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

General Information
  • Interactive Voice Response System (IVR)
  • My Account
  • Definitions
  • Helpful Reminders
  • Quick Links
  • Medical and Regulatory Resources

Products and Services


Affordable Care Act (ACA)
  • ACA Preventive Health Services
  • ACA Grace Period for Marketplace Subsidized Members

Member/Patient Information
  • Member Cooperation Affects Reimbursement
  • Member Eligibility and Verification
  • Member Financial Obligations
  • Member Responsibility for Non-covered Services
  • Member Fraud or Misrepresentation

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

Claims and Payment Information
  • Billing Practices
  • Claim and Payment Integrity Audits
  • DRG Validation
  • Hospital Bill Audits
  • Reimbursement Guidelines
  • Hospital Acquired Conditions
  • 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
  • Urgent Care Billing
  • Clinic Visits Billed by a Facility
  • Treatment Room Services Billed by a Facility

Modifiers
  • Modifiers
  • Modifier 22 – Unusual procedural services
  • Modifier 25 – Significant, separately identifiable evaluation and management service by the same physician on the day of a procedure or other service
  • Modifier 26 – Professional component
  • Modifier TC – Technical component
  • Modifier 33 – Preventive health service or a diagnostic test for treatment or monitoring of a health condition
  • 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 procedure prior to anesthesia administration
  • Modifier 74 – Discontinued outpatient procedure prior to anesthesia administration
  • Modifier 76 – Repeat procedure by same physician
  • Modifier 78 – Return to the operating room for a related procedure during post-operative period
  • Modifier 80 – Assistant surgeon
  • Modifier 81 – Minimum assistant surgeon
  • Modifier 82 – Assistant surgeon when qualified resident surgeon is not available
  • Modifier 91 – Repeat clinical diagnostic laboratory test
  • Modifier XE – Separate encounter
  • Modifier XP – Separate practitioner
  • Modifier XS – Separate structure
  • Modifier XU – Unusual non-overlapping service

Special CPT
® Coding
  • Allergy Immunotherapy
  • Anesthesia Services Reporting Requirements
  • Bone Mineral Density Test Billing
  • Chiropractic Care
  • Clinical Trial Coverage Billing
  • 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
  • Vision Exam/Refraction Services

Mental Health Coverage
  • Autism Spectrum Disorder Treatment
  • Applied Behavior Analysis Treatment of Autism
  • Eating Disorders
  • Hypnotherapy
  • Mental Health and Substance Use Disorder – Outpatient
  • Residential Treatment for Mental Health & Substance Use Disorders
  • Residential Facilities
  • Billing for Psychotherapy Services
  • Definitions for Levels of Care

Pharmacy
  • Pre-Authorization (PA)
  • Step/Contingent Therapy
  • Quantity Limits
  • Specialty Pharmacy Management
  • Appeals
  • New-to-Market Medications
  • Formularies, Forms and Information

Medical Management
  • Appeal Process for Medical Determinations and Expedited Appeals
  • Coverage
  • Pre-authorization
  • Pre-authorization Requirements
  • Pre-authorization List
  • Pre-authorization for Genetic/Genomic Testing
  • Pre-authorization Requirements for High Tech Radiology
  • No Out-of-State Coverage for Individual Metallic Members
  • Pre-notification, Pre-authorization and Eligibility Requirements
  • Postoperative Global Period
  • Care Management and Referrals
  • Utilization Management
  • Medical Policies

Hospital and Inpatient Information
  • Inpatient Admissions Concurrent Review
  • Inpatient Pre-admission Review
  • Inpatient Pre-certification Requirements
  • Observation Services
  • Hospital Inpatient Readmissions

Miscellaneous
  • Advanced Practice Nurses, Physician Assistants, Certified Nurse Midwives,
    and Clinical Nurse Specialists
  • Allergy Injections
  • Ambulance Services
  • Chiropractic
  • Cardiac Monitoring, Durable Medical Equipment (DME) and Laboratory Services
  • Hearing Aid Billing
  • Flu Immunizations
  • Physical, Occupational and Speech Therapy
  • Sleep Studies 

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
  • PCP Changes Made by Members
  • 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

Comprehensive Primary Care Plus (CPC+)


Network Terms and Conditions
  • PCP Requirement
  • Credentialing and Participation Requirements
  • Confidentiality of Member Information
  • Medical Records and Confidentiality
  • Network Participation Guidelines
  • 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