Individual and Small Group Metallic Plans Chart Chase Program

QualChoice is required by the Centers for Medicare & Medicaid Services (CMS) to submit complete diagnostic data regarding members enrolled in our individual and small group metallic health plans. As a valued part of our provider network, your cooperation and support in facilitating a medical record review is key to gathering this information.

We have partnered with Change Healthcare, Datafied, and Ciox® to conduct the medical chart review. A representative from one of these vendors will work with you to provide retrieval options and a list of the requested members’ medical records.

QualChoice now offers a bidirectional feed into your Electronic Medical Record (EMR) to help increase efficiency and accuracy in closing care gaps. If you are currently using Healow, Epic, Meditech, Oracle Cerner®, or Veradigm® (formerly Allscripts), email our risk adjustment team at [email protected] for details about this new tool. You can also contact them for information about our other programs, as well as questions about ICD-10 coding and documentation.

Want to learn more about risk adjustment? Visit our For Providers page at QualChoice.com to access helpful forms and information. 

End of the Federal Public Health Emergency

Earlier this year, the Biden administration announced the end of the federal Public Health Emergency (PHE) related to the COVID-19 pandemic, effective May 11, 2023. QualChoice is committed to making sure you have the information you need during this transition.

Some members have been notified of changes to their benefits related to cost-sharing. If applicable, these changes are reflected in their plan documents. We are making ongoing efforts to connect with any members who need to take action in order to keep their coverage.

Any policy changes will be communicated via email and will be available online. While we do not anticipate any strain on our provider network related to the end of the PHE, we are available to answer any questions or concerns you have. Please email us at [email protected], or call 501-228-7111. We appreciate everything you have done to keep our community healthy throughout the duration of the pandemic. Thank you for your efforts in helping Arkansas live better.

Glucagon-Like Peptide 1 (GLP-1) Agonists for Weight Loss: Drug Shortages and Labeled Indications

GLP-1 agonist medications have been approved for the treatment of type 2 diabetes, prevention of cardiovascular disorders in patients with type 2 diabetes, and weight loss.

A rise in social media awareness of GLP-1 agonists as a weight loss solution has led to increased demand. As a result, there has been a national shortage, and patients with type 2 diabetes have had difficulty mantaining treatment.

Semaglutide and liraglutide are GLP-1 agonist medications. Semaglutide has several formulations including Ozempic® (type 2 diabetes), Rybelsus® (type 2 diabetes), and Wegovy® (weight loss). Liraglutide has formulations including Victoza® (type 2 diabetes) and Saxenda® (weight loss). A newly approved medication, Mounjaro® (type 2 diabetes), has emerged as well. Although semaglutide and liraglutide have formulations that are FDA-approved to treat obesity, Mounjaro is only FDA-approved for treatment of type 2 diabetes.

QualChoice records show that Mounjaro has consistently seen the highest number of prior authorization requests each month for the past six months. Requests for Mounjaro have largely been approved with an appropriate diagnosis of type 2 diabetes. Requests for Mounjaro for the treatment of obesity have been and will continue to be denied as this drug is not FDA-approved to treat obesity. There will continue to be a high number of requests for many of these products, often used for weight loss alone, which is a non-covered benefit.

Below is a reference chart for GLP-1 agonist medications. Please evaluate your patients to ensure they are utilizing the medications appropriately and as indicated.