Provider Manual

Welcome to the QualChoice Health Insurance Provider Manual! This online manual contains operational information for physicians, hospitals and other healthcare providers who participate in the QualChoice network. Our goal is to make it easy for you to work with us. We will modify this manual periodically to keep you up-to-date.

Click on the section title to review the topics listed for that section.

This Manual and any other written materials provided by QualChoice Health Insurance are proprietary and confidential. If there is a conflict between the Manual and the Provider Agreement, the Provider Agreement supersedes.

Title & Description
About QualChoice Introduction About Us Commitment to Members and Providers HIPAA and HITECH Compliance Disclaimer Main Office Location Contact Us Last revised January 22, 2025
General Information Interactive Voice Response System (IVR) My Account Definitions Helpful Reminders Quick Links Medical and Regulatory Resources Last revised June 1, 2021
Products and Services Last revised January 1, 2021
Affordable Care Act (ACA) ACA Preventive Health Services Last revised April 30, 2021
Member/Patient Information Member Cooperation Affects Reimbursement Member Eligibility and Verification Member Financial Obligations Member Responsibility for Non-covered Services Member Fraud or Misrepresentation Member Rights and Responsibilities Last revised July 15, 2021
Claims Filing Acceptable Claim Formats Assignment of Benefits Coordination of Benefits (COB) Corrected Claims Corrected Claims Guidelines Electronic Claims Submission Paper Claims Submission Splitting Claims Timely Filing Using the Correct Request Form When to File a Claim NDC Numbers Required for Drug Reimbursement Claims Last revised January 1, 2021
Claims and Payment Information Add-on Codes Billing Practices Claim and Payment Integrity Audits DRG Validation Hospital Bill Audits Reimbursement Guidelines Hospital Acquired Conditions Emergency Department Coding and Reviewing ClaimsXten™ Review Clear Claim Connection™ Claims for Worker's Compensation Claim Rejections or Delays Complete/Clean Claims Electronic Funds Transfer/Electronic Remittance Advice Payments and Offsets Payment Reconsideration and Appeals Subrogation Global Surgical Packages Billing Multiple Radiology Services Urgent Care Billing Clinic Visits Billed by a Facility Treatment Room Services Billed by a Facility Last revised June 1, 2021
Modifiers Modifiers Modifier 22 – Increased procedural services Modifier 25 – Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service Modifier 26 – Professional component Modifier TC – Technical component Modifier 33 – Preventive services Modifier 50 – Bilateral procedure Modifier 51 – Multiple procedures Modifier 52 – Reduced services Modifier 53 – Discontinued procedure Modifier 54 – Surgical care only Modifier 55 – Postoperative management only Modifier 56 – Preoperative management only Modifier 57 – Decision for surgery Modifier 59 – Distinct procedural service Modifier 62 – Two Surgeons Modifier 73 – Discontinued outpatient hospital/ambulatory surgery center (ASC) procedure prior to the administration of anesthesia Modifier 74 – Discontinued outpatient hospital/ambulatory surgery center (ASC) procedure after administration of anesthesia Modifier 76 – Repeat procedure or service by same physician or other qualified health care professional Modifier 78 – Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period Modifier 80 – Assistant surgeon Modifier 81 – Minimum assistant surgeon Modifier 82 – Assistant surgeon when qualified resident surgeon is not available Modifier 90 – Reference (outside) laboratory Modifier 91 – Repeat clinical diagnostic laboratory test Modifier 95 – Synchronous telemedicine service Modifier XE – Separate encounter, a service that is distinct because it occurred during a separate encounter Modifier XP – Separate practitioner, a service that is distinct because it was performed by a different practitioner Modifier XS – Separate structure, a service that is distinct because it was performed on a separate organ/structure Modifier XU – Unusual nonoverlapping service, the use of a service that is distinct because it does not overlap usual components of the main service Last revised July 1, 2021
Special CPT^® Coding Allergy Immunotherapy Anesthesia Services Reporting Requirements Bone Mineral Density Test Billing Care Plan Oversight Services Chiropractic Care Clinical Trial Coverage Billing Consultation Codes Diabetes Management Training Flu Vaccination Billing Hemodialysis Services Billing Immunization Coverage Infusion Codes Intraoperative Neurophysiologic Monitoring Mammography or Breast Digital Tomosynthesis (3D digital mammogram) Nutritional Counseling in Chronic Disease Prenatal and Delivery Services Billing Preventive Health Benefit Routine and Complex Office Procedures Smoking and Tobacco Cessation Telemedicine Payment Policy Transitional Care Management Services Vision Exam/Refraction Services Last revised July 15, 2021
Mental Health Coverage Eating Disorders Mental Health and Substance Use Disorder – Outpatient Residential Facilities Last revised January 22, 2025
Pharmacy Pre-Authorization (PA) Step/Contingent Therapy Quantity Limits Specialty Pharmacy Management Appeals New-to-Market Medications Formularies, Forms and Information Last revised January 8, 2025
Medical Management Appeal Process for Medical Determinations and Expedited Appeals Coverage Definitions for Levels of Care Pre-authorization Pre-authorization Exemption Pre-authorization Requirements Pre-authorization List Pre-authorization for Genetic/Genomic Testing Pre-authorization Requirements for High Tech Radiology Pre-notification, Pre-authorization and Eligibility Requirements Postoperative Global Period Care Management and Referrals Utilization Management Medical Policies Last revised January 22, 2025
Hospital and Inpatient Information Inpatient Admissions Concurrent Review Inpatient Pre-admission Review Inpatient Pre-certification Requirements Observation Services Hospital Inpatient Readmissions Quality Improvement Last revised July 15, 2021
Miscellaneous Advanced Practice Nurses, Physician Assistants, Certified Nurse Midwives, and Clinical Nurse Specialists Allergy Injections Ambulance Services Autism Spectrum Disorder Treatment Billing for Psychotherapy Services Cardiac Monitoring, Durable Medical Equipment (DME) and Laboratory Services Durable Medical Equipment (DME), Prosthetic/Orthotic Appliances and Medical Supplies Hearing Aid Billing Hypnotherapy Flu Immunizations Physical, Occupational and Speech Therapy Residential Treatment for Mental Health & Substance Use Disorders Sleep Studies Last revised January 22, 2025
Provider/Practice Information and QualChoice Procedures Adding a Provider to an Existing Practice Provider Changes and Updates Provider Directory Opening and Closing to New Patients Out-of-Network Referrals QualChoice Medical Directors Provider Relations Representative QualChoice.com Provider Log-In Quality Results Provider Newsletter and Quick Alerts Healthcare Fraud Treating Your Family Member or Yourself Non-Discrimination/Language Help Quick Links Last revised January 1, 2021
Network Terms and Conditions Credentialing and Participation Requirements Practitioner Right to Review and Correct Information Practitioner Right to Be Informed of Application Status Confidentiality of Member Information Medical Records and Confidentiality Network Participation Guidelines Network Terms, Conditions, and Credentialing Standards Non-Discrimination and Availability of Services Appointment Availability and Wait Times Utilization of Network Providers Continuity of Care Plan for Cessation of Services No Member Billing: Exceptions Notification of Changes in Status and Legal Actions Policies and Procedures & Terms and Conditions Provider Subcontracting Dispute Resolution and Arbitration — Administrative and Professional Professional Dispute Resolution Provision of Covered Medical Services Last revised July 15, 2021

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Provider Manual