Frequently Asked Questions

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.

Billing Questions

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).

Changing PCP

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 to pay?
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 longer allowed.

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 you.

On-Line Services

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.

Out-of-Network Doctors

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 are lower.

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.

Job Loss

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.

Travel/Emergency Care

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.

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