QualChoice Health Insurance
December 1, 2016
In This Issue
Medical Policy Review
 
New or Revised Forms
Check the Provider Forms & Information page at QualChoice.com frequently for the most current forms.

Your Provider Relations Representatives
Call your Provider Relations Representatives for any questions: 800.235.7111 or 501.228.7111, Monday-Friday, 8:00 a.m. to 5:00 p.m. (CST).

Amanda Davis
800.235.7111, ext. 5279
 
Doug Kabrey
800.235.7111, ext. 5726
 
Britt Knopp
800.235.7111, ext. 5245
 
Lisa Baker
800.235.7111, ext. 5345

ALERTS AND REMINDERS
Individual Metallic Plan Members 
Must Have PCP
Beginning January 1, 2017, all members of QualChoice individual metallic plans (Bronze, Silver, Gold, Platinum and Catastrophic) will be in the Select network and will be required to choose a PCP. Members who do not choose a provider will be assigned one. These members will have a unique QualChoice card.

Rosters of newly assigned members will be available through My Account* under the Provider Reports tab.
 
Specialists filing claims for these members will be required to submit the referring PCP's name and NPI # when billing for services with POS codes 11, 12, 17, 19, 22 and 24. PCP name and NPI are NOT required for POS codes 20, 21, 23 and 81.
 
*If you haven't registered for the new My Account provider portal, view the step-by-step video here: Using My Account. 
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.
 
Advantmed, a medical record retrieval company, will contact your office by fax and telephone to collect medical records on our behalf.
  • Data collection begins in February and continues through the first week of May 2017.
  • Information will be collected from individual medical records randomly selected throughout our network.
For any questions or concerns regarding the HEDIS data collection, please contact your QualChoice Provider Relations Representative.
Reconsideration and Appeals Update
A new Provider Appeal Form is now ready to use for clinical denials only. Clinical denials include:
  • Not medically necessary
  • Experimental and investigational
  • Lack of pre-auth when the amounts are provider liability
The Request for Reconsideration Form has been for use with administrative denials only. Administrative denials include:
  • Timely filing
  • Clinical edits
  • Coding
  • Reimbursement, etc.
New eviCore Portal for Radiology 
Pre-Authorization
Beginning Dec.3, users visiting CareCore National and MedSolutions sites will be automatically redirected to the new eviCore.com. Inside the portal will be all the forms and guides you use today, without needing to log out between patients.
 
Pre-authorization is required for the procedures listed below, rendered in an outpatient setting such as a physician's office, free-standing center (including radiology center) or hospital outpatient department.

* CT Scan
* Nuclear Medicine
* Nuclear Cardiology
* MRI/MRA
* PET Scan
 
For Pre-authorization Online, go to QualChoice.com. After provider log-in, select Pre-authorization for Radiology ServicesPhone: 800.533.1206; Mon.-Fri., 7:00 a.m.-7:00 p.m.
 
Request pre-authorization at least 5 business days prior to date of service to allow for follow-up/review time. Provider NPI # is required. File claims with QualChoice.
RetinaVue Diabetic Retinopathy Screening
Primary Care Providers have a new resource in managing the care of patients with diabetes. The RetinaVue Network enables PCPs to easily perform retinal exams in a primary care setting. The four-step process is simple:
  1. Use a handheld device, the Welch Allyn RetinaVueTM 100 Imager, to acquire non-mydriatic fundus images.
  2. Transfer images through a HIPAA-compliant RetinaVue Network.
  3. A board-certified retinal specialist evaluates the images.
  4. A diagnostic report with referral/screening plan is returned to the PCP the same day--usually completed in 90 minutes.
RetinaVue exams count toward the HEDIS measure of annual diabetic exams, and QualChoice reimburses for the codes used. Patient compliance also increases, since screening for diabetic retinopathy can take place during a routine office visit. 
INDUSTRY NEWS
CPC+ Update
The Centers for Medicare & Medicaid Services (CMS) has announced the practices selected for the Comprehensive Primary Care Plus (CPC+) model. QualChoice will reach out to those practices for contract amendments.
 
CPC+ integrates many insights from the original CPC initiative, including 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.