- Appeal Process for Medical Determinations and Expedited Appeals
- Pre-authorization Requirements
- Pre-authorization List
- Pre-authorization for Genetic/Genomic Testing
- Pre-authorization Requirements for High Tech Radiology
- Pre-notification, Pre-authorization and Eligibility Requirements
- Postoperative Global Period
- Care Management and Referrals
- Utilization Management
- Medical Policies
Appeal Process for Medical Determinations and Expedited Appeals
If a member or provider disagrees with a coverage decision, an appeal may be made in writing within 180 days of the denial or adverse determination. An expedited appeal may also be requested. See Pre-authorization and Concurrent Review Guidelines or Your Right to Appeal.
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 completed Pre-authorization Request Form according to the Pre-authorization and Concurrent Review Guidelines at least five (5) days prior to the proposed service date. The medical decision will be made on the information provided, so complete and accurate information is necessary. 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 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 Your Right to Appeal.
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.
Site-of-service medical necessity reviews are part of our pre-authorization process that supports member benefit plans, requiring care to be medically necessary as well as cost-effective. Ambulatory care centers frequently offer significant cost savings compared with a hospital setting, which can help many of our members save on out-of-pocket costs. Ambulatory care centers may provide more convenient care experiences for members, as well.
As healthcare continues to evolve and consumers increasingly demand a wider range of quality, cost effective options for their healthcare services, we anticipate a continued focus on place of service. We encourage you to review network ambulatory care centers in your area that best meet your needs and your patients’ needs.
Online Automatic Pre-authorization
For faster pre-authorization, use our online Cite® AutoAuth system. Register or sign in to the My Account portal at QualChoice.com. Select Pre-authorization and follow the prompts to enter your clinical criteria. A determination can often be made within seconds. Links to training materials are also available in the portal.
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 by mail or fax. It is the responsibility of the network provider to inform the member at that time that the request has been approved.
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.
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 provider 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.
All pre-authorization denials undergo a physician review and are denied by a physician. If the member and/or the attending physician disagree with the denial, he/she may contact our Care Management Department and request an appeal. Specific details are noted in Pre-authorization and Concurrent Review Guidelines.
A pre-authorization list (searchable by service type or category) is maintained at QualChoice.com.
- Home Care
- Genetic Testing
- Inpatient Services
- Medication Limitation Information
- Out-of-Network Care, diagnostics, lab, etc.
- Outpatient Services
- Surgical Treatments
- Transplants (including transplant evaluations, except cornea)
Pre-authorization for Genetic/Genomic Testing
QualChoice covers genetic/genomic testing when medically necessary with pre-authorization and clinical documentation. We do not cover genetic/genomic testing for conditions that treatment cannot alter or that 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.
Pre-authorization Requirements for High Tech Radiology
National Imaging Associates, Inc (NIA), a subsidiary of Magellan Health, manages our high tech imaging radiology requirements. See NIA Radiology Requirements and information on the Utilization & Pre-authorization page at QualChoice.com.
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
- Stress echo and echocardiography
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 NIA pre-authorization, call 866-249-1587 (Monday to Friday 7:00 a.m. – 7:00 p.m.). Review the NIA imaging criteria Imaging criteria can also be found in the My Account portal.
Pre-notification, Pre-authorization and Eligibility Requirements
- Members are required to call QualChoice prior to admission to an out-of-network facility. A determination will be made as to whether care management is an appropriate option for the member.
- 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).
- QualChoice attempts 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 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.
Postoperative Global Period
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 members, 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:
- Determination of the medical necessity of requested services
- Provision of referrals to network providers
- Negotiation for discounts and services when non-contracted providers are involved
- Recommendation of benefit alternatives designed to provide more appropriate and cost effective treatment
- Facilitation of referral to a specialist or medical consultant
Cases are assessed and evaluated in regard to the following:
- 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 healthcare 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.
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 members. The outcome is reduced healthcare 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.
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.
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
- 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 healthcare 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 to clarify availability of coverage before providing the service.
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:
- Effective date and 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 Quick Alerts.
Benefit Inquiry or Pre-determination
Beginning December 1, 2017, written pre-determination requests must be submitted using the Predetermination Request Form. Please note that, as of January 1, 2018, paper requests that are received at QualChoice without the Predetermination Request Form will be returned to the submitting provider, along with instructions to resend the request using the appropriate form.
A medical benefit inquiry will assist you in obtaining a pre-determination as to whether a particular service or supply will be eligible under the QualChoice medical plan and if it meets the medical necessity guidelines.