QUALCHOICE OF NORTH CAROLINA
Updated 10/2000

These data reflect the most commonly purchased benefits package for each of the health plans in the year 2000.

HMO General Information
Background Information	QualChoice of North Carolina, Inc. received its HMO license from the NC Department of Insurance on September 9, 1994. It began operations on October 1, 1994. QualChoice is a for-profit corporation, owned by The North Carolina Baptist Hospitals, Incorporated.
Type of HMO	QualChoice operates an IPA/network model HMO. That means that it contracts directly with physicians in the community or with networks of physicians.
Type of Products	QualChoice’s most commonly purchased health plan provides members a choice of three options each time services are needed. Under Option 1 ("HMO gatekeeper" option), care is arranged by the member’s primary care provider and out-of-pocket expenses are lower than the other two options. Option 2 gives members more freedom to choose among specialists in the QualChoice network, but also has greater out-of-pocket expenses than Option 1. This is similar to an open-access model. Under Option 3, members seek care outside of the network, but have the greatest out-of-pocket expenses. Option 3 is similar to standard group medical insurance or indemnity models.
Accreditation	QualChoice has not been accredited by an external accreditation organization. Not all health plans seek accreditation. The accreditation process is very expensive and some plans choose not to participate. This does not necessarily mean that OCCI is bad, but it does make it more difficult to judge the quality of care provided by the plan.
Enrollees	QualChoice offers HMO coverage to both large and small employer groups. It does not offer coverage to individuals ("non-group" coverage) or Medicaid recipients. QualChoice does offer an HMO option to Medicare beneficiaries in the following counties: Alexander, Alleghany, Burke, Caldwell, Catawba, Davidson, Davie, Forsyth, Rowan, Stokes, Surry, Wilkes, and Yadkin.
Counties in which HMO has an Active Presence	As of June 30, 2000, Qualchoice had 58,939 commercial group members in the following North Carolina counties: Alamance, Alexander, Alleghany, Ashe, Avery, Burke, Cabarrus, Caldwell, Catawba, Davidson, Davie, Durham, Forsyth, Guilford, Iredell, Lincoln, McDowell, Mecklenburg, Orange, Randolph, Rockingham, Stanly, Stokes, Surry, Watauga, Wilkes, Wilson and Yadkin.
Customer Service Number	336-716-0911 or 1-800-816-0911
Covered and Excluded Services and Limitations
Hospital Care
Inpatient Services		Covers: Room and board in semi-private room. Private room covered when medically necessary. Nursing care. Radiology services. Radiation therapy and chemotherapy. This may include the use of X-rays, radiation or radioisotopes. Pharmacy services and supplies. Diagnostic laboratory tests. Operating room charges. Labor and delivery charges. Anesthesia for surgery or maternity care. Circumcision of a newborn child in the hospital. One medical visit per day per diagnosis by a physician while member is admitted in a hospital. Services of a second physician when the member has an "exceptional complication" in surgery, maternity or inpatient care. Medically necessary consultation with a physician who is a specialist in member’s illness or disease. Limits: QualChoice limits payments for: Anesthesia if the provider who administers it also performs the care or assists the physician who performs care and receives payment under any other part of this HMO plan. Surgical procedures when there is more than one surgical procedure done at the same time. Also, payments are limited if surgery is done at two different times when it could have been performed at one time. Excludes: Care in hospitals that are not considered short-term acute care general hospitals.
Outpatient services		Covers: Covered services in the outpatient department of a hospital, as well as those delivered in a health center, diagnostic center or licensed treatment center. This includes birthing centers, ambulatory surgical centers or hemodialysis centers.
Emergency care		General Guidelines: If you have a medical emergency, go to the nearest emergency room that can provide the treatment you need. You are covered for emergency services without prior authorization until the condition is stabilized. Cost Sharing: Members are required to pay a set amount for each emergency room visit unless admitted to the hospital through the emergency room. Notification: If, after you are stabilized, you are admitted through the emergency room, call QualChoice to inform them of your condition and the services you are receiving.
Urgent Care		Covers: Urgent care within the service area. Enrollees have the option of going to an urgent care Center as opposed to an Emergency Room. Cost Sharing: Copayments apply.
Ambulance		Covers: Medically necessary ambulance services from a licensed carrier.
