Credentialing and Participation Requirements

Along with the credentialing information specified in your provider application, QualChoice is required to review the following information prior to the final assessment of each provider:

  • Licensure status in applicable states
  • DEA/CDS certificate, if applicable
  • Board Certification status
  • Malpractice Insurance coverage, dates and amounts
  • Work history
  • National Practitioner Data Bank reports
  • Education and training
  • Medicare/Medicaid sanctions
  • State disciplinary actions
  • Medicare opt-out reports

QualChoice will also review internal quality of care, service, and any member complaint reports. QualChoice will monitor providers’ quality of service based on a number of criteria:

  • Quality Issues
    • Care/Services not provided
    • Care/Services not provided in reasonable amount of time
    • Condition no better after treatment
    • Confidentiality breach
    • Error/delay in diagnosis
    • Error/delay in treatment
    • Informed consent issue
    • Member dissatisfied with treatment plan
    • Patient rights not otherwise classified
    • Poor communication
    • Provider discounted member’s statement
    • Quality issues not otherwise classified
  • Provider Behavior
    • Inappropriate conduct
    • Provider behavior not otherwise classified
    • Provider non-compliant
    • Provider Uncaring/insensitive
  • Pharmacy Issues
    • Count error
    • Delivery Error
    • Dose Error
    • Medication Error
    • Pharmacy issue not otherwise classified
  • Access Issues
    • Access issues not otherwise classified
    • After-hours access issues
    • Difficulty obtaining referral approval from PCP
    • Difficulty with referral coordination
    • Long wait in office/ED
    • Medical record issue
    • Member could not get an appointment in a timely manner
    • Member sees NP/PA instead of PCP despite specific request
    • New Member refused treatment
    • Office blocks access to provider
    • Provider sent member to ED instead of seeing in office
    • Provider will not return phone calls
    • Referral management
  • Office Staff
    • Office staff friendliness
    • Office communication adversely impacts interactions
    • Office staff will not return member’s phone calls
    • Office staff not otherwise classified
  • Environmental Issues
    • Safe environment

Confidentiality of Member Information

QualChoice treats all member and network provider records and information obtained from network provider as confidential. Disclosure of such records or information is only to the extent permitted by appropriate patient consent and authorization and as permitted or required by law. Member medical records are maintained in accordance with the requirements stated in the Provider Agreement.

Medical Records & Confidentiality

Record Maintenance

As stated in the Provider Agreement, network providers agree to maintain adequate and accurate medical and financial records concerning QualChoice members receiving Covered Medical Services.

Request for Medical Records

In accordance with the Provider Agreement, network providers will provide timely information and/or copies of member medical records to QualChoice or the applicable plan administrator without charge. All original medical records remain the property of the network provider and will not be removed or transferred from network provider except in accordance with applicable laws.

Failure to Submit Medical Records

Failure to provide medical records within 30 days for a submitted claim may result in non-payment. Failure to provide medical records when requested for a claim already paid may result in QualChoice recouping the payment. Repeated failure to provide requested records may result in termination of network status.

Confidential Information

The network provider agrees that confidential information received from QualChoice is not to be disclosed to any person or entity for any purpose except as authorized in writing by QualChoice or as required to fulfill obligations under their Provider Agreement or as otherwise required by law.

Likewise, QualChoice will maintain appropriate confidentiality of all materials received from network provider and will disclose such information only as required to fulfill its obligations under the Provider Agreement and as otherwise required by law.

Patient Consent and Authorization

Network provider agrees to obtain appropriate written patient consent and authorization to release medical records and information necessary for QualChoice to administer member benefits.

HIPAA Compliance

QualChoice is committed to the highest level of confidentiality with our members’ personal and medical information, and actively enforces the Health Insurance Portability and Accountability Act of 1996 (HIPAA) regulations. Our employees are held to high standards in accessing and maintaining confidential information as outlined in our corporate and departmental policies and procedures.

As a QualChoice participating provider it is your responsibility to comply and cause your agents, employees and subcontractors to comply, with all laws, rules, regulations and QualChoice policies and procedures that may now or hereafter be enacted or adopted with respect to the privacy or security of protected health information, as defined in HIPAA.

