4/25/2024

Provider Manual

Miscellaneous

Advanced Practice Nurses, Physician Assistants, Certified Nurse Midwives and Clinical Nurse Specialists

QualChoice accepts network participation for Advanced Practice Nurses (APN), Physician Assistants (PA), Certified Nurse Midwives (CNM), and Clinical Nurse Specialists (CNS). Our Credentialing Committee accepts providers in the network based on demonstration of acceptable performance on administrative and discretionary criteria. This acceptance does not mean a provider will be accepted as participating for all plans administered by QualChoice or for any programs offered by QualChoice affiliates.

The collaborating physician of an APN or the supervising physician of a PA must be practicing in the same area of specialty as the APN or PA. Examples of acceptable arrangements include: PA acting as assistant at surgery has delegated services agreement with the operating surgeon; APN working in mental health or substance use specialty has collaborating agreement with a psychiatrist.

Services provided by Physician Extenders to inpatients are limited to:

  • Follow-up services for patients who are substantially recovered
  • Discharge services
  • Assistant surgeon services when the supervising/collaborating physician is the primary surgeon

Covered medical services provided by APNs and PAs incident to physician services must meet CMS incident to services standards. Medical Coverage Policy: BI344 Physician Extenders

Allergy Injections

If all terms and conditions of coverage are met, allergy injections/services are covered in the physician’s and allergist’s office. Medical Coverage Policies: BI111 Allergy Testing and BI117 Allergy Immunotherapy

Ambulance Services

Ambulance services are covered for ground or air transport if all terms and conditions of the member’s benefit plan or contract are met. Reimbursement is subject to the cost sharing amounts and benefit maximum specified in the member’s Benefit Summary. Medical Coverage Policy: BI445 Ambulance Services

Chiropractic

Chiropractic X-rays have specific requirements. For coverage and limits, consult the member’s coverage document or contact QualChoice Customer Service at 501.228.7111 or 800.235.7111. A Chiropractic X-Ray Services Pre-authorization Request Form must be submitted before X-rays are rendered. Medical Coverage Policies:  BI020 Chiropractic Care and BI220 Chiropractic X-Rays

Cardiac Monitoring, Durable Medical Equipment (DME) and Laboratory Services

The following requirements apply to all QualChoice participating providers and healthcare professionals, and to all laboratory services, clinical and anatomic, ordered by physicians and healthcare professionals.

Cardiac Monitoring Services

Cardiac monitoring services must be referred to a QualChoice network participating provider unless the provider is otherwise pre-authorized by QualChoice or another payer. Our network includes multiple national, regional and local providers of cardiac event monitoring services (CardioNet, Inc.; Telerhythmics, Inc.; Heart Care Corp of America; Philips Remote Cardiac and others), who provide a comprehensive range of services on a timely basis to meet the needs of our participating providers.

Participating cardiac monitoring services are listed under Other Facilities in our Provider Directory. For assistance in locating or using a participating cardiac monitoring provider, please contact your Provider Relations Representative.

If you require a specific cardiac monitoring test for which you believe no participating provider is available, please contact QualChoice in advance to confirm that the specific test is covered. We will work with you to assure that those covered tests are performed, even if that means the use of a non-participating provider.

Durable Medical Equipment (DME)

Some DME requires pre-authorization. See our Pre-authorization List and Medical Coverage Policies for more information. Durable medical suppliers are listed under Other Facilities in our Provider Directory.

All DME, orthotics, prosthetics and supply items must be obtained from a participating provider, except in this circumstance: If an item is not available from a participating provider, whether or not pre-authorization is required, the ordering physician must submit an Out-of-Network Authorization Request Form or a letter of medical necessity. Unless the member has an out-of-network benefit for DME, payment will be denied if this information is not submitted. See Out-of-Network Authorization Request Form.

Note: Even when medically necessary, certain items (for example, some orthotic devices) may not be covered under a member’s benefit plan. Other items (for example, prosthetic devices) may be subject to benefits limits. Please contact a Customer Service representative for specific information about a member’s benefit plan and any additional pre-authorization requirements.

Laboratory Services

QualChoice maintains a network of more than 25 national, regional and local providers of laboratory services. These labs provide a comprehensive range of services on a timely basis to meet the needs of our participating physicians. They also provide clinical data and related information to support HEDIS reporting, care management and other clinical quality improvement activities. Please note that in many benefit plans, members receiving services in out-of-network laboratories may incur increased financial liability and higher out-of-pocket expenses.

Participating providers are contractually required to refer laboratory services to a participating laboratory provider, except as otherwise pre-authorized by QualChoice or another payer. Participating laboratory providers are listed under Other Facilities in our Provider Directory. For assistance in locating or using a participating cardiac monitoring provider, please contact your Provider Relations Representative.

If you require a specific laboratory test for which you believe no participating laboratory is available, please contact QualChoice in advance to confirm that the specific test is covered. We will work with you to assure that those covered tests are performed, even if that means the use of a non-participating laboratory. In this event, QualChoice may require use of a particular non-participating laboratory, and will not cover charges for the test if not done at the required laboratory. See Out-of-Network Authorization Request Form.