Care for Students Outside of Service Area		Excluded, unless purchased under rider.
Non-Urgent Care Outside of Service Area		Covers: Under the HMO gatekeeper option (Option 1), treatment received for illness or injury when traveling out of the service area will be covered only if: You could not have reasonably foreseen the condition. You could not reasonably return to the service area to receive treatment from your PCP. QualChoice’s Medical Director agrees that the treatment was medically necessary. You contact QualChoice within 48 hours or by the close of the first business day after receiving care. You submit all claims and proof of service to QualChoice in writing within 90 days after the date of service.
Professional Services
Professional Services (general)		Covers: Office or home visits made by a physician and routine well-child pediatric visits for children. Also covers medically necessary medications, injectables, radioactive materials, dressings and casts that are administered by your PCP for preventive or treatment purposes. Cost Sharing: Copayments apply. No copayment for well-child pediatric visits under the age of 2.
OB/GYN		Covers: OB/GYN services. A referral is not required for services of participating obstetrician/ gynecologist for health care services related to female reproductive system and breasts. Cost Sharing: Copayment may apply.
Diagnostic Procedures		Covers: Medically necessary imaging and laboratory tests and services ordered by a physician. This includes diagnostic X-rays, X-ray therapy, electrocardiograms, laboratory tests and diagnostic clinical isotope services. Excludes: Diagnostic or laboratory tests for research or study purposes.
Therapeutic Treatment Services		Covers: Radiation, Chemo-therapy, Respiratory Therapy Cost Sharing: Cost sharing may apply.
Allergy Testing		Covers: Medically necessary tests to determine the nature of allergies. Also covers allergy shots to treat the allergies.
Preventive Services
Annual Physicals (well-baby, well-child)		Covers: Physical examinations, including well child care and all physicals for dependents through age 18. Excludes: Exams for obtaining or maintaining employment, insurance or professional or other licenses.
Immunizations		Covered. Excludes: Immunizations for travel and employment.
Preventive Clinical Services		Covers: Mammograms, pap smears, and PSA (when recommended by a participating physician).
Other Health Promotion/Disease Prevention Activities		Excludes: Instructional or educational programs, such as, but not limited to, childbirth classes, nutritional counseling, vocational training and testing, or weight maintenance programs.
Diabetic Treatment		Covers: Medically necessary diabetes outpatient self-management training and educational services, equipment, supplies, medications and laboratory procedures. Limits: QualChoice shall arrange for the provision of diabetes self-management training and education services. Cost Sharing: Cost sharing may apply.
Conception Services
Prenatal Care and Obstetrical Services		Covers: Prenatal visits, postnatal visits, complications of pregnancy and miscarriage. Coverage includes initial examination and medical care of a newborn child in a hospital, newborn foster child or child placed in a home while waiting for final adoption.
Family Planning		Covers: Sterilization services for the member and spouse. With the purchase of a rider, covers: Birth control devices and the insertion or removal of contraceptive devices or drugs, including, but not limited to, Norplant, Intrauterine Devices (IUD), or diaphragms. Excludes: The reversal of voluntary sterilization, and sterilization for dependents.
Abortion		Covers: Abortions if medically necessary. Excludes: Elective abortions.
Infertility Services		Excluded, unless purchased under rider. With the purchase of a rider-- Covers: The initial diagnostic workup to confirm a diagnosis of infertility. Excludes: Services for treatment of infertility, such as artificial insemination, in-vitro fertilization, fertility drugs, sonograms or other fertility procedures.
Mental Health and Substance Abuse Services
Mental Health Inpatient		Covers: Inpatient hospital care, partial hospital day and evening programs, or intensive outpatient programs and outpatient care if referred by the plan. QualChoice has a special network of mental health providers. To obtain services under the HMO gatekeeper option (Option 1), you must first call QualChoice for a referral. Services must be preauthorized, medically or psychologically necessary, and received at a network facility. Under the HMO gatekeeper option (Option 1), members may substitute two partial hospitalization or intensive outpatient programs for every one hospital day. Limits: Services are limited to those that are appropriate for treatment or diagnosis of mental health conditions. Services are limited to those which can reasonably be expected to improve your condition or prevent further deterioration. Certain day limits apply. Notification: You must call QualChoice prior to an admission to a hospital or inpatient facility, or for partial hospitalization treatment. You will be charged a non-notification penalty if you fail to call QualChoice, except in cases where you are not medically able to comply.