This includes, without limitation:

  • HIPAA privacy regulations, 45 C.F.R. Part 164,
  • Any guidelines issued by governmental authorities concerning such regulations, and,
  • Any QualChoice policies and procedures related to HIPAA regulations, as such policies are included in the Provider Manual.  Such policies may require that a Business Associate Agreement be executed. 

All QualChoice participating providers are responsible to meet all obligations under these laws, rules and regulations, by implementing such activities as monitoring changes in the laws, implementing appropriate mitigation and corrective actions, and timely distribution of notices to patients (members), government agencies and the media when applicable.

In the event that QualChoice receives a complaint or becomes aware of a potential violation or breach of an obligation to secure or protect member information by a provider, QualChoice will notify the provider and request that the provider respond to the allegation and implement the appropriate corrective action.

QualChoice recommends sending protected health information to QualChoice through our secure email service or by secure fax.

Network Participation Guidelines

The QualChoice Provider Agreement and the Provider Manual is between QCA Health Plan, Inc., and the Network Provider, a duly licensed provider in the state in which he/she practices. QualChoice Holdings, Inc., is the parent company of QCA Health Plan, Inc., and QualChoice Life and Health Insurance Company, Inc. (collectively 'QualChoice').

Practitioners requesting participation must complete the credentialing process and agree to follow network policies as defined in the Provider Agreement and the Provider Manual. For information about participation, please contact a Sr. Provider Relations Representative.

Utilization of Network Providers

To the extent permitted by law, and in accordance with procedures established by QualChoice, network provider shall cooperate and communicate freely with other health care entities providing health care services to members in order to establish integrated medical records.

Network provider, consistent with the exercise of his/her professional medical judgment; shall provide or arrange for the provision of Covered Medical Services to members through network providers unless:

  • pre-authorization for use of an out-of-network provider at the member’s in-network benefit level is obtained from QualChoice, or;
  • the member chooses to utilize his/her out-of-network benefits if such benefits are available under his/her health plan, or to assume full financial responsibility for the services rendered, if no out-of-network benefits are available. In the second event, network provider must document in writing the member’s decision to utilize his/her out-of-network benefits or to assume full financial responsibility for the out-of-network services in the member’s medical record, and provide such documentation to QualChoice upon request.

See also:

Out-of-Network Referrals

Learn more here.

Continuity of Care Plan for Cessation of Services

In the event of termination of an in-network provider of hospital, QualChoice will provide timely notification to members in order to maintain continuity of medical care services for our members. Members will be notified in writing of any significant changes in the availability or location of covered services, provider terminations, cessation of services or any other significant changes. QualChoice will assist members with transfers to alternate services in a timely manner whether the receiving provider is the same provider member had been seeing or a different provider.

Provider Termination

Provider or hospital terminations occur when the provider or hospital is no longer in the QualChoice network due to relocation outside the service area, death, retirement, de-credentialing or contract termination, request to cease participation in the QualChoice network, or is placed on restrictions with regards to debarment from the Federal Employee Health Benefit Plan.

QualChoice strives to provide at least a 30 days advance notice to members when a contract with a medical group, individually contracted provider, or hospital terminates. QualChoice providers and hospitals are required by their contracts to notify QualChoice when terminating from the network; however, there are times when no advance notification is received.

When no advance notification is received, QualChoice will update the on-line provider directory within 3 days of notification.

If the provider terminating is a Primary Care Physician, the process outlined in Consumer Notification of PCP Status Policy will be followed.

Medical Plan no longer offered to Member

Medical Plan terminations occur when the QualChoice no longer offers the benefit plan selected by the member. In some instances, QualChoice may no longer offer coverage in the geographic region where the member lives.

QualChoice will provide the required notification to the member when the benefit plan is being discontinued for any reason. The notification will include options available to the member and assistance in achieving those options.

Assignment of Benefits

Member Responsibility for Non-Covered Services

Network Terms, Conditions, & Credentialing Standards

QualChoice accepts providers into the network upon successful completion of the credentialing process. Should any provider fail to meet credentialing standards as set by QualChoice, QualChoice reserves the right to deny designation of the provider as a network provider.

