QualChoice Quality Results Provider Newsletter

The Centers for Medicare & Medicaid Services (CMS) five-year CPC+ multi-payer model began in January 2017. Arkansas has been chosen as one of 14 regions nationally to participate.

QualChoice is pleased to take part in this improvement initiative, and will join the program as a participating payer on April 1, 2017. Contracts were mailed in mid-February to CPC+ enrolled providers, who are asked to sign and return the contracts no later than March 15, 2017 in order to participate with QualChoice in the program.

For general questions about CPC+, visit the Centers for Medicare and Medicaid Services.

Using the Correct Request Form

Only a Request for Reconsideration form will be accepted for claims reconsideration for members enrolled in QualChoice health plans. See Section IV of the Request for Reconsideration form for a list of reasons to make a reconsideration request.

Clinical denials (such as not medically necessary, experimental and investigational or when claim amounts are provider liability) are not eligible for the reconsideration process and should be handled via the Provider Appeal Form.

NOTE: A request submitted on the wrong form will not be reviewed.

To ensure you are using the latest version of a form, download it from QualChoice.com. Select Providers, Forms/Information.

Medical Record Review for HEDIS Reporting

QualChoice is compiling data on 2016 clinical outcomes to demonstrate performance on Healthcare Effectiveness Data and Information Set (HEDIS) standards, which are designed to help consumers compare performance across plans.

Record collection began in February and will continue through mid-May. Advantmed, a medical record retrieval company, will contact provider offices by fax and telephone to collect medical records on our behalf.

CERiS Review Program

Because QualChoice has a fiduciary duty to review all claims for accuracy, CERiS is currently performing line item reviews of facility claims for QualChoice. CERiS is an independent facility claim review service whose professional review process identifies errors, unrelated charges, and non-separately billable charges on facility claims for inpatient and outpatient services. Any individual facility charges disallowed by CERiS are identified specifically in accordance with CMS' published billing guidelines.

Stay Connected! Sign Up for My Account

The original provider portal will soon be unavailable. To maintain access to your QualChoice account, please sign up for the My Account portal.

My Account is streamlined, easy-to-read and mobile-friendly. View claims and pre-authorizations, generate reports, check member eligibility and more. Register now to access the My Account provider portal pages. View the step-by-step video here: Using My Account .

If you've already signed up for My Account, thank you!

Individual Metallic Plan Members Must Have PCP

Beginning January 1, 2017, all members of QualChoice individual metallic plans (Bronze, Silver, Gold, Platinum and Catastrophic) were included in the Select network and were required to choose a PCP. Members who did not choose a primary care provider were assigned one. Rosters of newly assigned members are available through My Account under the Provider Reports tab.

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