Durable Medical Equipment (DME), Prosthetic/Orthotic Appliances and Medical Supplies

Coverage for DME, prostheses, orthotics and medical supplies varies depending on the member’s specific benefit plan. All covered services must meet medical criteria and be obtained from a participating provider. Each member’s plan may have different items that require pre-authorization and may also have an annual limitation.

When it is more cost effective, QualChoice may purchase rather than lease equipment for members. QualChoice will not pay any lease or rental payments in excess of the purchase price of the applicable equipment. Reimbursement will be according to the current Provider Agreement.

  • Codes – Current HCPCS codes are required on all bills. Appropriate use of modifier RR for rental and NU for purchase is required for all equipment.
  • Rent to Purchase Items – All items will be reimbursed on a rental basis up to the purchase price, unless otherwise specified as rental only or purchase only. For rent-to-purchase items, purchase price shall be equivalent to 10 months rental of equipment. Once equipment is considered purchased, QualChoice is responsible for any maintenance and repair.
  • Service for Purchased Items – Any repair or maintenance of an item that has been deemed purchased will be provided at an additional cost. As repair rates vary by item, reimbursement for these services will be negotiated on a case-by-case basis by our Care Management Department. Pre-authorization is required for repair and maintenance fees.
  • Rental Items – Equipment that is provided on a rent-to-purchase basis must be submitted with modifier RR for all rental months, including the final month.
  • Purchase-Only Items – Equipment that is provided on a purchase-only basis must be new and submitted with an NU modifier. Any exceptions to this policy must be pre-approved by our Care Management Department.
  • Supplies – Standard supplies are included in the initial set-up, rental and/or purchase price of the equipment. Contact our Care Management Department for appropriate authorization when special supplies are needed.

Excluded from Coverage

Personal comfort, hygiene, over-the-counter and disposable items; or any equipment, devices and supplies that are not primarily intended for medical use. Medical Coverage Policies:  BI249 Prosthetics, BI217 Orthotic Devices and Orthotic Services, and BI352 Repair and Replacement of Durable Medical Equipment

Hearing Aid Billing

If the member requires only one hearing aid, you should always bill the monaural code (one ear) that applies to the type of hearing aid you are supplying. Use the appropriate RT or LT modifier to indicate which ear. If the member requires hearing aids for each ear, you should bill the binaural code with modifiers. Regardless of billing a monaural or binaural code, only one unit should be billed. A claim should not be submitted until the hearing aid has been placed in the member’s ear — not when the order for the hearing aid is placed. Medical Coverage Policy: BI049 Hearing Aids

Flu Immunizations

Standard flu shots may be obtained from a network pharmacy at no member cost and subject to the limitations of QualChoice medical policies. Reimbursement for flu shots obtained through network pharmacies is limited to $25.00.

Standard flu shots (trivalent, quadrivalent, with or without preservatives, intradermal or intramuscular) administered by a network provider are covered in full.

Non-standard immunizations (antibiotic-free or recombinant-DNA derived preparations), require pre-authorization and are only indicated with a history of anaphylaxis (severe allergic reaction). Medical Coverage Policy: BI010 Flu Immunizations

Physical, Occupational and Speech Therapy

QualChoice covers physical and occupational therapy only if the services are ordered or prescribed by a physician or chiropractor and provided by a:

  • Licensed physical therapist
  • Licensed physical therapy assistant supervised by a licensed physical therapist
  • Licensed occupational therapist
  • Licensed occupational therapy assistant supervised by a licensed occupational therapist

Physical Therapy (PT) and Occupational Therapy (OT) services require a written Plan of Care signed by the therapist and physician to be submitted to our Care Management Department.

Coverage limits on the number of visits are determined by the member’s specific benefits. Please check the member’s coverage documents for details or contact QualChoice Customer Service at 501.228.7111 or 800.235.7111.

Speech therapy services are covered under specific member benefit limits. All speech therapy services must be ordered or prescribed by a physician. Medical Coverage Policies:  BI307 Physical and Occupational Therapy Services and BI067 Speech Therapy

Sleep Studies

For patients with suspected obstructive sleep apnea, the preferred study is an unattended home sleep test that records at least three channels and is interpreted by an independent sleep specialist. These studies are covered without pre-authorization when performed through a contracted, Joint Commission accredited Independent Diagnostic Testing Facility (IDTF).

If there are significant comorbidities (heart failure, COPD, seizure disorder or other sleep disorders), an attended sleep lab study may be requested through the pre-authorization process. For patients with documented obstructive sleep apnea, an auto-titrating CPAP machine may be used in most cases. All requests for sleep lab titration studies require pre-authorization. Frequency of sleep tests is limited. QualChoice contracts with freestanding sleep study centers which are eligible for payment of the technical component of sleep study services. Search for sleep study centers under Other Facilities in our Provider Directory.

Freestanding sleep study centers must bill the technical component of sleep medicine procedures for reimbursement. The physician who interprets the study must bill for the professional component. Medical Coverage Policy: BI306 Obstructive Sleep Apnea (OSA)