Member Cooperation Affects Reimbursement

All member benefit certificates -- Evidence of Coverage (EOC), Certificate of Coverage (COC), Policy or Summary Plan Description (SPD) -- define areas in which the member’s cooperation is needed to adequately process claims or provide good customer service. If the member fails to provide that cooperation, QualChoice may not be able to determine benefits, or may decide to deny benefits for lack of cooperation. The charges for services would then become the member’s responsibility.

Because provider reimbursement is subject to the terms of the member’s benefit certificate, providers should be aware of the terms of the benefit certificate, including those terms that require member cooperation. Providers should encourage our members who are patients to fully cooperate in providing all information needed to properly evaluate and effectively process their claims.

If the member fails to cooperate and claims are denied on that basis, providers will not be entitled to any reimbursement from QualChoice for the services in question.

Areas in which we need and request member cooperation include but are not limited to:

  1. Obtaining medical records or other claims-related information;
  2. Obtaining information regarding other coverage the member may have (coordination of benefits);
  3. Obtaining information regarding the status of a dependent, such as a disabled child or a college student; and,
  4. Obtaining information regarding third party liability (e.g., auto accident), subrogation or work-related injuries.

Member Eligibility and Verification

Eligibility

Member eligibility is contingent on the member meeting the enrollment qualifications of his/her benefit certificate. 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.

The provider is responsible for requesting the member’s most current QualChoice ID card and for properly submitting claims. It is the member’s responsibility to provide their current QualChoice ID Card to the provider. If the member fails to provide their card following a request by the provider, liability for all charges will revert to the member.

Verification of eligibility is NOT a guarantee of payment by the health plan, and charges for ineligible services become the responsibility of the member.

Note: The ID card is for identification purposes only and does not guarantee eligibility. Eligibility must be verified each time services are received. QualChoice provides eligibility information based on data received from the employer group as of the date of verification. Final determination of eligibility and benefits will be at the time of claim processing. Non-eligibility will result in member liability for charges incurred.

Verification

Verify member eligibility and benefits before rendering, including information on copayments, coinsurance, deductibles and plan limits which may apply to the specific service. Ask member to present a QualChoice ID card at the time of service and include a copy in the patient’s file.

Verify member eligibility and benefits at QualChoice.com after signing in to My Account*. Or call the Customer Service number on the front of the member’s ID card and use the interactive voice response (IVR) menu options. You can also speak directly to a Customer Service representative Monday through Friday, 8:00 a.m. to 5:00 p.m.

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 will 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.

* Using My Account.

Identification Cards

Sample member identification cards:

Member Financial Obligations

In most situations, members are responsible for part of a network provider’s bill for services (i.e., the member’s co-payment, coinsurance and deductible) as specified in the member’s benefit certificate.

Member Responsibility for Non-covered Services

A network provider may charge a member for services which:

  • Are determined by QualChoice or the applicable payer to be excluded by the member’s health plan, or
  • Would otherwise be covered, but have been determined to be not medically necessary under the following conditions:
  • The network provider has confirmation from QualChoice or the plan administrator before providing the services that they are not covered or are not medically necessary;
  • The member requests and agrees in writing before the services are provided to pay for the services, after having been fully informed by the network provider that they are not covered under their health plan;
  • The written agreement is specific to the service being provided; (a blanket agreement to be responsible for any services deemed not medically necessary is not acceptable), and;
  • A copy of the written agreement is kept in the member’s medical records in the network provider’s office and furnished to QualChoice on request.

Member Fraud or Misrepresentation

If a member has obtained coverage by intentionally misrepresenting a material fact related to his or her past medical history or other relevant background on an application, or if a member has filed fraudulent insurance claims, we may elect at our discretion to terminate the member’s health plan coverage or insurance contract, or to rescind the coverage.

If coverage is rescinded, it is retroactive to the first date that the member’s coverage became effective, even if that date was months or even years before the fraud or misrepresentation was made known. This means that the member, in effect, never had any coverage because the coverage was obtained through fraud or an intentional misrepresentation of a material fact.

Accordingly, providers may be asked to refund prior claims payments made for such a member, and any pending claims for such a member will be denied on grounds that no coverage existed on the date of service.

It is in a provider’s best interest to identify any member fraud or misrepresentation as early as possible, not only to protect all members and the public at large from the costs of such improper activity, but also to protect providers.

Note: To avoid potential identity theft or fraud, ask the member for a separate form of identification, preferably photographic, along with the member’s QualChoice ID card.

Please report fraud, waste or abuse through any of the following means:

  • Phone: 228.7111 or 800.235.7111, ext. 6740; or 501.707.6740
  • Fax: ATTN Fraud, Waste and Abuse Dept., 501.228.0135
  • E-mail: Fraud@qualchoice.com
  • Mail: QualChoice | ATTN:  Fraud, Waste and Abuse Dept. | P. O. Box 25610 | Little Rock, AR 72221

All reports are confidential and will be investigated as appropriate, including applicable referral to law enforcement and regulatory bodies. Please include as much detail as possible to ensure our ability to investigate each issue. Reports may be made anonymously.