- Main Office Location
- Contact Us
- Interactive Voice Response System (IVR)
- Medical Directors
- Provider Relations Representatives
- Provider Directory
- Where to Find Information
- Provider Log-In
- Provider Newsletter "Quality Results" and Action Alerts
- Provider Changes and Updates
- Member Eligibility/Verification and Identification Cards
- Coverage and Pre-Authorization
- Helpful Reminders
- Provider Support
- Website Links
12615 Chenal Pkwy., Ste. 300, Little Rock, Arkansas 72211.
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.
- Phone: 501.228.7111
- Toll Free: 800.235.7111
- Fax: 501.228.0135
QualChoice observes the following holidays: New Year’s 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. There is access to an after hour’s voice mail. Information can be faxed 24 hours a day to 501.228.9413 or 800.228.9413.
Helpful Extensions, Email Addresses and Fax Numbers
Select 4 for Provider Menu Options
|Press 1 for||
Customer Service — For questions regarding benefits, eligibility, pre-authorization, claim status, appeal status or payment dispute.
|Press 3 for||
Provider Network Services — For provider credentialing, contracts, fee schedules, IPA/PHO updates or provider information changes/updates: firstname.lastname@example.org | Fax: 501.707.6811
|Press 4 for||
Provider Network Operations — For 835, EFT, EDI or provider password information. BU_PR@qualchoice.com | Fax: 501.707.6815
- P.O. Box 25610
- Little Rock, AR 72221
- 12615 Chenal Parkway, Suite 300
- Little Rock, AR 72211
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.
- #1 = Information entered is correct
- #2 = Information entered is NOT correct
Two full-time Medical Directors partner with our provider community to review medical issues and help establish QualChoice coverage policies.
We are committed to working with our network providers and their staff, to ensure that our members receive the right care at the right time, resulting in better health outcomes. A direct phone queue for providers means an immediate response to your questions and issues. Resources are also available 24/7 at qualchoice.com.
A Senior Provider Relations Representative will serve as your point of coordination for all network activities and ongoing operations, including contracting and information about QualChoice. Assigned regionally, the Provider Relations Rep can also assist you with specific inquiries or challenges. Provider Relations Reps and their territories are listed on the Provider Network Territory Map.
We make every effort to list providers correctly in our online directory.
Each provider listing indicates:
- Whether accepting new patients
- Board certification
- Hospital/facility affiliation
- Clinic location
- Eligibility verification (including accumulators) - behind provider login
- Claim status - behind provider login
- Pre-Authorization List
- Provider Newsletters
- Provider Forms and Information
- Medical Policies
Registration is required to access member eligibility or claim status. Please call us at 501.228.7111 or 800.235.7111, ext. 7011 if you do not have an authorized user name and password.
Starting August 1, 2015, each individual user in your office, group or facility using the QualChoice web portal for daily transactions must have a separate secure account.
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.
We also communicate with providers via targeted mailings, electronic newsletter Quality Results and provider Action Alerts, as well as seminars and education materials. Updates to pre-authorization requirements are listed in Quality Results, at least 30 days before becoming effective. If you are not receiving Quality Results or Action Alerts, please click the "Subscribe Today" button on the Quality Results page or contact your Provider Relations Representative.
It is important that we maintain a current record of your demographic information to ensure:
- Timely & accurate claims payment
- IRS reporting accuracy
- Distribution of email communications
- Provider Directory accuracy
To update your information:
Member eligibility is contingent on the member meeting the enrollment qualifications of his/her benefit plan. Because health plans provide benefits only for the period in which the member is eligible, a member who terminates employment, discontinues premium payment for benefits, exceeds the age limits for coverage as a dependent, or otherwise loses eligibility will not receive benefits for dates outside of the eligibility period.
Because events leading to ineligibility can occur at any time, providers are encouraged to verify eligibility at the time services are to be rendered. QualChoice verifies eligibility based on the information we have been provided. Should a member receive benefits outside of the eligibility period, no payment will be made by the health plan, regardless of whether or not eligibility was verified at the time.
