Be Sure to Use In-Network Services 

Referring patients to out-of-network laboratory or pathology groups violates your provider's agreement with QualChoice, and causes patients to pay significantly more for these services. When services are not available through an in-network provider, participating providers must contact Care Management at 800.235.7111, ext. 7014 to submit an Out-of-Network Authorization Request Form. Read More

As released in a July 26, 2013 announcement, the U.S. Food and Drug Administration (FDA) limits use of Nizoral (ketoconazole) oral tablets due to potentially fatal liver injury and risk of drug interactions and adrenal gland problems.

• Determinations for these admissions will be made for medical necessity, appropriate length of stay and level of care based on nationally accepted industry standards and following ARBenefits Medical Policies.
• Failure to obtain appropriate pre-certification will result in the facility writing off the charges for covered services.

For ARBenefits pre-certification, call 1.877.815.1017. Follow the prompts for the American Health Holding intake staff.

Updated Drug Formularies 

Updated Basic, Core, Enhanced and Federal formularies, effective September 1, have been posted at qualchoice.com. The Essential Formulary, for all Affordable Care Act Qualified Health Plans (Gold, Silver, Bronze, Catastrophic) has also been posted there. It will be effective January 1, 2014.

Feds OK Arkansas Medicaid Expansion 

ModernHealthcare.com

The Obama administration will allow Arkansas to move forward with a widely watched plan to expand Medicaid to cover an additional 200,000 residents by giving most of them premium assistance for plans in the state health insurance exchange. Read the entire article.

ClaimCheck Plus Modifier Tips 

Make sure modifiers are valid for procedures; if they are not, the claim line will be denied. Some examples/guidelines are:

• Make sure modifiers are valid for the procedure being billed or the claim line will be denied.
• Modifier 50, bilateral, is not valid on a procedure with bilateral in the description or with PT/OT codes.
• RT or LT is not valid on a procedure with bilateral in the description. Read More

Quality Results is your newsletter, designed to serve you, our valued network providers. Your views are important to us. If you have ideas for articles, or suggestions to improve this newsletter, please e-mail us at
 newseditor@qualchoice.com