QualChoice is committed to excellence and quality in our products and services. To demonstrate that commitment, we are audited and accredited by leading independent organizations who work to improve quality through review and reporting.
NCQA—The National Committee for Quality Assurance (NCQA) is a nonprofit organization dedicated to improving healthcare quality. The NCQA seal is a widely recognized symbol of quality. Organizations displaying the seal must pass a rigorous review and report on their performance each year. Their Healthcare Effectiveness Data and Information Set (HEDIS) standards ensure that purchasers and consumers have the information they need to compare healthcare quality.
QCA Health Plan, Inc. (QCA) and QualChoice Life and Health Insurance Company, Inc. (QCLH) currently hold NCQA Interim Health Plan Accreditation. The accreditation includes Commercial-HMO and Exchange-HMO (QCA) as well as Exchange-PPO (QCLH) product lines. The interim accreditation is effective as of April 24, 2020 and expires on October 24, 2021.
We empower our members to take an active role in their care and the care of their families. We urge them to ask questions, understand conditions and treatments and evaluate options. We assist members in:
Provider Network—We know that improving healthcare quality is a team effort. That’s why our network includes some of the best doctors and hospitals in the state. We review Primary Care Provider (PCP) medical records periodically for compliance with standard medical record-keeping, documentation and standard medical practices.
Pharmacy Network—Prescriptions filled by QualChoice members at Magellan-participating pharmacies are screened for safety and appropriateness. Factors considered include: drug-age conflict, drug-drug interaction, drug-pregnancy conflict, drug-disease conflict, late refill, refill too soon, therapeutic duplication, low daily dose, excessive use and high daily dose.
Organizational Collaboration—QualChoice collaborates with national organizations aimed at increasing patient safety, including:
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.
Being a member means there are things you should expect from your health plan. These are some of your rights:
It’s also important to know what you can do to get the most from your coverage:
The full list of rights and responsibilities is in your Member Handbook.
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.
MAKING APPOINTMENTS
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:
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.
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:
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:
As a valued practitioner, 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.
The Consumer Assessment of Healthcare Providers and Systems Survey (CAHPS), the Qualified Health Plan Enrollee Experience Survey (QHPEES), and the Outpatient Mental Health Survey (OPMH) offers your patients and opportunity to report their satisfaction with their healthcare, including their experience with their practitioners, providers and the health plan. The survey results are used to determine whether patients and members are happy with their experience and likely to stay with their practitioner, provider or health plan or if there are opportunities to improve their care and satisfaction with their health care.
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. Your feedback informs improvement opportunities and quality initiatives.
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. Please review your provider manual regarding this correction process. You also have the right to review the status of your credentialing or re-credentialing application at any time by calling your health plan Provider Engagement Representative.
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. Nationally 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.
Clinical decision-making criteria are available to you electronically at the point of care through EHR, the Provider Portal and on the Website.
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 benefits of the plan 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.
Health equity is the state in which everyone has a fair and just opportunity to attain their highest level of health. Achieving this requires ongoing societal efforts to:
To achieve health equity, we must change the systems and policies that have resulted in the generational injustices that give rise to racial and ethnic health disparities. For more information about Culturally and Linguistically Appropriate Services (CLAS) Standards, see https://thinkculturalhealth.hhs.gov/clas.
Together, we must make language assistance services available to people with Limited English Proficiency (LEP) at all points of contact during all hours of operation and at no cost to our members. We are here to help get language assistance to QualChoice members and providers without unreasonable delay at all vital points of contact. You can schedule language services, including telephone and face-to-face interpretation for non-English languages and American Sign Language, by calling our Provider Customer Contact Center or by calling the toll-free number on the back of our member’s ID card. Additional resources are found on the website.
The health plan encourages our providers to engage in Cultural Humility trainings and education to promote positive interaction with diverse cultures. For more information about the Cultural and Linguistic Competency e-Learning Program from the Office of Minority Health (OMH), see https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=1&lvlid=6. This program is designed to build knowledge, skills, and awareness of cultural and linguistic competency and CLAS as a way to improve quality of care.
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:
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.
Every year QualChoice assesses appointment accessibility with 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.
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:
Member responsibilities include:
We encourage you to reference the Provider Manual to review the full list of rights and responsibilities.