Application and Appointment of Provider

Any provider applying as a network provider must complete the appropriate application and provide documentation of educational and professional credentials. To request an application, email pr@qualchoice.com.

The name of the network provider, practice addresses and phone numbers, specialty(ies), and educational and professional qualifications will be used by QualChoice for the purpose of informing members, prospective members, and other providers of the identity and qualifications of our network providers.

See also: 

Provider Changes and Updates

Notification of Changes in Status & Legal Actions

Medical Staff Membership

Network providers agree to maintain staff membership and privileges, or be able to facilitate arrangements for admissions, necessary to perform his/her obligations with at least one inpatient hospital network facility.

No Member Billing: Exceptions

Network provider shall not bill, charge, collect a deposit from, or seek compensation, remuneration or reimbursement from, or have any recourse against any member or persons other than QualChoice for Covered Medical Services. This includes, but is not limited to:

  • Nonpayment by or insolvency of QualChoice;
  • Payment disallowed in whole or in part because of the network provider’s failure to meet or comply with any of the applicable requirements of their Provider Agreement, including patient care reimbursement, authorization, and utilization review program requirements, or the policies, rules, or regulations of the applicable health plan.

Notification of Changes in Status and Legal Actions

Network provider must notify QualChoice in writing immediately of:

  • any change in Federal EIN number, practice name or address(es) or patient accessibility, or,
  • any action or proceeding with respect to his/her licenses or,
  • any change in his/her certification or accreditation by any association or organization of provider specialists, or,
  • the occurrence of any of the events specified in their Provider Agreement.

We encourage all network providers to check their listing in our Provider Directory to ensure the information we provide to our members is accurate.

If any information is incorrect, a Provider Information Change Form must be submitted to QualChoice within thirty (30) days prior to the effective date to ensure accurate data is displayed on the Provider Directory and to avoid impacts to claims processing.

Policies and Procedures and Terms and Condition

QualChoice has adopted and amends, supplements, or modifies from time to time, rules, regulations, and policies necessary to illustrate, implement, or clarify the terms and provisions of its health plans. Further, QualChoice may amend, supplement or modify its programs and procedures as needed to meet its obligations under the Provider Agreement or its agreements with its payers, or to comply with state and federal laws.

QualChoice shall provide written notice to network provider at least 30 days in advance of the effective date of any amendment or supplement to any such rule, regulation, policy or procedure.

Provider Subcontracting

Participating providers who subcontract or delegate any function of the Provider Agreement to process, handle, or access QualChoice member protected health information in oral, written or electronic form, must submit specific subcontracting information to QualChoice.

  1. Participating providers agree to require each current subcontracted provider to sign and return a Network Provider Agreement to QualChoice within ten (10) business days of the network provider signing their contract with QualChoice.
  2. If participating provider has not contracted with any new subcontracted providers; and if participating provider does not bill and collect for services of a subcontracted provider, then the participating provider agrees to require each new subcontracted provider to enter into a Network Provider Agreement with QualChoice on terms acceptable to QualChoice within thirty (30) days of becoming a subcontracted provider.
  3. Participating facility providers agree to provide QualChoice with credentialing and other information, as required by QualChoice, concerning any subcontracted providers. Following review of such information, QualChoice will advise participating facility if such provider has been approved as a Network Provider.
  4. Participating providers agree to promptly amend agreements with subcontractors, in the manner requested by QualChoice, to meet any additional requirements that may apply to the services..

If you have any questions regarding provider subcontracting or to obtain a copy of the Network Provider Agreement, contact Provider Services at pr@qualchoice.com or by phone at 501.228.7111 or 800.235.7111, ext. 7011.

Dispute Resolution and Arbitration — Administrative and Professional

Payment Reconsideration and Appeals

Note: The provisions of this section are considered separate and distinct from the arbitration provisions set forth in the Provider's Agreement.

All participating providers have a right to request reconsideration of any payment determination made by QualChoice. A Request for Reconsideration form must be submitted within the time frames noted below. The request should be accompanied by a copy of the notice of the standard denial or other documentation of the denial, an explanation outlining the details of the request for a review and all documentation to support a reversal of the decision, up to and including any medical records relevant to the dispute. Failure to include required information may result in the request being rejected.

