Introduction

Thank you for becoming a participating provider with QualChoice! Since the administration of healthcare can be complicated, we’ve designed this Provider Manual (hereinafter “Manual”) to be a resource for providers, containing coverage guidelines to the most common procedures and policies. Questions? Please email us at PR@qualchoice.com or contact us at 501.228.7111 or 800.235.7111 and ask to speak to a Provider Relations Representative.

About Us

Learn more about QualChoice.

Commitment to Members and Providers

QualChoice is dedicated to taking care of Arkansans, which means we have a personal commitment to taking care of our members, providers and clients. In addition to helping finance the high cost of illness, we work to promote enhanced member health by focusing on preventive health screenings that can lead to early diagnosis and treatment.

Whether protecting the privacy/security of members and providers, answering questions or processing claims quickly, we are committed to providing outstanding service. We value our provider network and work hard to give you the tools you need to better serve your patients. If you have any comments or suggestions about how we can better serve you, please email us at PR@qualchoice.com or call 501.228.7111 or 800.235.7111.

HIPAA and HITECH Compliance

As stated in the Provider Agreement, QualChoice is required to comply with various privacy and security standards under federal and state law, including, but not limited to the Health Insurance Portability and Accountability Act of 1996 (HIPAA), as modified or supplemented by the HITECH Act, implementing regulations and guidance (collectively, “the Standards”).

      • Standards for the Privacy of Individually Identifiable Health Information (45 CFR Parts 160 and 164, as amended) (hereinafter the “Privacy Rule”)
      • Standards for Electronic Transactions (45 CFR Parts 160 and 162) (hereinafter the “Transactions and Code Sets Rule”)
      • Security Standards for the Protection of Electronic Protected Health Information (45 CFR Parts 160 and 164) (hereinafter the “Security Rule”)

HIPAA and HITECH describe how QualChoice may collect, use and disclose our members’ Protected Health Information (PHI) and provide our members with rights (e.g., access, amendment, restriction, etc.) to their PHI. PHI refers to individually identifiable information, including demographic information, that (i) relates to the past, present or future physical or mental health or condition of an individual; the provision of healthcare to an individual, or the past, present or future payment for the provision of healthcare to an individual; (ii) identifies the individual (or for which there is a reasonable basis for believing that the information can be used to identify the individual).

Disclaimer

This Manual is a component of your QualChoice Provider Agreement and is meant to provide clarity and implementation guidance. In the event of a conflict or inconsistency between this Manual and your Agreement, the provisions of your Agreement will take precedence.

In the event of a conflict or inconsistency between state regulatory requirements and this Manual, the regulatory provisions will control, except when members’ benefit contracts fall outside the scope of those regulatory provisions.

QualChoice makes no representations or warranties with respect to the content hereof. Further, QualChoice reserves the right to revise this Manual without obligation on our part to notify any person or entity of such revision or changes. Revisions are effective immediately upon publication.

Updates to any part of this Manual may be made by QualChoice at any time. QualChoice may give notice of such updates in a variety of ways, depending on the nature of the update, including issuance of a letter to providers, publication in Quality Results Providers’ newsletter, Provider Quick Alert or other publications of QualChoice, or posting to the QualChoice web site, www.qualchoice.com.

This guide is not intended to provide legal advice on any matter and may not be relied on as a substitute for obtaining advice from a legal professional. Third party websites or materials mentioned throughout this Manual are maintained by organizations over which QualChoice has no control, and accordingly, QualChoice disclaims any responsibility for the content and accuracy of such information or the quality of such products or services, which are mentioned for informational purposes only. The products or services referred to may not be covered by all benefit plans, and providers should always review the member’s particular health benefit coverage document.

Any five-digit physician’s current procedural terminology (CPT) codes, descriptions, numeric modifiers, instructions, guidelines and other material are copyrighted by the American Medical Association. All Rights Reserved.

Note: This Manual is provided for the convenience of providers participating in any QualChoice network. Nothing in this Manual shall be interpreted as guaranteeing coverage of any service, treatment, drugs or supplies because coverage or non-coverage is always governed exclusively by the terms of the member’s health benefit coverage documents. Accordingly, in case of any question or doubt about coverage, providers should always review the member’s particular health benefit coverage document.

Unless otherwise indicated, any reference in this Manual to “company” or “us,” shall refer to QualChoice.

The QualChoice Network Provider Agreement and the Manual is between QCA Health Plan, Inc., and the Network Provider, a duly licensed provider in the state in which he/she practices. QualChoice Holdings, Inc. is the parent company of QCA Health Plan, Inc., and QualChoice Life and Health Insurance Company, Inc. (collectively “QualChoice”).

Other policies and procedures, not reflected in this Manual, are published regularly in our provider newsletter, Quality Results, in official plan documents or in other special publications, letters or notices, including but not limited to credentialing standards, appeals policies and procedures, network terms and conditions and Provider Agreements. To ensure you have the most current information, please visit QualChoice.com or contact us Monday through Friday, 8:00 a.m. to 5:00 p.m., at 501.228.7111 or 800.235.7111 and ask to speak to a Provider Services Representative.

Main Office Location

12615 Chenal Pkwy., Suite 300
Little Rock, Arkansas 72211

Contact Us

We are always available to help you serve your patients! Our hours are Monday-Friday, 8:00 a.m. to 5:00 p.m. Please feel free to contact us.

Provider Relations

      • Phone: 228.7111, ext. 7004
      • Toll Free: 235.7111, ext. 7004
      • Fax: 228.0135
      • PR@QualChoice.com

Customer Service

For questions regarding benefits, eligibility, pre-authorization, claim status, appeal status or payment dispute:
800.235.7111 or 501.228.7111

Provider Network Services

For provider credentialing, contracts, fee schedules, IPA/PHO updates or provider information changes/updates:
PR@qualchoice.com
Fax:  501.707.6811

Provider Network Operations

For 835, EFT, EDI or provider password information:
BU_PR@qualchoice.com
Fax:  501.707.6815

QualChoice observes the following holidays: New Year’s Day, Martin Luther King Day, Memorial Day, Fourth of July, Labor Day, Thanksgiving and the Friday following, as well as Christmas Day. Our offices are closed on these dates. After-hours voice mail is available. Information can be faxed 24 hours a day to 501.228.9413 or 800.228.9413.

Correspondence

QualChoice
P. O. Box 25610
Little Rock, AR 72221

Deliveries

QualChoice
12615 Chenal Parkway, Suite 300
Little Rock, AR 72211