4/18/2024

Provider Manual

General Information

Interactive Voice Response System (IVR)

24/7 Access to Benefit & Claim Information
Verify benefits, check claim status or the existence of an authorization. To access, you will need:

  • 11-digit QualChoice provider ID number
  • Member's QualChoice ID number 

 To check claim status, you will also need:

  • The date of service formatted as a six-digit number (for example July 5, 2013 would be 070513). More than one date of service or claim may be checked in a session.

When using the IVR system, always listen to the prompts, as menu items may change. For questions or assistance with your ID number, contact Provider Network Operations at 501.228.7111 or 800.235.7111, ext. 7011.

My Account

 Our provider account pages now have a cleaner, simpler interface. They’re also faster and more secure. And they’re mobile-friendly, so you can manage your account on the go!

  • Check member eligibility and benefits
  • Search and view claims and RAs
  • Search and view referrals and pre-authorizations
  • Generate useful reports

Learn how to manage My Account.

Existing Users

When you sign in, you’ll be asked to update your account and select a new password (your username will not change).

New Users

Registration is required to access My Account provider pages. Call us at 501.228.7111 or 800.235.7111, ext. 7011 if you do not have an authorized user name and password.

A Portal Administrator (PA) must be designated for each practice or group via the Provider Portal Administrator Designation Form. Complete a form for each administrator needed.

Only a PA may assign access to other users in the group, by filling out a Provider Portal Access Form for each user.

Once your account has been created, we will contact you with further instructions.

Portal Designation and User Access Forms

Need Help?
For more information, contact the QualChoice Business Services Department: 501.228.7111 or 800.235.7111 ext. 7011.

Definitions

These definitions are for general reference. In the event of a conflict, the provisions of your Provider Agreement or member health plan or policy takes precedence.

  • AFFILIATE means a person or entity directly or indirectly controlling, controlled by or under common control with NovaSys.
  • ATTACHMENT means any document, including an addendum, schedule or exhibit, attached to the agreement as of the effective date.
  • ALLOWED CHARGES or ALLOWANCE means the fee per service agreed upon in a contractual arrangement between QualChoice and a participating provider, the usual amount charged by the participating provider, whichever is less (referred to in Benefit Certificates as the Maximum Allowable Charge). See your Provider Agreement for complete details.
  • BENEFIT CERTIFICATE is the document QualChoice provides to members defining the scope of covered services for their plan and the terms, conditions, limitations or exclusions that apply to that coverage; also referred to as Evidence of Coverage (EOC), Certificate of Coverage (COC) or Summary Plan Description (SPD).
  • BRAND-NAME MEDICATION means any prescription medication that has a patented trade name separate from its generic or chemical designation.
  • CASE MANAGEMENT is a program under which nurses or care managers are employed or contracted by QualChoice or other payer to communicate with members and/or providers, facilitating access to benefits under the members’ health plan. The nurses identify benefit options for outpatient or home treatment settings and, where appropriate, with the physician’s independent professional judgement, identify and offer members a choice of cost-effective health plan coverage alternatives to hospitalization. QualChoice case management nurses are licensed professionals who use their specialized skills to communicate effectively with physicians about member benefits and coverage options. They do not provide any medical or psychological services to members. All treatment decisions remain exclusively with the member and his/her physicians.
  • CLEAN CLAIM has, as to each particular Product, the meaning set forth in the applicable Product Attachment or, if no such definition exists, the Provider Manual.
  • COINSURANCE is a fixed percentage of the Allowed Charges, if any, of Covered Medical Services; required to be paid by a member under a Benefit Certificate.
  • COMPANY means, as appropriate in the context, NovaSys and/or one or more of its Affiliates, except those specifically excluded by NovaSys.
  • CONTRACT YEAR means the twelve-consecutive-month period commencing on the contract effective date and renewing on each anniversary of that effective date.
  • COPAYMENT is a fixed dollar amount representing a portion of the Allowed Charge, if any, of Covered Medical Services required to be paid by a member under a Benefit Certificate.
