Welcome to the QualChoice Health Insurance Provider Manual! This online manual contains operational information for physicians, hospitals and other health care 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
  • Products and Services
  • Mission Statement
  • Our Service Philosophy
  • Our Core Values
  • Commitment to Members & Providers
  • HIPAA and HITECH Compliance
  • Disclaimer

General Information
  • Main Office Location
  • Contact Us
  • Medical Directors
  • Where to Find Information
  • Member Eligibility/Verification
  • Provider Directory
  • Coverage and Pre-Authorization
  • Definitions
  • Helpful Reminders
  • Provider Support
  • Website Links
  • Provider Relations Representatives
  • Interactive Voice Response System (IVR)

Affordable Care Act (ACA)
  • ACA Grace Period for subsidized members
  • ACA Preventive Health Services

Claims Filing
  • Acceptable Claim Formats
  • Claims Submission Requirements
  • Electronic Claims Submission
  • Electronic Funds Transfers (EFT)
  • Electronic Remittance Advice (ERA)
  • Paper Claims Submission
  • Timely Filing
  • Claim Check Review
  • Clear Claims Connection
  • Claim Rejections or Delays
  • Corrected Claims

Additional Claims and Payment Information
  • Assignment of Benefits
  • Billing Practices
  • DME, Labs, and Cardiac Monitoring - Special Requirements
  • Cardiac Monitoring Services
  • Modifiers 25, 50, 57, 59, 91
  • Anesthesia Services Reporting Requirements
  • Subrogation
  • Workers' Compensation
  • Coordination of Benefits (COB)
  • Payments and Offsets
  • Payment Reconsideration and Appeals
  • Member Obligations

Mental Health Coverage

  • Pre-Authorization
  • Step/Contingent Therapy
  • Quantity Limits
  • Specialty Pharmacy Management
  • Appeals
  • New-to-Market Medications

Medical Management
  • Utilization Management
  • Pre-Authorization Requirements
  • Concurrent Review of Inpatient Admissions
  • Appeal Process for Medical Determinations and Expedited Appeals
  • Pre-Authorization List
  • Pre-Authorization Requirements for High Tech Radiology
  • Pre-Admission Review/Pre-Certification Requirements
  • Observation Beds
  • Postoperative Global Period (BI106)
  • Care Management and Referrals
  • Provision of Covered Medical Services
  • Out-of-Network Referrals (BI109)
  • Genetic/Genomic Testing Policies

  • Advanced Practice Nurses, Physician Assistants, Certified Nurse Midwives,
    and Clinical Nurse Specialists
  • Allergy Injections
  • Ambulance Services
  • Chiropractic Requirements
  • Hearing Aid Billing
  • Physical Therapy, Occupational Therapy and Speech Therapy
  • Sleep Studies
  • DME, Prosthesis/Orthotic Appliances, and Medical Supplies

Network Terms and Conditions
  • Credentialing and Participation Requirements
  • Confidentiality of Member Information
  • Medical Records and Confidentiality
  • Network Participation Guidelines
  • Utilization of Network Providers
  • Out-of-Network Referrals
  • Continuity of Care
  • Network Terms, Conditions and Credentialing Standards
  • 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