Quality Results
News and Updates for Providers
June 2017
Let's Collaborate!
We want to work more closely with providers to find the most efficient way to deliver high-quality, cost-effective, patient-friendly healthcare. In an effort to be better practice partners, we want to explore success factors with you and solicit your feedback. 

Read more.
Please Submit Medical Records for IVA
To complete the Initial Validation Audit (IVA) in compliance with the Affordable Care Act (ACA), representatives of Complete Provider Resource will be contacting providers in July 2017. The representatives will request member records with dates of service from January 1, 2016 to December 31, 2016. We appreciate your cooperation in this important time-sensitive request per your plan agreement.

Be Sure to Use In-Network Services
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.

Denial of Coverage for Procedure Change
When a radiologist changes a member's test or procedure and provides a service not requested by the ordering physician, coverage will be denied. In many instances, the ordering physician has already received pre-authorization for the ordered test.

Data Sharing to Prevent Fraud, Waste and Abuse
We are now submitting claims data to LexisNexis® Risk Solutions on a quarterly basis to be reviewed for fraud, waste and abuse.

Coverage Decisions
We work to make sure our members get the right healthcare in every care setting. We support proper care decisions based on medical necessity and the member's specific health plan. When a service needs pre-authorization, our Medical Director and clinical staff follow QualChoice Medical Coverage Policies and the peer-reviewed and nationally noted guidelines of MCG Health, LLC. 

Updated Forms
To make sure you are using current QualChoice forms, please download directly from the Forms page at QualChoice.com each time you need to use one.
In the Media
Stephen Compton of QualChoice gives important information on the risks for heart disease and stroke, and tells how to stay "heart healthy."
In the Community
Walk with Me - Aug. 19, 2017
One Walk - Oct. 8, 2017
Race for the Cure - Oct. 14, 2017
Dove Tree Wrapping Party -   Dec., 2017 (date TBA)

1704 NS 004