Utilization Management

Criteria for Utilization Management Decisions

Our utilization management program uses nationally recognized criteria and registered nurse reviewer assessments of psychological and medical factors to determine the medical necessity of inpatient admissions and some outpatient procedures. Registered nurses consult with our Medical Director and physician specialists to explore treatment alternatives and discuss the best options for patients. The outcome is reduced health care costs and assurance that the best alternative treatments have been assessed.

All utilization management decision and notice requirements are developed consistent with applicable state and federal laws and regulations and accreditation standards.

AFFIRMATIVE STATEMENT

QualChoice does not compensate individuals conducting utilization review for issuing denials of coverage, and it does not provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. Financial incentives for utilization review do not encourage decisions that result in underutilization. Utilization management decision making is based on medical necessity, applicable coverage guidelines and appropriateness of care and service.

Pre-Authorization Requirements

Elective Services
All elective inpatient admissions and designated outpatient services must be pre-authorized to determine medical necessity and appropriate site of care. Pre-authorization must be requested according to our Pre-Authorization and Concurrent Review Guidelines at least five (5) business days prior to the proposed service by calling QualChoice or submitting a Pre-Authorization Request Form

Verbal Approvals for Authorization Requests 
QualChoice network providers will receive a verbal approval when requesting an authorization. It is the responsibility of the network provider to inform the patient at that time that the request has been approved.

Emergency Care
Requests for procedures/services needed on an emergency basis must be made within 48 hours of admission. All emergency care is subject to review by QualChoice for medical necessity. If medical necessity is not established, payment will be denied. If in an emergency a member goes to an out-of-network facility’s emergency room for treatment, and the member is admitted at that out-of-network facility, the member, a family member or the facility must notify QualChoice once the member is stabilized, but no more than 48 hours after initial treatment. Unless notified, charges incurred will be paid at the out-of-network benefit level. Refer to Out-of-Network Referrals (BI109) medical policy. When members use emergency rooms for treatment, specific emergency cost sharing will apply. Please review Pre-Authorization and Concurrent Review Guidelines.

Clinical Review
A nurse will review the request and may contact the provider for pertinent medical information. If the nurse cannot approve the request, it is referred to the Medical Director for a final decision. If criteria are not met, or if the physician does not provide the information necessary for review, the service will not be authorized. QualChoice will notify the facility and the physician verbally and in writing of the denial decision. See Pre-Authorization and Concurrent Review Guidelines for complete information.

Pre-Authorization Denials
All pre-authorization denials undergo a physician review. If the member and/or the attending physician disagree with the denial, he/she may contact our Care Management Department and request Medical Director reconsideration within three (3) business days of the denial. Specific details are noted in Pre-Authorization and Concurrent Review Guidelines.

Concurrent Review of Inpatient Admissions

Using recognized evidence-based criteria, QualChoice conducts concurrent review on all inpatient stays to ensure the medical appropriateness and necessity of continued hospitalization. Concurrent review also helps ensure effective discharge planning and care transitions. See Pre-Authorization and Concurrent Review Guidelines.

Appeal Process for Medical Determinations and Expedited Appeals

If the member or provider disagrees with the decision, an appeal may be made in writing within 180 days of the denial. An expedited appeal may also be requested. See Pre-Authorization and Concurrent Review Guidelines or Appeal Rights & Requests.

Pre-Authorization List

A pre-authorization list (searchable by service type or category) is maintained online.

  • Equipment
  • Home Care
  • Immunizations
  • Inpatient Services
  • Medication Limitation Information
  • Medications
  • Out-of-Network Care
  • Outpatient Services
  • Surgical Treatments
  • Transplants (including transplant evaluations, except cornea)

ARBenefits — Arkansas State and Public School Medicare Retirees

QualChoice administers the claims payment for Arkansas State and Public School Medicare retirees. We administer the ARBenefits Premium plan for non-Medicare spouses and dependent children. 

ARBenefits has contracted with a third-party vendor, American Health Holding, Inc. (AHH), not affiliated with QualChoice, to provide utilization management for services that require pre-authorization and concurrent review on NON-Medicare members only. For ARBenefits pre-authorization, contact AHH at 877.815.1017, press 2. (Pre-authorization is not required for Medicare eligible members.)

Pre-Authorization Requirements for High Tech Radiology

 

EviCore National, LLC manages our high-tech radiology requirements. See EviCore Quick Reference Guide.

