- Review Your Demographic Information
- Taxonomy Code Update
- Diabetes and Eye Health Outreach
- New Online Member Portal
- Be Sure to Use In-Network Services
- CPC+ Update
- New and Amended Medical Coverage Policies
Alerts and Reminders
Healthcare Provider Taxonomy Codes are designed to categorize the type, classification, and/or specialization of health care providers. The National Plan and Provider Enumerator System (NPPES) requires providers to enter this 10-digit expanded specialty code when applying for their NPI.
The taxonomy code is important because the Arkansas Insurance Department (AID) will now be using a provider’s taxonomy code to assist in determining the network adequacy of the payers involved in the Health Insurance Marketplace. In conjunction with the information being sent to AID from the payers, AID will use the taxonomy code attached to a provider’s NPI that is on file at the NPPES. If a provider’s taxonomy has changed or a provider believes his/her taxonomy codes need to be more specific, the provider should go to the NPPES and revise the taxonomy code.
Some reasons to revise a taxonomy code:
- A physician might have completed an additional fellowship.
- A certified nurse practitioner may have started collaborating with a specialist and is no longer in the primary arena.
- A facility may have built a new wing for additional services.
Please update any needed information to ensure correct benefit adjudication and network adequacy.
Because diabetes is the leading cause of new cases of blindness in adults, our Care Management team is reaching out to QualChoice members and others through Primary Care Providers.
QualChoice Provider Representatives are visiting PCP clinics to offer them educational materials to share with their patients. The materials encourage diabetics to take steps to manage their vision, including getting an annual eye exam.
New more streamlined, easier-to-read, mobile-friendly member account pages are now live. We're proud to provide this improvement to make health insurance simpler for our members. FAQs, a downloadable user guide and video tutorials are available at QualChoice.com. New and improved Employer, Broker and Provider account pages are also in the works.
Contracted QualChoice providers are required to use in-network laboratory or pathology groups. Using out-of-network facilities violates your agreement with QualChoice and causes patients to pay significantly more for these services. When services are not available through an in-network provider, contact Care Management at 800.235.7111, ext. 7014 to submit an Out-of-Network Authorization Request Form.
To find a participating independent provider, go to QualChoice.com, select Provider Search.
Non-participating Provider Reimbursement
Services from a non-participating provider (even in an in-network setting) are now reimbursed to the member. Example: An insured member goes to an outpatient facility and the in-network specialist uses a non-participating anesthesiologist during a procedure. Non-participating providers receive a one-time notification of this reimbursement policy. The notice advises them that they are responsible for collecting payment directly from the insured member and that QualChoice is open to contracting directly with them.
Please make sure to refer patients to in-network facilities for services such as genetic testing, other lab work, DME and anesthesia.
BRCA Genetic Testing
It is extremely important to use in-network labs to order BRCA testing, to avoid high cost share for members and providers. In-network BRCA testing for QualChoice members is available at Lab Corp. All genetic testing for QualChoice members requires pre-authorization.
The Centers for Medicare & Medicaid Services (CMS) is introducing the Comprehensive Primary Care Plus (CPC+) model. CPC+ integrates many insights from the original CPC initiative, including the critical role of practice readiness, aligned payment reform, actionable performance-based incentives, and robust data sharing. It offers an innovative payment structure to support providers’ ability to deliver high-value and high-quality care.
Participating practices may choose from two tracks. Track 1 will most closely resemble the original CPC model, while track 2 will require more advanced competencies. Practices can apply for either track, but CMS will determine practice competencies required for each track.
The five-year CPC+ multi-payer model will begin in January 2017. Payer proposals were solicited beginning in April 2016 in order to identify regions with high payer interest. Once the regions are announced by CMS, eligible practices may apply up until September 1.