Have questions about your health plan, coverage or claims? Look through the many
topics below and see if we have addressed it. If not, you should call or email us
– we are happy to help you.
If I have questions about my bill, whom do I call?
You have several options if you have a billing question. Claims information is available
to you on-line under Members Tools, Check Claim Status and also through our automated
voice system 24-7. If you need to speak to a QualCare Advocate, they will gladly
assist you at 800-992-6613, Monday through Friday from 8 AM to 6 PM (EST).
How do I change my Primary Care Provider (PCP)?
Not all QualCare plans require the use of a PCP, but if your specific plan does,
changing your Primary Care Provider is easy and quick. First, you will need to select
a new physician that is part of our network. You can do that on our Home Page by
clicking on Find a Doctor. Once you select your new PCP call us at 800-992-6613,
Monday through Friday from 8 AM to 6 PM (EST). We can make that change for you quickly
and with no hassle.
How do I know how much my co-payment will be or whether I even have to pay it?
You can find out how much your co-payments are on-line by going to Member Tools
and then selecting View Benefit Summary. We also have a Plan Hotline that you can
call at 800-992-6613, Monday through Friday from 8 AM to 6 PM (EST).
How is a deductible different from a co-payment and how do if I know how much I have
A deductible is the amount of covered medical expenses you will pay out of your
own pocket each calendar year before benefits begin to be paid by your health plan.
Your deductible only applies to certain expenses. A co-payment is the fee charged
to you for a covered medical expense or for a covered prescription drug expense.
It is easy to find out the status of your deductible payment by calling our Plan
Hotline toll free at 800-992-6613, Monday through Friday from 8 AM to 6 PM (EST).
For information about co-payments you can go to Member Tools and click on View Benefit
Summary or call us at the toll free number listed above.
Health Plan Coverage
How can I find out what is covered by my health plan?
You have 24-7, online access to information about your health plan. Simply look
under Members Tools and click on View Benefit Summary. You also can call us at 800-992-6613,
Monday through Friday from 8 AM to 6 PM, if you would prefer to speak to one of
our Customer Service Advocates.
Health Care Reform
How will national health care reform affect me?
The passage of the Patient Protection and Affordable Care Act on March 23, 2010
was intended to move the nation closer to providing all Americans with access to
health care coverage. Some of its provisions became effective on September 23, 2010,
but the most comprehensive elements will not be in place until 2014. QualCare is
committed to full compliance with the new law, and we are fulfilling our obligation
to implement new benefit and health plan requirements.
Below, we have briefly outlined the reforms that are effective now and while no
one knows how the new law will play out, we have tried to help by sharing our understanding
of some of the reforms that will affect you immediately.
The three provisions that will directly affect you this year are:
1. Lifetime dollar limits on essential benefits are eliminated and the phase out
of annual dollar limits on essential benefits begins.
2. Dependents coverage up to the age of 26 is mandated
3. Pre-existing condition exclusions for enrollees under 19 years of age are no
Naturally this is just a quick overview of the most immediate tenets of the law,
but if you are interested in learning more there are many sites which can assist
What online services does QualCare offer?
You can review your membership information, check the status of a claim, search
for in-network providers, locate a hospital near your work or home, download forms
and documents, and view our medical policies.
These online services are listed under Member Tools on our Home Page.
What if a doctor is not in your network but I would like to go to him/her?
You should first check to see if your health plan covers out-of-network costs. In-network
physicians have a pre-negotiated contract with QualCare and therefore your costs
If your plan provides out-of-network benefits and you choose to go to an out-of-network
physician you will be responsible for the deductible and co-insurance specified
in your plan. Also, because the physician does not have a pre-negotiated contract
with QualCare, you may be responsible for the amount in excess of the plan’s allowed
amount up to the covered services.
If your plan does not provide out-of-network benefits and you choose to go to an
out-of-network provider you may be responsible for all costs.
In the case of an emergency, you may use a participating or non-participating provider
at the in-network level of cost share and QualCare will hold you harmless from any
balance bill amount.
How do I know if I need to get pre-certification for a procedure?
All specialty services require pre-certification as well as in-patient and outpatient
procedures, except for emergency care, which requires notification only. You can
find this information online by visiting Member Tools, View Benefit Summary.
Once you have determined you need a pre-certification, you can contact our Plan
Hotline for assistance toll free at 800-992-6613, Monday through Friday, 8 AM to
6 PM (EST) to get your pre-certification. Please allow three to five business days
for the pre-certification process.
What happens if I lose my job? Will I still have health plan coverage?
Please contact your former employer’s benefits office to understand your continuation
of health benefit options.
Researching Health Treatment Options
How can I research my health care options (ie. hospitals and treatment options)?
QualCare’s My Health Manager lets you compare hospitals and treatment options. It
also gives you the ability to read about the latest in medical news, check out prevention
tips and map out a health improvement plan for you and your family.
How do referrals work? What if I don’t get one and I need one?
Depending on what type of health plan you have, you may or may not need a referral
for certain services. You can go to Member Tools and click on View Benefit Summary,
to determine if you are need to get a referral. You also can call us toll free at
800-992-6613, Monday through Friday from 8 AM to 6 PM.
If you receive medical services that required a referral you may pay more for that
service or it may not be covered.
If I am traveling and get sick what happens?
For routine medical treatment, you are required to obtain medical coverage from
network providers. You are covered only for emergency and urgent care once you travel
outside the service area.