Pre-authorization is required for the following:

  • Computed Tomography (CT) Scans
  • Nuclear Medicine
  • Nuclear Cardiology
  • Magnetic Resonance Imaging (MRI/MRA)
  • Positron Emission Tomography (PET) Scans

Rendering Location Exclusions:

  • Imaging studies performed in conjunction with emergency room services
  • Inpatient hospitalization
  • Outpatient surgery (hospitals and free standing surgery centers)
  • 23-hour observations

For EviCore pre-authorization, call 800.533.1206 (Monday to Friday 7:00 a.m. – 7:00 p.m.)

EviCore imaging criteria can be found by clicking here, clicking the link under "Resources and Tools" on the Provider landing page, or logging into your account and following these steps:

  1. Log in as a provider at qualchoice.com
  2. After log in, select Pre-Authorization for Radiology Services
  3. Select Criteria
  4. Select Radiology Criteria
  5. Select QualChoice (at right)

Pre-Admission Review/Pre-Certification Requirements

Pre-Admission Review

Pre-Admission review is the process of confirming eligibility and collecting information prior to inpatient admissions and selected ambulatory procedures at in-network facilities.

Pre-admission review required for:

  • All planned/elective admissions for acute care
  • All unplanned admissions for acute care
  • All Institutional care not in an acute hospital, such as in a rehabilitation or skilled nursing facility
  • All admissions following outpatient surgery
  • All admissions following observation
  • All newborns admitted to Neonatal Intensive Care Unit (NICU)
  • All newborns who remain hospitalized after the mother is discharged (within 24 hours of the mother’s discharge)

Pre-Certification Requirements

  • 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.
  • The provider/treating physician bears the primary responsibility for obtaining pre-certification. Calls are also accepted from the admitting facility or member.
  • Pre-certification does not guarantee payment. Granting pre-certification only means 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 later 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.

Elective Admissions

Non-Elective Admissions

Emergency Admissions

Within 5 business days prior to admission

Weekday admissions: within 24 hours

Weekend/federal holiday admissions: by 5:00pm local time on the next business day

Within 48 hours of admission or 2 business days after performed. If patient is unable to provide coverage information, the facility should notify QualChoice as soon as the information is known.

NOTE: Notification by the facility is required even if it was supplied by the physician and a pre-authorization approval is on file.

NOTE: Pre-certification is not required for most QualChoice health plans. Check your patient’s particular plan.

Pre-Notification Requirements for Out-of-State or Out-of-Network

  • Pre-notification is a process where a member is required to call QualChoice prior to admission to an out-of-network facility.
  • Pre-notification provides information to determine if care management would be an appropriate option for the member.
  • Pre-notification is not required for outpatient treatment.
  • Provider understands and agrees that pre-authorization for inpatient treatment, pre-notification or any “verification of benefits” or other eligibility inquiries made prior to, at or after admission, or provision of any services to members are not a guarantee of payment.
  • Pre-authorization means that based on information provided to QualChoice, coverage for the admission (and for the initial number of inpatient days authorized for reimbursement) will not be denied solely on the basis of lack of medical necessity (as defined by the member’s health plan).
  • While QualChoice endeavors in good faith to report member eligibility information available within its records or computer systems at the time of admission or provision of services, provider acknowledges and agrees that it is not possible to guarantee accuracy of such records or computer entries.
  • Provider understands and agrees that the eligibility of all members and coverage for any services shall be governed by the terms, conditions and limitations of the member’s health plan, which shall take precedence over any inconsistent or contrary oral or written representations.
  • If, following any inpatient treatment or other services, it is discovered or determined that premiums had not been paid for a member’s coverage, that a former member was no longer employed and eligible for participation in the health plan at the time of the admission, or that coverage had lapsed or terminated for any reason specified in the member’s health plan, no reimbursement shall be due from QualChoice (or the applicable payer) for such services.

Observation Beds

Observation services are reimbursed according to the provider agreement. Hospital stays over 24 hours will not be reimbursed as observation. Observation will only be reimbursed up to 24 hours. Observation services delivered in conjunction with outpatient surgery will only be reimbursed for stay that extends more than 6 hours after completion of the surgery, and only if such stay is medically necessary.  Facility charges for observation beds are to be billed under revenue code 762.

Coverage guidelines for observation beds are as follows:

  • Observation bed charges will be recognized from general acute care hospitals only.
  • Reimbursement for observation bed charges will be limited to one day’s semiprivate room allowance.
  • Hospital outpatient surgery fee schedule amount (global allowance) will encompass observation bed charges and related services.
  • Observation bed services occurring within 24 hours of a hospital admission will be considered part of the inpatient hospital billing. The admission date will be the day that the patient is first considered an observation patient. For purposes of pre-authorization (if applicable), the admission will be treated as an emergency so that the 48 hours prior notice requirement will not have to be met.  

