My Account: Sign in Register Home Shop Plans & Services Already a Member? For Brokers For Providers News & Tips About Accreditation and Quality Home About Us Accreditation and Quality Accreditation and Audits QualChoice is committed to excellence and quality in our products and services. To demonstrate that commitment, we are audited and accredited by leading independent organizations who work to improve quality through review and reporting. NCQA—The National Committee for Quality Assurance (NCQA) is a nonprofit organization dedicated to improving healthcare quality. The NCQA seal is a widely recognized symbol of quality. Organizations displaying the seal must pass a rigorous review and report on their performance each year. Their Healthcare Effectiveness Data and Information Set (HEDIS) standards ensure that purchasers and consumers have the information they need to compare healthcare quality. QCA Health Plan, Inc. (QCA) and QualChoice Life and Health Insurance Company, Inc. (QCLH) currently hold NCQA Interim Health Plan Accreditation. The accreditation includes Commercial-HMO and Exchange-HMO (QCA) as well as Exchange-PPO (QCLH) product lines. The interim accreditation is effective as of April 24, 2020 and expires on October 24, 2021. Promoting Quality and Safety by Empowering our Members We empower our members to take an active role in their care and the care of their families. We urge them to ask questions, understand conditions and treatments and evaluate options. We assist members in: Choosing quality doctors and hospitals Accessing health information Following health and immunization guidelines Improving Quality of Care and Patient Safety through Partnerships Provider Network—We know that improving healthcare quality is a team effort. That’s why our network includes some of the best doctors and hospitals in the state. We review Primary Care Provider (PCP) medical records periodically for compliance with standard medical record-keeping, documentation and standard medical practices. Pharmacy Network—Prescriptions filled by QualChoice members at Optum-participating pharmacies are screened for safety and appropriateness. Factors considered include: drug-age conflict, drug-drug interaction, drug-pregnancy conflict, drug-disease conflict, late refill, refill too soon, therapeutic duplication, low daily dose, excessive use and high daily dose. Organizational Collaboration—QualChoice collaborates with national organizations aimed at increasing patient safety, including: National Quality Forum National Patient Safety Foundation America's Health Insurance Plans Additional Information For Members For Providers Get the Most from Your Coverage You deserve quality healthcare. And you also deserve to have the information you need to get the most from your coverage. Goals for quality are set and reviewed by your health plan to make sure you get the care you need. This information is part of a Quality Program designed to improve the services and care you receive. It provides details about your coverage and services available to you. Contact Customer Service to learn more about the Quality Program. Know Your Rights Being a member means there are things you should expect from your health plan. These are some of your rights: You should have access to all the services available to members. You should be treated with courtesy and respect. You should be able to get a copy of your medical record. You should know your medical data will be kept private. There are policies in place to guard your health records and protected health information. It’s also important to know what you can do to get the most from your coverage: Ask questions if you don’t understand your rights. Be sure to keep your scheduled appointments. Keep your Member ID Card with you so you have it at appointments. Tell your doctor if you have gotten care in an emergency room. The full list of rights and responsibilities is in your Member Handbook. Getting the Care You Need PRIMARY CARE PROVIDER (PCP) Your PCP is the doctor you’ll see for routine checkups and care. Your PCP will help find other types of healthcare providers if you need one. You can also search Find a Doctor or Hospital on the QualChoice website to find a PCP or specialist. MAKING APPOINTMENTS You should be able to schedule an appointment with your PCP and get medical care when you need it. You may have to wait a little longer to get in to see certain other types of providers, like specialists. Call Customer Service if you can’t get an appointment in a timely manner. GETTING PRESCRIPTIONS FILLED You should get high quality medications and the right treatment for your conditions. But not all drugs are covered. And some may need to be approved before they’re covered. The Preferred Drug List (PDL) is located on your health plan website. It is updated regularly and lists drugs that are covered by insurance. Talk to your doctor or pharmacist to review the PDL and answer questions about your medications. KNOWING IF A SERVICE IS COVERED The Utilization Management (UM) Department looks at your health records and may also talk with your doctor to decide if a service you need is covered. These decisions are not based on financial reasons. And doctors and staff are not rewarded for saying no to care. All UM decisions are based on: If the service is medically necessary If the service works well If the service is right for you NEW SERVICES AND TECHNOLOGY New medicines, tests and procedures come out every year. A team of doctors and other experts decide if new medical care will be covered by your health plan. Your plan covers care that is medically necessary. Not every new medical service is covered for all members. IF A SERVICE IS DENIED If a service is denied, you have the right to appeal that decision. You will be sent a letter explaining how to make an appeal. All appeal requests are decided according to your request, condition and benefits. GETTING MORE HELP IF YOU NEED IT Care Management is for members who may need extra help taking care of their health. Some people have several health conditions and see more than one doctor. Others need help arranging the services their doctors may have ordered. Working with a care manager lets you understand major health problems, work well with your doctors and get the care you need. Get More Information Your Member Handbook is a great source for information about your coverage and benefits. It also lists important phone numbers. You can also contact Customer Service for additional help at 800.235.7111or TDD/TTY: 711. Translation services are available if you need them. Contact Customer Service to get: A paper copy of your Member Handbook, Privacy Notice or anything on your health plan website Help finding a doctor and making an appointment Help speaking with a care manager Help with an appeal for a service that’s been denied QualChoice.com also has a lot of helpful information. Visit it to find the Member Handbook, Find a Doctor or Hospital tool, and the Preferred Drug List. You can also use it to help you manage your health and send a message directly to QualChoice using the QuicQuestions tool. Creating an online MyAccount member account is free and easy. With it, you can: Find or change your PCP Request a new Member ID Card or print a temporary ID Card View and update your personal information View your claims information QualChoice is committed to giving great customer service! 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