  • COVERED MEDICAL SERVICES means a service or supply provided to a member by a licensed physician, hospital, facility or other designated provider that meets the QualChoice definition of medically necessary and is a covered benefit under the applicable Benefit Certificate as determined by QualChoice or other payer.
  • DEDUCTIBLE is a fixed dollar amount representing a portion of the Allowed Charges, if any, of Covered Medical Services required to be paid by a member prior to payment for such services by a Benefit Certificate.
  • DRUG FORMULARY is a comprehensive list of preferred generic and brand-name drugs which have been evaluated for safety and efficacy by our Pharmacy and Therapeutics (P&T) Committee, made up of physicians and pharmacists in community practice. Drug Formularies are subject to change at the discretion of QualChoice or other payers.
  • EMERGENCY CARE means healthcare services to evaluate and treat medical conditions of recent onset and severity, including but not limited to, severe pain that would lead a prudent layperson with an average knowledge of medicine and health to believe that his/her condition, sickness or injury is such that failure to get immediate medical care could result in placing the patient’s health in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part. The QualChoice Medical Director or designee shall determine whether emergency services were required, subject to appeal, under the applicable member appeals procedure.
  • GENERIC MEDICATION means any chemically equivalent reproduction of a brand-name medication whose patent has expired.
  • GROUP CONTRACT is the contract between a QualChoice or insurance policy payer and an employer, which sets forth terms of enrollment, membership, payment, coverage, terms, conditions, limitations and exclusions under which a group may obtain a health benefits coverage for its members under a defined Benefit Certificate.
  • HOSPITAL means an acute general care hospital, psychiatric hospital or rehabilitation hospital licensed as such by the appropriate state agency. It does not include any of the following, unless required by applicable law or approved by the Board of Directors of the company: hospitals owned or operated by state or federal agencies, convalescent homes or hospitals, homes for the aged, sanitariums, long-term care facilities, infirmaries or any institution operated mainly for treatment of long-term chronic disease. For complete details, see the member’s applicable Benefit Certificate.
  • INPATIENT STATUS is defined as a hospital stay greater than 24 hours or greater than 12 hours plus an overnight stay while receiving medically necessary treatment — unless the stay is related to uncomplicated ambulatory surgery.
  • MAINTENANCE CARE is treatment to promote optimal function in the absence of significant symptoms, or to maintain a current level of function where significant improvement is not expected. Such care is not considered medically necessary and is not covered.
  • MAXIMUM OUT-OF-POCKET limit includes annual deductible, coinsurance, medical and prescription drug copayment. Out-of-Pocket limits are generally based on calendar year. If a member sees an out-of-network provider without approval, the lack of a contractual relationship means balance billing is possible (which is not subject to and may far exceed maximum out-of-pocket limits).
  • MEDICAL DIRECTOR is a trained and licensed medical doctor who works for QualChoice to review medical issues and to contribute to our coverage policies. A Medical Director does not practice medicine or give any medical advice or counseling.
  • MEDICALLY NECESSARY means a Covered Medical Service that meets the following criteria:
    1. Provides for the diagnosis or treatment of the member’s covered medical conditions;
    2. Is consistent with and necessary for the diagnosis, treatment or avoidance of the member’s specific illness, injury or medical condition in relation to any overall medical/health conditions (i.e., evidence must show that the service or intervention will make a difference in outcome for the member; if there is no evidence that a service or intervention will improve [or prevent the worsening of] an member’s condition, then, by definition, the service or intervention is not medically necessary);
    3. Meets the standards of good and generally accepted medical practice, as reflected by scientific and peer reviewed medical literature or credible specialty society guidelines that have met the Institute of Medicine and American Medical Association standards to avoid conflicts of interest, for the specific and overall illness, injuries, and medical conditions present;
    4. Is not primarily for the convenience of the member, his or her family, his or her physician, or other provider; and
    5. Is the most effective, safe and cost-efficient level of service or supply appropriate for the member’s illness, injury, or medical/health condition(s).

