Coverage Policies

Important! Please note:

Current policies effective through April 30, 2024.

Take me to policies effective May 1, 2024.

Use the index below to search for coverage information on specific medical conditions.

High-Tech Imaging: High-Tech Imaging services are administered by National Imaging Associates, Inc. (NIA). For coverage information and authorizations, click here.

Medical Providers: Payment for care or services is based on eligibility, medical necessity and available benefits at time of service and is subject to all contractual exclusions and limitations, including pre-existing conditions if applicable.

Future eligibility cannot be guaranteed and should be rechecked at time of service. Verify benefits by signing into My Account or calling Customer Service at 800.235.7111 or 501.228.7111.

QualChoice follows care guidelines published by MCG Health.

Clinical Practice Guidelines for Providers (PDF)

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

INDEX:



Effective Date: 09/18/1995	Title: Sex Assignment
Revision Date: 01/01/2017	Document: BI064:00
CPT Code(s): None
Public Statement
*Effective Date:* a) This policy will apply to all services performed on or after the above revision date which will become the new effective date. b) For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply. Medical and surgical services, supplies and equipment intended to assist or complete the differentiation of a baby born with undifferentiated or ambiguous genitalia, will be covered.
Medical Statement
For children born with ambiguous genitalia, sex assignment and related charges are considered medically necessary and shall be covered as a basic medical service. Individualized therapy (mental health, hormones or surgery) provided for gender dysphoria (per DSM V criteria) may be covered according to guidelines in BI531.
Reference
Addendum: Effective 01/01/2017: Limited scope of policy to surgery for congenital ambiguous genitalia or indeterminate sex. Refer to (new) BI531 for individualized treatment of gender dysphoria.
Application to Products
Unless indicated otherwise, this policy applies to all QCA Health Plans, unless a specific limitation exists. Consult individual plan sponsor benefit descriptions for self-insured plans. In the event of a discrepancy between this policy and a self-insured customer’s benefit description, the benefits plan will be followed. Applicable state mandates will be followed with respect to self-funded non-ERISA plans and fully insured plans. Federal mandates will apply to all plans.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.

This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.