Verification of eligibility is NOT a guarantee of payment by the health plan, and charges for ineligible services become the responsibility of the member.
Member eligibility and benefits should be verified before rendering services, this includes information on co-payments, coinsurance, deductibles and plan limits which may apply to the specific service. Please ask members to present a QualChoice ID card at the time of service and include a copy in the patient’s file.
You can verify benefits by signing in to My Account or by calling Customer Service at 501.228.7111 or 800.235.7111.
Covered benefits are not the same for all QualChoice members. Some plans have annual limitations specific to particular benefits and services, including but not limited to:
- Mental health
- Physical, speech and occupational therapy
- Home medical equipment
A member who has exhausted all available benefits for the current year would not have any further benefits for that service until the beginning of a new year. Benefit limits are applied as claims are paid. QualChoice can only verify the amount of benefits remaining as of the last claim payment cycle.
Verification of eligibility and/or benefit coverage is NOT a guarantee of payment by the health plan.
Sample member identification cards:
- Insured Group Identification Card
- Self-Funded Group Identification Card
- Insured Individual Identification Card
- Health Insurance Marketplace Insured Individual Identification Card
Certain services may be considered cosmetic, investigational, not medical (dental) or otherwise not covered under the plan. Any service for which coverage is in question must be submitted for predetermination before the service is provided.
All elective inpatient admissions and designated outpatient services must be pre-authorized to determine medical necessity and appropriate site of care. The provider should submit a Pre-Authorization Request Form according to the Pre-Authorization and Concurrent Review Guidelines at least five (5) days prior to the proposed service date. A care management nurse will review the request and may call the provider to obtain pertinent medical information. If the care management nurse cannot approve the request, it is referred to the Medical Director for a final decision. The provider and/or member will be notified in writing of the decision.
If the criteria are met, the nurse will evaluate for case management or discharge planning needs at the time of pre-authorization.
If the criteria are not met, the member and provider will be notified of the decision, why their request was not authorized and of their right to appeal.
If the member or the provider disagrees with the pre-authorization decision, he/she may request an appeal in writing within 60 days of the denial. An expedited appeal may also be requested. See Appeal Rights & Requests.
Our decision only affects whether reimbursement is available under the plan. The decision to proceed with the service rests solely with the member and the physician.
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.
ALLOWED CHARGES or ALLOWANCE means the fee per service agreed upon in a contractual arrangement between QualChoice and a participating provider or the usual amount charged by the provider, whichever is less. 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.
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 employed by QualChoice communicate with members’ physicians to facilitate 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 judgment, 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 services or counseling to members. All treatment decisions remain exclusively with the member and his/her physicians.
COINSURANCE is a fixed percentage of the cost, if any, of Covered Medical Services; required to be paid by a member under a health plan.
CONTRACT YEAR means the twelve-consecutive-month period commencing on the Group Enrollment Contract effective date and renewing on the anniversary of that effective date.
CO-PAYMENT is a fixed dollar amount representing a portion of the cost, if any, of Covered Medical Services required to be paid by a member under a health plan.
COVERED MEDICAL SERVICES means a service provided to a member by a licensed physician, hospital, facility, or other designated provider that is medically necessary and covered under the applicable health plan as determined by QualChoice or the payer.
DEDUCTIBLE is a fixed dollar amount representing a portion of the cost, if any, of Covered Medical Services required to be paid by a member prior to payment for such services by a health plan.
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.
EMERGENCY CARE means health care 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 possessing 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.
EMERGENCY PRESCRIPTION means any prescription medication prescribed in conjunction with emergency services and deemed necessary by a physician to be immediately needed by the covered person. See member’s applicable health plan or policy for complete definition and details.
FORMULARY is a specified list of covered prescription medications. This list is subject to change.
GENERIC MEDICATION means any chemically equivalent reproduction of a brand-name medication whose patent has expired.
GROUP CONTRACT is the contract between a health plan 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 plan or insurance policy coverage for its members.