Postoperative Global Period (BI 106)

A global period is a period of time starting with a surgical procedure and ending some period of time after the procedure. QualChoice follows the postoperative global periods used by the Centers for Medicare and Medicaid (CMS).

Each surgical and/or invasive procedure will have a global period of zero to 90 days. This means that all usual postoperative services occurring within that time frame are included in the QualChoice allowance and reimbursement of the surgical/invasive procedure. Providers will not receive additional payments. Only those postoperative services that are considered significant and separately identifiable should be billed; QualChoice retains sole discretion to determine whether such services are eligible for payment as separate services.

Care Management and Referrals

We use a proactive and positive relationship-building approach in working with patients, their families and physicians to develop and monitor the most appropriate treatment plan. Care management review and intervention are triggered by complex conditions, terminal illness, and catastrophic illness. Members whose diseases do not fall into these specific categories, but are likely to use a high level of medical resources in a 12-month consecutive period are also identified and potentially enrolled.

Our QCARE health and wellness programs create an impact on both the quality and the cost of care received by our members through interventions, such as:

  1. Determination of the medical necessity of requested services
  2. Provision of referrals to network providers
  3. Negotiation for discounts and services when non-contracted providers are involved
  4. Recommendation of benefit alternatives designed to provide more appropriate and cost effective treatment
  5. Facilitation of referral to a specialist or medical consultant

Cases are assessed and evaluated in regard to the following:

  • Age
  • Type of illness
  • Secondary diagnosis
  • Special equipment needs
  • Current treatment plan
  • Type of treatment
  • Treatment location
  • Potential for complications
  • Physician specialty
  • Financial concerns
  • Family dynamics

Our QCARE programs may be targeted to specific conditions, such as our core care management programs, or designed to improve or maintain overall health, such as our health and wellness programs. Regardless of their focus, all QCARE programs are intended to supplement and reinforce the care and guidance you provide to our members.

Identifying Members for Referral

Members are identified or referred for care management through a number of sources. Referrals may come from an internal department at QualChoice or from an external source, such as the member’s family, physician, or other health care professional or facility. Members may also self-refer.

To refer a QualChoice member for care or disease management, contact Customer Service at 501.228.7111 or 800.235.7111 (Monday-Friday, 8:00 a.m. to 5:00 p.m.) and ask to speak to a care manager, or submit a Care Management Referral Form.

Provision of Covered Medical Services

Network providers are responsible to provide covered medical services to QualChoice members who request them. A network provider may decline to accept a QualChoice member as a patient under the following circumstances:

  1. If network provider determines that his/her practice has reached maximum patient load, and can no longer accept any new patients to his/her practice regardless of source of payment, the network provider may decline to accept any new QualChoice members as patients. In this instance, the network provider must provide 90 days prior written notice of his/her practice restriction to the QualChoice Provider Relations Department or complete and submit a Provider/Practice Change Form.

    However, if the provider is an in-network physician he/she shall continue to permit their current patients (who were not enrolled previously in a health plan) to designate them as a PCP upon the patient’s enrollment in a health plan.

  2. If network provider provides written request to QualChoice to restrict or discontinue a specific member from selecting or accessing him/her due to unacceptable or disruptive behavior of the member or a dependent or guardian; or when a member, dependent or guardian has initiated or threatened legal action against the network provider, his/her practice, or practice associates.

Coordination of Services

Network providers are contractually responsible to coordinate provision of Covered Medical Services with other network providers, including without limitation, timely completion and forwarding of medical records and clinical information in accordance with appropriate patient consent and authorization and applicable QualChoice policies.

Medical Policies

QualChoice medical policies are based on research of current medical literature and review of common medical practices in the treatment and diagnosis of disease. The QualChoice Medical Director and Medical Advisory Committee (MAC) review each policy before it is implemented. Evaluation of clinical evidence and development of policies occur in a consistent and timely manner to promote access to safe and effective services for all members. As medical practices and knowledge are constantly changing, QualChoice reserves the right to alter, amend, change, or supplement medical policies as needed.

The MAC meets at least four times per year. Voting membership includes, at a minimum, but not limited to; eight to twelve board-certified participating practitioners chosen from the following practice areas:

  • Primary Care
  • OB/GYN
  • Medical Subspecialties
  • Surgical Subspecialties
  • Behavioral Health and Substance Abuse

Other specialty providers may be included as necessary for peer review and clinical input. The QualChoice Chief Medical Officer chairs the MAC and is a non-voting member, unless the outcome of the vote is tied, in which case the chair may render a tie-breaking vote.

