Introducing our 2023 Primary Care Quality Program  

QualChoice understands that the provider-member relationship is a key component of ensuring superior healthcare and the satisfaction of our members. Because QualChoice recognizes these important partnerships, we are pleased to offer the 2023 Primary Care Quality Program, which rewards PCPs for improving quality and closing gaps in care. Click here to access program details and incentive information..

Prenatal and Postpartum Service Codes

As a healthcare provider, you understand the importance of prenatal and postpartum care for your patients. Seeking this care early in the pregnancy and attending all the recommended visits can increase successful outcomes for both the parent and child(ren).

Prenatal care takes place before the delivery date and postpartum care takes place seven to 84 days after delivery.

QualChoice wants to make sure all members who are going through prenatal or postpartum journeys get the care they need, and that it is properly documented. To ensure a complete picture of all the services offered, you must indicate the first date of prenatal care and the first date of postpartum care when billing any of the bundled service codes below. Proper documentation will lead to timely billing and paying out of claims.

Bundled Services:

• Full duration of pregnancy: 59400, 59510, 59610, 59618
• Partial duration of pregnancy: 59410, 59425, 59426, 59515, 59614, 59622

For prenatal care, please indicate the date the visit(s) occurred and evidence of one of the following:

• A diagnosis of pregnancy
• A basic physical obstetrical examination
• Evidence that a prenatal care procedure was performed
• Documentation of LMP, EDD, or gestational age

For postpartum care, please indicate the date the visit(s) occurred and evidence of one of the following:

Pelvic exam

• Evaluation of weight, blood pressure, breasts, and abdomen
• Notation of postpartum care
• Perineal or cesarean incision/wound check
• Screenings for depression, anxiety, tobacco use, substance use disorder, or preexisting mental health disorders
• Glucose screening for patients with gestational diabetes
• Documentation of any of the following:
• Infant care or breastfeeding
• Resumption of intercourse
• Birth spacing or family planning
• Sleep/fatigue
• Resumption of physical activity
• Attainment of healthy weight

For more information about these and other quality measures, visit our Provider Resources page today.

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. 

CPT® II Codes

CPT II codes are reporting codes that relay important information to the health plan. This information can close quality care gaps related to specific health outcome measures. Reporting these codes can improve outcome measures that are included in primary care quality programs. Click here to access our provider resource and learn more about CPT II codes..