New for 2017: Members of Individual Plans Must Have PCP

Beginning January 1, 2017, QualChoice individual metallic plan (Bronze, Silver, Gold, Platinum and Catastrophic)
members, as well as those with insurance through HealthCare.gov or Arkansas Works, will be in the Select network and will be required to choose a PCP. These members will have a unique QualChoice ID card to help you identify them: 

IQChoice New Member ID Card   QualChoice New Member ID Card   QC Life and Health New Member ID Card

Members who do not choose a provider will be assigned one. Rosters of newly assigned members will be available
through My Account* under the Provider Reports tab.

Specialists: When filing claims for these members you must submit the referring PCP’s name and NPI # when billing
for services with Place of Service (POS) codes 11, 12, 17, 19, 22 and 24. Referring PCP name and NPI # are NOT
required for POS codes 20, 21, 23, 51, 52 and 81.

Specialist Claim Filing for Individual Metallic Plan Members

POS Codes: 11, 12, 17, 19, 22, 24

Must submit referring PCP name and NPI #

POS Codes: 20, 21, 23, 51, 52, 81

Not required to submit referring PCP name and NPI #

 

*To register for the My Account provider portal, visit Using My Account and view the step-by-step video. 

Frequently Asked Questions

The following physician types will be considered PCPs:
  • Pediatricians
  • Family or General Practice physicians
  • Internal Medicine physicians
  • Geriatric physicians
QualChoice individual metallic plan (Bronze, Silver, Gold, Platinum and Catastrophic) members will be in the Select network and will be required to choose a PCP. These members will have a unique QualChoice card to help you identify them.
PCPs: You need to confirm you are the designated PCP for each member. You will be responsible for coordinating all healthcare services to other network providers. All covered services received from the designated network PCP will be covered based on the member’s benefits plan. Services received from a participating non-designated PCP will not be covered (unless the servicing provider is located in the same clinic as the designated network PCP), and claims will be denied as provider liability.
Rosters of newly assigned members will be available through My Account under the Provider Reports tab.
Members are encouraged to pick a PCP from our Select network. If the member does not select one, a PCP will be assigned based on:
  • The PCP the member visits most frequently
  • The member's home address if the member has not visited a PCP
  • Members will not be assigned to a PCP practicing at an urgent care clinic
If you see a member who wasn’t assigned to you:
  • You will be liable for services because they were not rendered by the designated PCP or a PCP provider type in the same clinic.
  • EOB Code IMP - Services not rendered by designated PCP, service not covered. (Provider Liability)
  • Members who seek outpatient services by non-participating providers but do not obtain pre-authorization will be denied as the member’s responsibility.
The member’s designated PCP can be located when checking member eligibility at QualChoice.com.
If you perform services without Designated PCP Name/NPI#:
  • You will be liable for services submitted without the designated PCP name/NPI#.
  • EOB Code IMS - Designated Referring PCP not on claim, service not covered. (Provider Liability).
  • Members do not need referral from their designated PCP for:
    • Obstetrical or gynecological treatment from a network obstetrician or gynecologist
    • Emergency services and care ordered by an emergency room doctor
    • Family planning and maternity services
    • Ancillary services
  • Members who seek outpatient services by non-participating providers but do not obtain pre-authorization will be denied as the member’s responsibility.
You can stop getting new primary care patients assigned to you by closing your practice to new patients. In order to close your practice, you must submit a Provider/Practice Change Form located at QualChoice.com (located under the Provider Forms section).
  • A member may change their PCP by:
  • Going through My Account online
  • Calling Enrollment
  • Submitting a PCP change form via mail, email or fax to Enrollment — the form is available online
Note:
  • Change forms received on or before the 25th of a month will become effective the 1st day of the following month. For example, a form received on April 24th will become effective on May 1st.
  • Change forms received after the 25th of the month will become effective on the 1st day of second following month. For example, a form received on April 27th will become effective on June 1st.
Members are allowed to change their PCP 11 times within a year; however, Care Management will review utilization if a member changes three or more times within a year.