For greater efficiency, providers are encouraged to pursue resolution with a Customer Service representative prior to filing a reconsideration request.

Type of Claim Dispute Time Frame to Submit
Claim dispute over timely filing requirements See Provider's Agreement
Claim dispute over contracted rate 180 days from the date on the original RA
Claim dispute over CPT Codes 180 days from the date on the original RA
Claim denied - failure to obtain pre-authorization 60 days from the date on the original RA
Claim dispute over medical determinations See Appeal for Medical Determinations

Contracted facility time frames in Provider Agreements supersede time frames in this Manual.

A. Timely Filing of Claims 

A provider may submit EDI information which proves claims were submitted timely and demonstration of timely follow-up. This information will be reviewed and a written decision issued within thirty (30) calendar days of submitting a Request for Reconsideration. If the insurance filed shows a plan other than QualChoice, the provider should include any information on when he/she was notified of other insurance and any circumstances that caused the delay.

If the provider can document that the member did not notify the provider that QualChoice was the correct insurance plan, and the provider made appropriate attempts to obtain that information, it may be determined that the claim should not be filed and the member can be billed by the provider -- if permitted by the member's policy.

If the provider continues to dispute the determination, the provider may file an appeal. A final decision will be made by our Internal Appeals Committee within thirty (30) days of the appeal.

B. Contracted Rate

When a provider disputes a claim not paid at the contracted rate, the provider has 180 days from the date on the original RA to submit a Request for Reconsideration along with any relevant rationale and documentation. The request is reviewed and a decision issued within 30 calendar days.

C. CPT Codes

When a claim determination based on CPT codes is disputed, a provider has 180 days from the date on the original RA to submit a Request for Reconsideration along with any relevant rationale and documentation. The request is reviewed and a decision issued within 30 calendar days.

  • If coding determination reflects a National Correct Coding Initiative (NCCI) edit, the decision is final.
  • If coding determination does not reflect an NCCI edit, and the provider disputes the determination, a final decision will be issued within 30 calendar days of the request.

D. Failure to Obtain Pre-Authorization for Services

When a claim is denied because pre-authorization was not obtained, a provider has 60 days from the date on the original RA to submit a Provider Appeal Form along with any relevant rationale and documentation. The request is reviewed and if the denial is not overturned, the request is considered a provider appeal and presented to our Internal Appeals Committee for a final decision within 30 days of the appeal.

A provider who violates an explicit contract provision (for example, failure to maintain an active license) and is removed from participation in the QualChoice network does not have any rights to dispute the decision.

As specified in the Provider Agreement (see "Selection, Designation and Removal of Network Provider"), a provider failing to cooperate with administrative requirements or continuing to violate administrative requirements may be removed from participation in the QualChoice network for cause. 

Administrative Dispute Resolutions

  1. The provider is notified by certified mail, return receipt requested, or overnight delivery that its network participation is being terminated for cause with the termination effective in the time frame specified in the Provider’s Agreement. The provider is deemed to have received the notification three (3) business days after it is sent.
  2. A provider who wishes to appeal Termination for Cause must notify QualChoice in writing within ten (10) business days of receipt of the notification of termination.
  3. QualChoice will assemble a dispute hearing panel within twenty (20) business days following receipt of notification of a provider’s appeal of the termination.
  4. The decision of this panel is final.

Rights of the Appellant

  • The appellant may, but is not required to, appear before the panel in person or by telephone.
  • The appellant may provide any additional written information believed to be relevant to the decision.
  • The appellant may appear with a legal representative. If the appellant is represented by counsel, QualChoice must be notified at least five (5) business days before the panel meets. In that case, QualChoice may also choose to be represented by counsel.

Professional Dispute Resolution

If it is determined that a contracted provider has acted in a manner that violates standards of professional competence or conduct, QualChoice may take action to suspend or terminate a provider’s participation in the QualChoice network.

If the provider disputes the action taken by QualChoice, the provider may enter a formal dispute resolution process. The purpose of the dispute resolution process is to protect the provider’s rights and the safety of our members.

