We pledge to treat our members with respect. As a QualChoice member, you have the right to:
- Information about QualChoice and its services.
- Access to health care providers in your plan’s network.
- Timely processing of claims, according to industry standards.
- Facts about how your claims were paid or denied. (Explanation of Benefits or EOB).
- Facts about your health, your care and likely outcome from a doctor or health expert in terms you can understand.
- Appoint another person to view and receive facts about your care.
- Information about treatment choices, no matter what the cost or benefit coverage.
- Know the name, title, and duties of any health care staff giving services to you.
- Work with health care experts in making your own health care choices.
- Emergency health care if you have a health problem that a reasonable person would believe needs immediate attention.
- Have all health care records treated as private unless the law allows them to be released.
- See all data in your health care records, subject to state and federal laws.
- Give your consent before the start of any surgery or care.
- Voice complaints and make appeals about QualChoice or your care, and receive a timely answer.
- Say no to any medicine, treatment or care from a network health care expert and to be informed of the health results and cost of refusing.
- Not be denied plan renewal based only on your health, as required by law.
- Be informed about and say no to any treatment that is experimental.
- Be informed of these rights and responsibilities.
- Give your opinion or suggest changes to our member rights and responsibilities policies.
You have the responsibility (duty) to:
- Give all facts needed for QualChoice and health care experts to give or arrange for care.
- Keep, or cancel in a timely way, all appointments with health care providers.
- Follow care plans that have been agreed on with your health care expert.
- Review your health plan and confirm benefits before receiving care.
- Show your ID card each time you get care.
- Discuss health care desires and/or concerns with doctors and other health care providers.
- Inform us of address or phone number changes so you can be sure of getting important messages.
- Use network doctors, facilities and other health care providers to receive full benefits.
- Pay any deductibles, copayments, or coinsurance amounts owed to health care providers.
- Learn about your health problems and take part in deciding on health care goals.
Your Rights and Protections Against Surprise Medical Bills
When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.
What is “balance billing” (sometimes called “surprise billing”)?
When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.
“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.
“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.
You are protected from balance billing for:
If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.
Certain services at an in-network hospital or ambulatory surgical center
When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.
If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.
You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.
When balance billing isn’t allowed, you also have the following protections:
- You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.
- Your health plan generally must:
- Cover emergency services without requiring you to get approval for services in advance (prior authorization).
- Cover emergency services by out-of-network providers.
- Base what you owe the provider or facility (cost-sharing) on what it would pay an in network provider or facility and show that amount in your explanation of benefits.
- Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.
If you believe you’ve been wrongly billed, please call us at 501.228.7111 or 800.235.7111 (TTY: 711).