Note: Diagnostic and therapeutic interventions for rare or new diseases or diseases that only affect remote populations may not have had clinical trials conducted that would enable the interventions to become generally accepted as noted in 3 above. Such interventions may be considered Medically Necessary IF:

    1. The intervention meets all other aspects of the definition of Medically Necessary;
    2. There is, in the opinion of our medical personnel, adequate scientific basis for believing that the intervention will be effective; and
    3. The intervention is not the subject of an ongoing phase I, II, III, or IV trial, or otherwise under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with a standard means of intervention.
  • MEMBER means a subscriber or such subscriber’s dependent entitled to Covered Medical Services under a Benefit Certificate.
  • OUTPATIENT is defined as use of ambulatory or ancillary services for diagnosis and treatment of Covered Medical Services.
  • PARTICIPATING IN-NETWORK HOSPITAL is a hospital that has contractually executed a Provider Agreement with QualChoice to provide comprehensive hospital services for QualChoice members. Refer to our Provider Directory for names of participating hospitals, physicians and providers. See your Provider Agreement for complete definitions and details.
  • PARTICIPATING IN-NETWORK PHARMACY is a licensed pharmacy contracted with the QualChoice or payer designated Pharmacy Benefits Manager (PBM) to provide pharmacy services to members as provided in the Benefit Certificate.
  • PARTICIPATING IN-NETWORK PHYSICIAN means a licensed doctor of medicine or osteopathy, who has a contractually executed Provider Agreement with QualChoice to provide or arrange to provide for the provision of healthcare services to our members. Refer to our Provider Directory for names of participating hospitals, physicians and providers. See your Provider Agreement for complete definitions and details.
  • PARTICIPATING IN-NETWORK PROVIDER means a healthcare provider (including durable medical equipment (DME), home health, etc.) who has contractually executed a Provider Agreement contracted with QualChoice to provide or arrange for the provision of healthcare services to our members. Refer to our Provider Directory for names of participating hospitals, physicians and providers. See your Provider Agreement for complete definitions and details.
  • PHYSICIAN means a Doctor of Medicine (M.D.) or a Doctor of Osteopathy (D.O.) licensed and qualified to practice medicine and perform surgery at the time and place a claimed service is performed. Physician also means a Doctor of Podiatry (D.P.M.), a Chiropractor (D.C.), a Psychologist (Ph.D.), an Oral Surgeon (D.D.S.) or an Optometrist (O.D.) licensed and qualified to perform the claimed health services at the time and place they are performed.
  • PRE-AUTHORIZATION is the process of reviewing inpatient admissions to determine if hospitalization is medically necessary, or if needed services could be provided in an outpatient or alternative setting. Pre-certification does not guarantee payment but means only that, based on the information provided to QualChoice, coverage for the admission (and for the initial number of inpatient days authorized for reimbursement), will not be denied solely for lack of medical necessity for inpatient treatment. Coverage and payment to all providers is subject to member eligibility, payment of premiums and all other terms and conditions of the member’s health plan.
  • PRESCRIPTION means an order to a pharmacy by a physician for a drug, medicine or medication for the benefit of and use by a covered person. For complete details, see the member’s applicable benefit plan or policy.
  • PRESCRIPTION MEDICATION means any medication or pharmaceutical that has been approved by the U.S. Food and Drug Administration, can be obtained only by a physician’s order, and bears the label “Caution: Federal Law prohibits dispensing without a prescription.” For complete details, see the member’s applicable benefit plan or policy.
  • PRODUCT means any program or health benefit arrangement designated as a “product” by NovaSys (e.g., NovaSys Product, Commercial, Network Access, Payor-specific Product, etc.) that is now or hereafter offered by or available from or through Company (and includes the Coverage Agreements that access, or are issued or entered into in connection with such product, except those excluded by NovaSys.
  • PRODUCT ATTACHMENT means an Attachment setting forth requirements, terms and conditions specific or applicable to one or more Products, including certain provisions that must be included in a provider agreement under the Regulatory Requirements, which may be alternative to, or in addition to, the requirements, terms and conditions set forth in the Agreement or Provider Manual.
  • PROVIDER means a Network Physician, Network Specialist, Network Mental Health Provider, Network Facility, Network Group, Network Group Physician, Network Allied Provider, or other provider who or which has entered into an agreement with QualChoice, directly or indirectly, to make Covered Medical Services available to Enrollees.
  • REGULATORY REQUIREMENTS means all applicable federal and state statutes, regulations, regulatory guidance, judicial or administrative ruling, requirements of Governmental Contract and standards and requirements of any accrediting or certifying organization, including, but not limited to, the requirements set forth in a Product Attachment.

Helpful Reminders

  • When a member schedules an appointment, please ask for their current insurance information.
  • When a member arrives at your office, please ask to see their current QualChoice ID card.
  • Maintain a current copy of the front and back of the member’s ID card in their file.
  • File claims with QualChoice in accordance with your Provider Agreement even if we are not the primary payer or in case of a motor vehicle accident (MVA).
  • File all claims for medical services electronically using the payer ID 35174.

270/271 Eligibility Request and Response  An eligibility and benefits request should be completed for every member at every visit to confirm membership, verify coverage and determine other important information such as copayment, coinsurance and deductible amounts. To learn more or enroll, contact Optum — Intelligent EDI Eligibility Service.

Member benefits may be verified by signing in to My Account or by calling Customer Service and using the interactive voice response (IVR) system or speaking to a Customer Service Representative at 501.228.7111 or 800.235.7111.

Quick Links

Provider Forms and Documents

Provider Quick Reference Guide

Provider Relations Territory Map

Provider Directory

Quality Results Provider Newsletter and Alerts

Medical and Regulatory Resources

   
Name Website
American Chiropractic Association www.acatoday.org
American Occupational Therapy Association www.aota.org
Arkansas Chiropractic Physicians Association www.archiro.org
Arkansas Chiropractic Society www.archirosociety.com
Arkansas Department of Health www.healthy.arkansas.gov
Arkansas Department of Human Services www.humanservices.arkansas.gov
Arkansas Foundation for Medical Care, Inc. www.afmc.org
Arkansas Hospital Association www.arkhospitals.org
Arkansas Medical Society www.arkmed.org
Arkansas Medicaid humanservices.arkansas.gov
Arkansas Medicare Services www.novitas-solutions.com
Health Care Payment Improvement Initiative www.paymentinitiative.org
Arkansas Physical Therapy Association www.arpta.org
Arkansas State Medical Board www.armedicalboard.org
Centers for Medicare & Medicaid Services www.cms.gov
Coordination of Benefits Agreement (COBA) www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/COBA-Trading-Partners/Coordination-of-Benefits-Agreements/Coordination-of-Benefits-Agreement-page.html
Federal Registers Online Site www.federalregister.gov
Information on Medicare Manuals www.cms.gov/manuals
Medical Group Management Association www.mgma.com
Medicare Training www.cms.gov/Outreach-and-Education/Outreach-and-Education.html
NPPES — National Plan & Provider Enumeration System nppes.cms.hhs.gov/NPPES/Welcome.do
OIG (Office of the Inspector General) www.oig.hhs.gov
SSA (Social Security Administration) www.ssa.gov