- PCP Requirements
- Advanced Practice Nurses, Physician Assistants, Certified Nurse Midwives, Clinical Nurse Specialists
- Allergy Injections
- Ambulance Services
- Chiropractic Requirements
- Hearing Aid Billing
- Flu Immunizations
- Physical Therapy, Occupational Therapy and Speech Therapy
- Sleep Studies
- DME, Prosthesis/Orthotic Appliances, and Medical Supplies
Beginning January 1, 2017, QualChoice individual metallic plan (Bronze, Silver, Gold, Platinum and Catastrophic) members, as well as those with insurance through HealthCare.gov or Arkansas Works, will be in the Select network and will be required to choose a PCP. These members will have a unique QualChoice ID card:
Members who do not choose a provider will be assigned one. Rosters of newly assigned members will be available through My Account* under the Provider Reports tab.
Specialists: When filing claims for these members you must submit the referring PCP’s name and NPI # when billing for services with Place of Service (POS) codes 11, 12, 17, 19, 22 and 24. Referring PCP name and NPI are NOT required for POS codes 20, 21, 23 and 81.
Specialist Claim Filing for Individual Metallic Plan Members
POS Codes: 11, 12, 17, 19, 22, 24
Must submit referring PCP name and NPI #
POS Codes: 20, 21, 23, 81
Not required to submit referring PCP name and NPI #
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 determines acceptance of providers in the network by who can demonstrate acceptable performance on the 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 that will be provided by 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 provided to 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 standards for incident to services.
Reference: Medical Coverage Policy BI344 on Physician Extenders for additional information.
Provided all the terms and conditions of coverage are met, allergy injections/services are covered in the physician’s and allergist's office.
Reference: Medical Coverage Policy BI111 and BI117 for additional coverage details.
Ambulance services are covered for ground or air transport subject to satisfaction of all terms and conditions of the member's benefit plan or contract. Reimbursement is subject to the member's Cost Sharing Amounts and Benefit Maximum specified in the member’s Benefit Summary.
Reference: Medical Coverage Policy BI445 for additional coverage details regarding ambulance services.
There are specific requirements for chiropractic x-rays. For coverage and limits the chiropractic provider will need to consult the member’s coverage document or contact QualChoice Customer Service at 501.228.7111 or 800.235.7111. A Chiropractic X-Ray Pre-Authorization Form must be submitted prior to x-rays being rendered.
Reference: Medical Coverage Policy BI020 and BI220 for information regarding chiropractic services.
Providers should always bill the monaural code (one ear) that applies to the type of hearing aid they are supplying, and bill each ear separately. Providers should use modifiers "LT" and/or "RT" on each line, whichever is applicable. One unit of service should be used per claim line. 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.
Reference: Medical Coverage Policy BI049 for additional coverage and benefit criteria.
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 administered by a network provider are covered in full. For non-standard immunizations such as preservative-free preparations, QualChoice will reimburse the same amount as the standard immunization. If there is a difference in cost, it will be covered by the agreement between the patient and the physician administering the vaccine.
Reference: Medical Coverage Policy BI010 for additional coverage details regarding flu immunizations.
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, or licensed occupational therapy assistant supervised by a licensed occupational therapist. PT and OT services require a written plan of care (see sample) 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.
Reference: Medical Coverage Policy BI307 for physical and occupational therapy services.
Speech therapy services are covered under specific member benefit limits. All speech therapy services must be ordered or prescribed by a physician.
Reference: Medical Coverage Policy BI067 for additional details on speech therapy.
For patients with suspected obstructive sleep apnea, the preferred study is a home sleep test that records at least three channels and is interpreted by a sleep specialist. Where other sleep disorders are suspected, or if a home sleep test fails to be diagnostic, a sleep study center may be used. There are limits on the frequency of sleep tests. QualChoice contracts with freestanding sleep study centers which are eligible for payment of the technical component of sleep study services. For a list of sleep study centers go to Provider Directory, select Other Providers.
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.
Reference: Medical Coverage Policy BI306 for coverage on sleep testing.
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.
Reference: Medical Coverage Policy BI249 and BI217 for prosthetic and orthotic devices.
Codes – Current HCPC 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 rates vary by item needing repair or maintenance, 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.
Reference: Medical Coverage Policy BI352, repair and replacement of DME.
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 modifier “NU”. Any deviation from 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. Our Care Management Department must be contacted and the appropriate authorization obtained when special supplies are needed.
Excluded from coverage are personal comfort items, hygiene items, all over-the counter items, disposable items, or any equipment, devices, and supplies that are not primarily intended for medical use.