For the purpose of the Professional Dispute Resolution, the term ‘provider’ applies to any person who contracts to provide services to members of a QualChoice administered health plan and whose ability to render such services is subject to licensing by an agency of the Arkansas state government, or would be subject to licensing by such agency if the provider practiced in the state of Arkansas, and whose participating status is determined by action of the QualChoice Credentialing Committee. The term shall not refer to any corporate entity.

Summary Suspension or Termination for Cause

  1. Summary Suspension: QualChoice may summarily suspend any provider if in the opinion of QualChoice the provider is engaged in behavior or is practicing in a manner that appears to pose a significant risk to the health, welfare, or safety of the provider’s patients.
  2. Termination for Cause: QualChoice may terminate a provider for cause if it is determined that the provider is not competent to safely render medical services or is practicing in a way that violates norms of professional conduct. Grounds for such termination include acts, demeanor, or conduct which is:
    • Below professional standards
    • Detrimental to patient safety or to the delivery of quality patient care
    • A failure to keep adequate medical records
    • Unethical (in violation of the AMA Code of Ethics or other appropriate professional body)
    • A violation of federal or Arkansas state law

Notifications

    1. Summary Suspension: The provider is immediately notified by telephone or fax. Summary suspension is effective immediately upon the decision, whether or not confirmation of notification is received. The provider is deemed to have received the notification three (3) business days after it is sent. A suspended provider wishing to appeal must notify QualChoice within five (5) business days of receipt of the notification letter.
    2. Termination for Cause: The provider is notified by certified mail that its network participation is being terminated for cause, with the termination effective thirty (30) days after the date of the notification letter. A provider wishing to appeal termination for cause must notify QualChoice within ten (10) business days of receipt of the notification letter.

First Level Appeal Panel

A First Level Appeal Panel is assembled within twenty (20) business days following notification that a provider is appealing the termination for cause or ten (10) business days for suspended providers. The panel will consist of at least three (3) members who have not previously been involved in the dispute. At least one member will be a participating provider who is a clinical peer of the appellant.

Rights of the Appellant

      • The appellant may, but is not required to, appear before the panel in person or by telephone.
      • The appellant may appear with a legal representative. If the appellant chooses to be represented by counsel the appellant must notify QualChoice at least five (5) business days before the panel meets. In that case, QualChoice may also choose to have legal counsel present.
      • The appellant may provide additional written material prior to the meeting. If such material is provided it must be submitted at least five (5) business days prior to the meeting.
      • If the First Level Appeal Panel overturns the suspension or termination, QualChoice will immediately return the provider to full participation retroactive to the suspension or termination date.
      • If the panel upholds the suspension or termination, the appellant has the right to a final appeal. See Final Appeal Panel information below.
      • The appellant will be notified by certified mail, return receipt requested, or overnight delivery, of the panel’s decision within ten (10) business days for Termination for Cause or five (5) business days for a Summary Suspension.

Final Appeal Panel

If the provider appeals the decision of the First Level Appeal Panel, QualChoice must be notified as follows:

      • Termination for Cause: Within ten (10) business days of receipt of the notification by the First Level Appeal Panel.
      • Summary Suspension: Within five (5) business days of receipt of the notification by the First Level Appeal Panel.

A Final Appeal Panel will meet within thirty (30) calendar days for Termination for Cause or fifteen (15) calendar days for Summary Suspension. The Final Appeal Panel will consist of at least three (3) members who have not been previously involved in the dispute. At least one member will be a clinical peer of the appellant.

If the panel overturns the suspension or termination: provider is immediately returned to full participation retroactive to the suspension or termination date.

If the panel upholds the suspension or termination: provider is suspended/terminated from the network effective the date of the original suspension/termination. The decision of the panel is final.

The Final Appeal Panel will notify the appellant by certified mail, return receipt requested, or overnight delivery of its decision as follows:

      • Termination for Cause: Within ten (10) business days of the meeting 
      • Summary Suspension: Within five (5) business days of the meeting 

Rights of the Appellant

    • The appellant may, but is not required to, appear before the panel in person or by telephone.
    • The appellant may appear with a legal representative. If the appellant chooses to be represented by counsel the appellant must notify QualChoice at least five (5) business days before the panel meets. In that case, QualChoice may also choose to have legal counsel present.
    • No additional information will be accepted for consideration by the Final Appeal Panel.