Coverage Policies

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

Note: For Arkansas State or Public School employees, services subject to pre-authorization are managed by Active Health Management, as noted in their Summary Plan Description.

High-Tech Imaging: After February 28, 2021, eviCore will no longer administer high tech imaging and nuclear medicine for QualChoice. Effective March 1, 2021, those services will be 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.

If not specified in a QualChoice coverage policy (Benefit Interpretation), QualChoice follows care guidelines published by MCG Health.

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:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 09/18/1995 Title: Residential Facilities
Revision Date: 03/05/2014 Document: BI060:00
CPT Code(s): None
Public Statement

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.

Most QualChoice plans do not cover residential care; refer to your Benefit Summary. 

 

If your plan covers residential treatment for mental health and substance abuse disorders, see BI449.

 

For CHI covered enrollees see BI208

 

Residential facilities may be legally constituted to provide medical and other services to live-in residents. Programs that do not provide skilled medical services on a daily basis are not covered under any circumstances.  Examples of residential facilities include, but are not limited to:

 

  • Substance abuse after-care facilities
  • Spinal cord, brain injury, independent living facilities
  • Adolescent psychiatric residential facility

Medical Statement

Medical Policy Statement:

 

Residence in and care provided by a residential facility is typically not covered. Although residential facilities may be legally constituted to provide medical and other services to live-in residents, programs that do not provide skilled medical services on a daily basis are not covered. 

 

In certain cases, at the sole discretion of QualChoice, the care that is provided by a provider in a residential facility may be covered even if facility charges are not.  Preauthorization is required.

 

There may be specific cases that warrant creation of an exception to this policy, based on this care being an alternative to care at an acute or sub acute inpatient facility. All such cases should be referred to case management.


Application to Products

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.