers if you need one. You can also search Find a Doctor or Hospital on the QualChoice website to find a PCP or specialist.
You should be able to schedule an appointment with your PCP and get medical care when you need it. You may have to wait a little longer to get in to see certain other types of providers, like specialists. Call Customer Service if you can’t get an appointment in a timely manner.
GETTING PRESCRIPTIONS FILLED
You should get high quality medications and the right treatment for your conditions. But not all drugs are covered. And some may need to be approved before they’re covered. The Preferred Drug List (PDL) is located on your health plan website. It is updated regularly and lists drugs that are covered by insurance. Talk to your doctor or pharmacist to review the PDL and answer questions about your medications.
KNOWING IF A SERVICE IS COVERED
The Utilization Management (UM) Department looks at your health records and may also talk with your doctor to decide if a service you need is covered. These decisions are not based on financial reasons. And doctors and staff are not rewarded for saying no to care. All UM decisions are based on:
- If the service is medically necessary
- If the service works well
- If the service is right for you
NEW SERVICES AND TECHNOLOGY
New medicines, tests and procedures come out every year. A team of doctors and other experts decide if new medical care will be covered by your health plan. Your plan covers care that is medically necessary. Not every new medical service is covered for all members.
IF A SERVICE IS DENIED
If a service is denied, you have the right to appeal that decision. You will be sent a letter explaining how to make an appeal. All appeal requests are decided according to your request, condition and benefits.
GETTING MORE HELP IF YOU NEED IT
Care Management is for members who may need extra help taking care of their health. Some people have several health conditions and see more than one doctor. Others need help arranging the services their doctors may have ordered. Working with a care manager lets you understand major health problems, work well with your doctors and get the care you need.
Get More Information
Your Member Handbook is a great source for information about your coverage and benefits. It also lists important phone numbers.
You can also contact Customer Service for additional help at 800.235.7111or TDD/TTY: 711. Translation services are available if you need them.
Contact Customer Service to get:
- A paper copy of your Member Handbook, Privacy Notice or anything on your health plan website
- Help finding a doctor and making an appointment
- Help speaking with a care manager
- Help with an appeal for a service that’s been denied
QualChoice.com also has a lot of helpful information. Visit it to find the Member Handbook, Find a Doctor or Hospital tool, and the Preferred Drug List. You can also use it to help you manage your health and send a message directly to QualChoice using the QuicQuestions tool.
Creating an online MyAccount member account is free and easy. With it, you can:
- Find or change your PCP
- Request a new Member ID Card or print a temporary ID Card
- View and update your personal information
- View your claims information
Providing Quality Care
As our valued provider, your ability to serve our members is important. QualChoice is here with information to help you provide the very best care. This information is part of our Quality Improvement (QI) program designed to address both the quality and safety of services provided to your patients and our members.
ANNUAL CAHPS SURVEY
The Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey is a chance for your patients to report their satisfaction with their healthcare, including their experience with their providers and health plan. The CAHPS survey scores are made available to the public and can determine whether patients and members stay with their provider or health plan or look elsewhere for their care. Surveys are sent to our member from February through June.
ANNUAL PROVIDER SATISFACTION SURVEY
You are essential to providing the highest-quality healthcare possible for our members, and your satisfaction is important to us, too. We assess your experience with the health plan through an annual Provider Satisfaction Survey. These survey results will be reviewed by QualChoice and will be key to helping us improve the provider experience, so please be sure to complete the survey if you receive one.
PROVIDER CREDENTIALING RIGHTS
During the credentialing process, QualChoice obtains information from various sources to evaluate your application. Ensuring the accuracy of this information is key, so please review and provide any corrected information as soon as possible. You also have the right to review the status of your credentialing or recredentialing application at any time by calling your health plan Provider Engagement Representative.
PROVIDER DIRECTORY & CONTINUED ACCESS TO CARE
If your address or telephone number changes, or if you can no longer accept new patients or are leaving the network, please notify QualChoice as soon as possible so we can update our Provider Directory. Having access to accurate provider information is vitally important to our members, and we want to work together to ensure continuity of care can be maintained for QualChoice members.
Utilization Management (UM) decisions are based only on the appropriateness of care and service and the existence of coverage.
QualChoice does not reward providers, practitioners or other individuals for issuing denials of coverage or care and does not have financial incentives in place that encourage decisions resulting in underutilization. Denials are based on lack of medical necessity or lack of covered benefit. National recognized criteria (such as InterQual or MCG) are used if available for the specific service request, without additional criteria (e.g., clinical/medical policies) developed internally through a process that includes a review of scientific evidence and input from relevant specialists.
Submitting complete clinical information with the initial request for a service or treatment will help us make appropriate and timely UM decisions. You may discuss any UM denial decisions with a physician or another appropriate reviewer at the time of notification of an adverse determination. You may also request UM criteria pertinent to a specific authorization request or for any other UM-related request or issue by contacting the UM department at the health plan.
TRANSITION TO OTHER CARE
Providing quality care to our members includes helping adolescents transition to an adult care provider. If you or one of your patients need assistance in finding an adult primary care provider or specialist, contact QualChoice or reference the information in the Provider Manual. We can assist in locating an in-network adult care provider or arranging care if needed.
The health plan formulary/Preferred Drug List (PDL) is based on the plan benefits and is updated on a regular basis. If you believe a medication merits an addition to the PDL, a request may be submitted using the Formulary Change Request form. The current PDL, which includes information regarding covered drugs, restrictions, prior authorization requirements, limitations, etc., is located on the health plan website.
ACCESS TO CASE MANAGEMENT
Our Care Management team is available for members who may benefit from increased coordination of services. The team is available to assist and support providers with member issues including non-adherence to medications/medical advice, multiple complex co-morbidities, or to offer guidance with a new diagnosis.
The care management team helps members:
- Achieve optimum health, functional capability and quality of life through improved management of their disease or condition.
- Determine and access available benefits and resources.
- Develop goals and coordinate with family, providers and community organizations to achieve these goals.
- Facilitate timely receipt of appropriate services in the right setting.
Early intervention is essential to maximizing treatment options and minimizing potential complications associated with illnesses, injury or chronic conditions. Members can receive services through face-to-face visits, over the phone or in a provider's office. You can directly refer members to the Care Management program at any time by calling the health plan or initiating a referral on the Provider Portal.
APPOINTMENT ACCESS STANDARDS
Every year QualChoice assesses appointment availability for PCPs, specialists and behavioral health practitioners. There are established standards for each type of appointment (routine care, urgent/sick visits, etc.) and type of practitioner. Please review the Provider Manual for the expectations of how quickly our members should be able to get an appointment.
MEMBER RIGHTS AND RESPONSIBILITIES
Providers are expected to follow member rights. Members are informed of their rights and responsibilities in their member handbook.
Member rights include, but are not limited to:
- Receiving all services the health plan provides.
- Being treated with dignity and respect.
- Knowing their medical records will be kept private, consistent with state and federal laws and health plan policies.
- Being able to see their medical records.
- Being able to receive information in a different format in compliance with the Americans with Disabilities Act.
Member responsibilities include:
- Understanding their health problems and telling their healthcare providers if they do not understand their treatment plan or what is expected of them.
- Keeping scheduled appointments and calling the physician's office whenever possible if there is a delay or cancellation.
- Showing their member ID card at appointments.
- Following the treatment plans and instructions for care that they have agreed on with their healthcare.
We encourage you to the Provider Manual to review the full list of rights and responsibilities.