QualChoice management staff included (non-voting) is:

  • Vice President of Quality and Care Management
  • Vice President of Network Services
  • Vice President of Pharmacy
  • Medical Director

QualChoice medical policies provide guidance for our members and providers regarding coverage criteria for specific medical and behavioral health technologies, including procedures, equipment, and services. In order to be eligible for coverage, all services must be medically necessary (unless otherwise provided in the member’s benefits contract). A medical policy is not an authorization, certification, explanation of benefits or a contract.

To the extent there are any conflicts between QualChoice medical policy guidelines and applicable contract language, the contract language prevails. QualChoice medical policies are not intended to override the health insurance contract that defines the insured’s benefits, nor is it intended to dictate to providers how to practice medicine. Physicians and other health care providers are expected to exercise their medical judgment in providing the most appropriate care.

NOTE: While a procedure, technology or drug may be medically useful, it still may be specifically excluded under the terms of a member's contract or benefit plan, or the use may be an investigational or experimental use of the service and therefore excluded under the experimental or investigational language of the member’s benefit contract or plan.

The absence of a specific coverage policy does not indicate that a service is covered. For example, a new device or a new use of an old device may not have been proven safe and effective, but coverage may also have not been previously requested, thereby providing us an opportunity to study the information on the safety and effectiveness of the new use of the device.

If you have questions about a coverage policy, or about a procedure or device that does not have a published coverage policy, please contact QualChoice at 501.228.7111 or 800.235.7111 before providing the service to clarify availability of coverage.

Search for a Policy by using one of the options below:

  • Search by keyword
  • Search by title alphabetically
  • Enter a medical policy number
  • Enter a procedure code (CPT/HCPCS)

Each policy contains the following information:

  • Title
  • Effective Date & Revised Date
  • BI (benefit interpretation) number
  • Public Statement (description of procedure or service)
  • Medical Statement (defines eligibility for coverage)
  • CPT codes used (for billing/coding/physician documentation)
  • Reference Sources
  • Application to Products (defines health plans/products policy applies to)

Medical Policy Dissemination

Medical policies are available to members, providers and the general public. Significant policy changes are communicated through our provider e-newsletter and email updates, Quality Results and Provider Action Alerts.

Out-of-Network Referrals (BI 109)

Network providers are contractually required to refer QualChoice members to in-network providers, including in-network facilities, labs and ancillary providers. Referrals to out-of-network providers require pre-authorization. Written referrals to in-network specialists are not required for QualChoice members. An Out-of-Network Authorization Request Form or a Letter of Medical Necessity must be completed by the ordering provider when referring to a non-participating provider (including facilities, labs, and ancillary providers) for services that are not available in network.

Mail or fax the Out-of-Network Authorization Request Form or Letter of Medical Necessity and pertinent medical records at least five (5) business days prior to the anticipated date of service to allow time for review and notification of the approval or denial of the referral.

QualChoice
Attn: Care Management Department
PO Box 25610
Little Rock, AR 72221
F: 501.228.9413 or 800.228.9413

QualChoice will notify the provider of the approval or denial. Providers can also call 501.228.7111 or 800.235.7111 to check the status of a referral. IMPORTANT:  Retroactive out-of-network referrals will not be accepted.

Reimbursement for Out-of-Network Providers

Effective October 2012 if an insured member receives medically necessary care from an out-of-network provider (even in an in-network setting) QualChoice may reimburse the member for the service rendered. Example: An insured member goes to an outpatient facility and the in-network specialist uses an out-of-network laboratory during a procedure.


On-Call Arrangements

As stipulated in the Provider Agreement, participating providers shall provide Covered Services for members directly or through arrangements with other in-network providers, 24 hours, 7 days a week. 

Genetic/Genomic Testing Policies

QualChoice covers genetic/genomic testing when medically necessary with pre-authorization and clinical documentation. QualChoice does not cover genetic/genomic testing for conditions that treatment cannot alter or specific interventions cannot prevent.

In all instances, genetic/genomic testing must be pre-authorized unless otherwise stated in a medical policy. An in-network laboratory must be used when available.

If genetic/genomic tests are not pre-authorized, the member may be responsible for the full cost. Additionally, if genetic/genomic testing is ordered and performed by an out-of-network lab and QualChoice determines the test was not medically necessary, the liability for all charges will revert to the member.

IMPORTANT! Before rendering any genetic testing services, inform members that they are likely to be responsible for the cost of these services. Please ensure that ALL providers and ancillary facilities are in-network, as any referral to an out-of-network facility may result in full liability for all charges reverting to the member.