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Carrier Agreements

QualChoice Application Agreement

Disclosures: All applicants must read.

I agree to and understand the following:

  1. The insurance I am applying for will not become effective until my application has been approved and I have paid the first month’s premium.

  2. If an agent/broker has worked with me on this application, he/she may receive compensation (payment) from QualChoice. Any such compensation is included in my insurance premium. (To learn more about any compensation involved, please contact your agent/broker.)

  3. If I am not truthful in my answers on this application, QualChoice may, in some cases, cancel my coverage as of the original starting date and I may not reapply for this coverage.

  4. If I give false information about tobacco use, QualChoice can change my premium to what it should have been when the policy began.

  5. My signature lets QualChoice coordinate my benefits with other insurance I may have.

  6. My signature authorizes QualChoice to release to my broker/agent necessary information about myself and any family members listed on this application. This includes information related to substance use or abuse, but not psychotherapy notes, as defined in Department of Health and Human Services HIPAA regulation 45 CFR §164.501. I understand that I may cancel this authorization by sending a written notice to QualChoice, Attn: IQChoice, P.O. Box 26208, Little Rock, AR 72221.

  7. QualChoice may call or email me for more information, if needed.

Authorized Signatures: In signing below, I agree that:

  1. My statements and answers in this application and any signed and dated attachments are true, complete and correct.

  2. I must let QualChoice know in writing of any changes to the information on my application before the policy effective date.

  3. I signed this application in the State of Arkansas and all applicants (excluding minor children) listed are permanent, legal residents of Arkansas.

Privacy Disclosure

We use and disclose protected health information (PHI) in a number of different ways in connection with health care operations, the payment for health care, and treatment. The following are only a few examples of the types of uses and disclosures of PHI that we are permitted to make without individual authorization.

A. Payment: We will use and disclose PHI to administer health benefits policy or contract, which may involve the determination of eligibility; claims payment; utilization review and care management; medical necessity review; coordination of care, benefits and other services; and responding to complaints, appeals and external review requests. Likewise, we may also share PHI with another entity to assist with subrogation of health claims or to another health plan to coordinate benefit payments. In some instances, we may also use and disclose PHI for purposes of premium billing, underwriting, and the determination of premium rates and co-payments, deductibles, coinsurance and other cost sharing amounts.

B. Treatment: We may disclose PHI to health care providers (doctors, dentists, pharmacies, hospitals and other caregivers) who request it in connection with treatment. We may also disclose PHI to health care providers in connection with preventive health, early detection and care management programs, in plans that offer these programs.

C. Health Care Operations: We will use and disclose your Protected Health Information to support other business activities, including the following:

  1. Quality assessment and improvement activities: peer review and credentialing of Network Providers and accreditation by independent organizations such as the National Committee for Quality Assurance and URAC;

  2. Performance measurement and outcomes assessment, health claims analysis and health services research;

  3. Operation of preventive health, early detection, care management, and coordination of care programs in plans that offer these programs, including information about treatment alternatives, therapies, health care providers, settings of care or other health-related benefits and services;

  4. Medical care review;

  5. Underwriting, premium determination and administration of reinsurance;

  6. Risk management, auditing, legal services and detection and investigation of fraud and other unlawful conduct;

  7. Transfer of eligibility and plan information to business associates (for example: pharmacists, mental health management companies) for the management of mental health benefits, and other programs as necessary to administer your benefit plan.

  8. Other general administrative activities, including data and information systems management and customer service.