Mental Health Outpatient		Covers: Partial hospital day and evening programs, or intensive outpatient programs and outpatient care if referred by the plan. QualChoice has a special network of mental health providers. To obtain services under the HMO gatekeeper option (Option 1), you must first call QualChoice for a referral. Services must be preauthorized, medically or psychologically necessary, and provided by a network provider or a network facility. Also covers the initial diagnostic workup to confirm a diagnosis of developmental delay disorder or learning disability. Under the HMO gatekeeper option only (Option 1), QualChoice will cover up to two evaluations to diagnose Attention Deficit Disorder (ADD/ADHD). If ADD is diagnosed, QualChoice will pay for six parent education classes. No services are covered for ADD/ADHD under the point-of-service or open-access models (Options 2 and 3). Limits: Services are limited to those that are appropriate for treatment or diagnosis of mental health conditions. Services are limited to those that can reasonably be expected to improve your condition or prevent further deterioration. Coverage is limited to a maximum number of visits per benefit year. Cost Sharing: Copayments may apply. Excludes: Services related to the treatment of chronic pain by any means other than psychotherapy, if it is determined that such pain has a psychological origin. Treatments that are considered experimental such as psychosurgery, megavitamin therapy, and treatments for so-called sexual addictions or co-dependency. Services for educational testing or treatment of learning disabilities or developmental delay disorder.
Substance Abuse Inpatient		Covers: Short-term crisis intervention and inpatient care that is medically or psychologically necessary care and is provided by a network provider. Covers detoxification treatment if medically necessary. QualChoice has a special network of substance abuse providers. Under the HMO gatekeeper option (Option 1), you must first call QualChoice for a referral in order to get services. Limits: Care and treatment are subject to a maximum dollar amount per benefit year and lifetime. Cost Sharing: A deductible and coinsurance may apply. Notification: You must call QualChoice prior to a admission to a hospital or inpatient facility, or for partial hospitalization treatment. You will be charged a non-notification penalty if you fail to call QualChoice, except in cases where your condition renders you unable to comply. Excludes: Detoxification treatment that requires medical involvement or is medically complicated.
Substance Abuse Outpatient		Covers: Covers short-term crisis intervention treatment that is medically or psychologically necessary care and is provided by a network provider. QualChoice has a special network of substance abuse providers. Under the HMO gatekeeper option (Option 1), you must first call QualChoice for a referral in order to get services. Limits: Care and treatment are subject to a maximum dollar amount per benefit year and lifetime. Cost Sharing: A deductible and coinsurance may apply. Excludes: Treatments that are considered experimental such as nutritionally-based therapies for alcoholism and substance abuse, or non-abstinence based substance abuse treatments.
Prescription Drugs and Medical Supplies
Prescription drugs		Excluded, unless purchased through a rider. With the purchase of a rider, covers: Prescription drugs according to a two- or three-tiered open formulary.
Blood		Covers: Blood and blood plasma. Excludes: Extra charges above the usual processing fee for collection, storage, or administration of donated blood.
Medical Supplies		Covers: Medically necessary supplies including syringes for a diagnosis of insulin dependent diabetes, ostomy bags and skin bond for diagnosis of colostomy, and support stockings for a diagnosis of phlebitis or other circulatory condition. Also covers infusion services and arch supports when ordered by a physician. Limits: Must be ordered by a physician and participating provider or supplier. Arch supports are limited to one pair per year. Excludes: First-aid supplies, air conditioners, humidifiers, dehumidifiers, air purifiers, and exercise equipment. These items are excluded even if they are prescribed by a physician.
Insulin and Diabetic Supplies		Covers: Equipment, supplies, medications and laboratory procedures used to treat diabetes.
Durable Medical Equipment, Prosthetics, and Orthotics
Durable Medical Equipment (DME)		Covers: Crutches, apnea monitor, glucometer, oxygen and oxygen equipment, orthopedic braces, wheelchairs, special hospital type beds, home dialysis equipment and other non-disposable equipment that is primarily used to treat a medical condition. Selected DME requires preauthorization by your physician. Limits: DME must be ordered by a physician and provided by a physician supplier or pharmacy. QualChoice will determine whether the equipment will be rented or purchased. Cost Sharing: Cost sharing may apply. The maximum payment is the purchase price of the equipment. Excludes: Air conditioners, humidifiers, dehumidifiers, air purifiers and exercise equipment.
