The information below applies to members enrolled in QualChoice individual Affordable Care Act-compliant plans. See your Certificate of Coverage for additional information.
Using an Out-of-Network Provider
A doctor or other health expert who is not in your network is called an out-of-network provider. Your benefits will be paid at a lower rate or not covered if you seek care from an out-of-network provider. Your in-network doctor must get our approval before you are seen by an out-of-network provider.
Coverage for out-of-network care is based on a Maximum Allowable Charge. You must pay your cost share amount plus the difference between the charges billed and the Maximum Allowable amount if the provider bills more than the allowed charge. This is called balance billing.
Check your Benefit Summary and Certificate of Coverage (COC) for details.
Submitting a Claim
There is no paperwork when you get service from an in-network provider for most covered care. Just show your QualChoice ID card and pay your cost share. Your provider will send the claim to us and we will pay the provider.
If you get out-of-network care, you or the provider must file a Medical Claim Form. Send it to:
ATTN: Claims Processing
P.O. Box 25610
Little Rock, AR 72221
Customer Service 501.228.7111
You should send your claim(s) within 60 days of the date of service. We must receive it within one year of the date of service for it to be reviewed for payment. You will get an Explanation of Benefits (EOB) by mail showing what you must pay and what was covered by your plan.
If you receive an advanced premium tax credit (APTC), and you have paid at least one full month’s premium there is a 3- month grace period:
- For the first month of non-payment, QualChoice will still pay your claims.
- For the second and third months of non-payment, your policy will continue, but your account will be put on claims hold. This means we will not pay your claims until we receive payment.
- If you have not made full payment by the end of the third month, your policy will be cancelled as of the last day of the first month of the grace period.
- If we cancel your policy because of nonpayment of premiums, you may not reapply until the next Open Enrollment Period (OEP) unless you qualify for a Special Enrollment Period (SEP). (If you have a qualifying event.)
Any payments we make for services received by you or your dependent(s) after the policy is cancelled must be returned to us within 60 days. As stated by the law, we may reduce future payments to you or your dependent(s) to get back any such payments. We may recoup payments made to providers from them. If you do not pay within the grace period(s) your policy will be canceled for all members. If we receive payments after the policy is cancelled, you will be refunded within thirty 30 days or in the next scheduled billing cycle.
A retroactive denial means that an already-paid claim has been reversed. You must now make payment. Reasons for this may be:
- Non-payment of premiums
- Giving false information
- Committing health insurance fraud
Member Refund for Overpayment
If you think you have been overbilled on your premium, contact:
QualChoice Finance Department
501.228.7111, ext. 7023
Some care may need to be reviewed for medical necessity. This means a service that:
- Diagnoses or treats a member’s covered health issue;
- Is needed to find, treat or avoid a certain illness, injury or medical state;
- Meets the standards of good and broadly accepted medical practice for the illness, injuries and health issues present;
- Is not mainly for the convenience of the member, his or her family, doctor, or other health expert; and,
- Is the most helpful, safe, and cost-efficient service or supply for the member’s illness, injury or medical/health issue(s).
Some care may call for pre-authorization and must be performed within a certain time span. If a service requires pre-authorization
and a pre-authorization is not received, claims for that service will be denied.
Services requiring pre-authorization.
Pre-authorization (pre-approval) is the process of deciding whether a service is medically necessary before it is performed. In-network doctors are required to obtain all necessary pre-authorizations. If you see an out-of-network provider, you are responsible for obtaining all necessary pre-authorization. If you don’t, your claim will be denied and you will be responsible for the full cost. Pre-authorized care must be performed within a certain time span. Medical pre-authorization requires not less than 2 business days. Pharmacy pre-authorization requires not less than 72 hours.
Services requiring pre-authorization.
Learn more about your Member Rights and Responsibilities.
Non-Formulary Prescription Drugs
You may ask for coverage for a non-formulary (non-covered) prescription drug. Your doctor or someone you name may also make the request on your behalf. Call 877.629.3118 or fax the completed Formulary Override Exceptions Pre-authorization (OptumRx) form to 888.852.1832. If the request is denied, you may ask for a second review by an outside reviewer. Call 501.219.5126 or fax the completed Formulary Override Exceptions Request for External Review to 501.707. 6844.
A standard request will be processed within 72 hours and an expedited request within 24 hours. An expedited request is made when a health care expert who knows of your health issue states that your life or health would be in danger or you may not get back complete health without the requested drug.
Explanation of Benefits (EOB)
An Explanation of Benefits (EOB) is a statement telling what medical care and/or services were paid on your behalf, what we paid, and what you must pay. You will receive your EOB after we process claims for the services you have received. It will include:
- Amount You Pay: This is your share of the cost for the services shown.
- Copayment: A fixed fee based on your benefit plan that may be required for office visits, outpatient care, or inpatient stays.
- Annual deductible: The deductible is the amount you have to pay each year before we start paying your claims. The EOB will show how much you have spent toward your deductible.
- Coinsurance: A percent of the approved charges, after deductible has been met. The amount is based on your benefit plan.
- Charges for services and/or supplies that are not covered by your plan. You may not have to pay for certain denied services. If so, that will be shown in the Notes section.
- The difference between the billed amount and the amount paid by your benefit plan to an out-of-network health expert.
Coordination of Benefits (COB)
You may have coverage under more than one health policy. Coordination of Benefits (COB) prevents duplicate payments for services. The COB states the order in which each health plan will pay a claim for benefits. The plan that pays first is called the primary policy and must pay benefits according to its policy terms. The plan that pays after the primary policy is the secondary policy. The secondary policy may cut the benefits it pays so that payments from all plans do not exceed 100% of the COB Allowable Expense.