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 plan or policy.
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 MEDICATION means a specific prescription for more than a one-month supply of a medication designated as “maintenance” for ongoing therapy of a chronic illness. For complete details, see the member’s applicable benefit plan or policy.
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.
MEDICAL DIRECTOR is a trained and licensed medical doctor who works for QualChoice to review medical issues and to contribute to our coverage policies. The Medical Director does not practice medicine or give any medical advice or counseling.
MEDICALLY NECESSARY means services or supplies that meet all of the following criteria in that such service or supplies are:
(a) provided for the diagnosis or direct care and treatment of a medical condition that is (1) not excluded from coverage under the member's coverage certificate and (2) determined by QualChoice or payer, applying its established medical policies and guidelines, to be covered under the member's health plan;
(b) appropriate and necessary for the symptoms, diagnosis and/or treatment of a medical condition covered by the member's health plan;
(c) within standards of good medical practice recognized within the organized medical community;
(d) not primarily for the convenience of the member, his/her family, his/her provider, or another medical provider; and,
(e) the most appropriate supply or level of service which can safely be provided.
MEMBER means a subscriber or dependent entitled to Covered Medical Services under a subscriber certificate issued by a health plan.
OUTPATIENT is defined as use of ambulatory or ancillary services for diagnosis and treatment.
PARTICIPATING IN-NETWORK HOSPITAL is a hospital that contractually agrees 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 with a written agreement to provide pharmacy services to QualChoice members as provided in the benefit certificate.
PARTICIPATING IN-NETWORK PHYSICIAN means a licensed doctor of medicine or osteopathy, who has a contract with QualChoice to provide health 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 health care provider (including durable medical equipment (DME), home health, etc.) who has contracted with QualChoice to provide or arrange for the provision of health care 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-CERTIFICATION 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. NOTE: Pre-certification is not required for most QualChoice health plans. Be sure to check your patient’s particular 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.
PROVIDER means a hospital, a physician, a certified registered nurse anesthetist or a psychological examiner (if the member’s plan covers psychological treatment services). Provider also includes any other type of health care provider approved by the company for reimbursement for services rendered. For complete details, see the member’s applicable benefit plan or policy.
- 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 QualChoice ID card.
- Maintain a current copy of the front and back of the member's ID card in file.
- File claims with QualChoice in accordance with your Provider Agreement even if we are not the primary payer or in case of MVA.
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.
|American Chiropractic Association||www.acatoday.org|
|American Occupational Therapy Association||www.aota.org|
|Arkansas Chiropractic Association||http://archiro.org/wp/|
|Arkansas Chiropractic Society||http://archirosociety.com/|
|Arkansas Department of Health||www.healthyarkansas.com|
|Arkansas Department of Human Services||www.state.ar.us/dhs|
|Arkansas Foundation for Medical Care, Inc.||www.afmc.org|
|Arkansas Hospital Association||www.arkhospitals.com|
|Arkansas Medical Society||http://www.arkmed.org/|
|Arkansas Medicare Services||https://www.novitas-solutions.com/|
|Arkansas Payment Improvement Initiative||http://www.paymentinitiative.org|
|Arkansas Physical Therapy Association||www.arpta.org|
|Arkansas State and Public School — Employee Benefits Division||www.arbenefits.org|
|Arkansas State Medical Board||www.armedicalboard.org|
|Centers for Medicare and Medicaid Services||www.cms.gov|
|Coordination of Benefits Agreement (COBA)||http://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||https://www.federalregister.gov/|
|GPO (Government Printing Office)||www.access.gpo.gov|
|Information on Medicare Manuals||www.cms.gov/manuals|
|Medical Group Management Association||http://www.mgma.com/|
|NPPES — National Provider Identifier||https://nppes.cms.hhs.gov/NPPES/Welcome.do|
|OIG (Office of the Inspector General)||www.oig.hhs.gov|
|SSA (Social Security Administration)||www.ssa.gov|