Prosthetic Devices		Covers: Artificial limbs, breast prosthesis, implanted lenses after cataract surgery, and one prosthesis per foot per benefit year. May also cover other prosthetic devices that replace all or part of an absent, permanently inoperable or malfunctioning body part. Limits: Prosthetics must be ordered by a physician and provided by a participating provider or supplier. QualChoice will determine whether the equipment will be rented or purchased. Cost Sharing: Cost sharing may apply. The maximum payment is the purchase price of the equipment.
Orthotic Devices		Covers: One molded shoe or prosthesis per foot per benefit year. Limits: Orthotics must be ordered by a physician and provided by a participating provider or supplier. QualChoice will determine whether the equipment will be rented or purchased. Cost Sharing: Cost sharing may apply. The maximum payment is the purchase price of the equipment. Excludes: Orthotics used solely to participate in sports.
Rehabilitative and Habilitative Services
Physical therapy		Covers: Medically necessary physical therapy services in a licensed therapist’s office or in a hospital. May impose visit limits.
Occupational therapy		Covers: Medically necessary occupational therapy services in a licensed therapist’s office or in a hospital. May impose visit limits.
Speech Therapy		Covers: Speech therapy that is medically necessary or when patient had the ability to speak but lost the ability due to an illness or injury. Covers initial evaluation to determine medical necessity of speech therapy. Excludes: Speech therapy for developmental delay disorder, learning disability, stuttering or stammering. May impose visit limits.
Pulmonary Therapy		Covered.
Chiropractic		Excluded, unless purchased under rider. Cost Sharing: Copayments apply.
Cardiac Rehabilitation		Covered. Cost Sharing: Cost sharing may apply.
Other Therapy Services		Excludes: The injection of sclerosing solutions for the treatment for varicose veins.
Skilled Nursing Facility		Covers: Care in a skilled nursing facility. Covers prescription drugs while receiving care at this facility. Limits: Coverage is limited to 90 days per benefit year. Excludes: Custodial care, such as walking, getting in and out of bed, bathing, dressing, eating and taking medicine.
Home-Based Services
Home Health		Covers: Medically necessary visits by home health agency personnel for services provided in the home. May require precertification by your physician. Services include: Intermittent home nursing by a registered nurse or nurses aide when medically appropriate. Physical, occupational, or speech therapy if provided through a Home Health Care Agency. Skilled treatments done by licensed or certified Home Health Care Agency personnel, including non-prescription medical supplies such as surgical dressings and saline solutions.
Private Duty Nursing		Excluded.
Hospice		Covers: Hospice care for terminally ill patients in the home. Also covers hospice provided in a free-standing hospice, a hospice unit within a hospital or skilled nursing facility, or in a regular hospital bed. Coverage includes: Part-time care provided by nurses, licensed practical nurses, or home health aides. Physical therapy, respiratory therapy, and radiation therapy and chemotherapy when required for control of symptoms. Social services. Laboratory examinations, X-rays. Medical supplies, drugs and medications prescribed by a physician. Services provided by the member’s own attending physician or hospice physician.
Transplants and Dialysis
Transplants		Covers: Medically necessary transplant services that meet QualChoice’s transplant criteria. Coverage includes up to 5 days of preoperative care in a hospital, and up to one year of post-operative care. Limits: Pre-authorization is required for all transplants. Organ Procurement: Covers tissue typing, surgical procedure, storage expense and transportation costs directly related to the donation of an organ or other human tissue used in a covered transplant procedure. Excludes: Artificial organs, organs from non-human donors, or services related to transplants involving artificial organs or organs from non-human donors.
Dialysis		Covers: Home dialysis equipment.
Other Services
Dental		Covers: Services for a dental accident to sound, natural teeth if the service is performed as a part of the initial emergency treatment for the accident. Includes services to restore the member to status prior to the accident. Requires precertification by your physician. Also covers procedures involving any bone or joint of the jaw, face, or head that are medically necessary to treat a condition that prevents normal functioning of that bone or joint. To be covered, the condition must have been caused by congenital deformity, disease or traumatic injury. Authorized therapeutic procedures include splinting and use of intra-oral prosthetic appliances to reposition the bones. Excludes: Coverage for damage to teeth after biting into food or other substances. Treatment for cavities and extractions. Orthodontic braces. Crowns, bridges, dentures or false teeth. Treatment for periodontal disease. Treatment for dentigerous cysts. Care of the gums or bones supporting the teeth. Removal of impacted teeth. Dental root form implants. Root canals. Other general dental procedures. Note: These services may be covered under a rider.
Vision		Covers: Diagnosis and treatment of diseases of, or injury to, the eyes. Covers one pair of eyeglasses or contact lenses following cataract surgery. Also covers routine vision examinations, services, contact lenses, and other routine vision care services or supplies at a discounted rate from participating providers. Limits: Routine eye examinations are covered for one exam per member per year. QualChoice has a maximum allowable benefit for eyeglasses or contact lenses following cataract surgery. The member must have a referral from the PCP. With the purchase of a rider– Covers: Eye surgery to correct myopia, hyperopia, astigmatism, or other surgical correction or visual impairment.
Hearing		Covers: Diagnosis and treatment of diseases of, or injury to the ears. With the purchase of a rider, covers: Routine hearing examinations, services or tests, hearing aids, and other routine hearing care services or supplies.
Foot Care		Excludes routine foot care.
Weight Loss		Excludes: Any surgery, medical services, or supplies meant to control obesity. Excludes dietary control, counseling or weight maintenance programs.
Smoking Cessation		Covers: Zyban, Nicotine replacement therapy, ALA Group Clinic, and QualChoice approved self-help materials. Limits: One course of Zyban is covered per calendar year if the member has prescription drug rider. QualChoice will cover the costs of attending one ALA Group Clinic per year (with a maximum allowance). Member must submit certificate of completion to QualChoice to be reimbursed for the program costs. To be reimbursed for the self-help materials, the member must submit a receipt to QualChoice. Cost Sharing: Cost sharing may apply. Nicotine replacement therapy is covered at 50% if the member is enrolled in an approved smoking cessation class.
Growth Hormones		Excluded unless medically necessary
Alternative Therapies		Covers: Limited chelation therapy for heavy metal poisoning. Excludes: Acupuncture (available through a rider), acupressure and hypno-therapy. Also excludes behavioral health treatments that are considered experimental and unproven, including psychosurgery, megavitamin therapy, nutritionally-based therapies for alcoholism and substance abuse, non-abstinence based substance abuse treatments and treatments for so-called sexual addictions or co-dependency.
Reconstructive/Cosmetic Surgery		Covers: Reconstructive surgery following mastectomy. Includes reconstructive breast surgery performed on non-diseased breast for symmetry with reconstructive surgery on diseased breast. Also covers reconstructive surgery to correct malformations or anomalies resulting in a functional defect of a covered child. Cosmetic surgery needed to correct physical deformities resulting from trauma, accident or disease. Surgery provided as a continuation of the initial medical care, or to restore the function of the injured body part. Excludes: Any procedures, services, equipment or supplies for elective cosmetic surgery intended to improve your appearance or for your psychological benefit.
Non-Emergency Transportation		Covers: Reasonable travel and lodging expenses, if you are referred out of the service area for care that is not available in the service area. Travel and transportation expenses for emergencies and transplants are also covered. Limits: Costs must be pre-approved in writing by Qualchoice. Excludes: Payment for all other travel and transportation expenses.
Excluded Services
Experimental or Investigational Services		Excluded.
Services not considered medically necessary		Excluded.
Non-emergency services rendered in the emergency room		Excluded.
Commonly excluded services		See list of commonly excluded services.
Definitions
Medically necessary		Meets statutory definition.
Experimental or Investigational		A drug, device, medical treatment or procedure that meets any of the following: The drug or device cannot be lawfully marketed without approval of the F.D.A Nor has approval for marketing been given at the time the drug or device is furnished. Reliable evidence shows that the drug, device, medical treatment or procedure is the subject of on-going clinical trials. Also the drug, device, medical treatment or procedure is under study to determine its maximum tolerated dose, toxicity, safety or effectiveness. Reliable evidence according to experts and authoritative published medical and scientific literature shows further studies or clinical trials are necessary to determine the maximum tolerated dose, toxicity, safety or effectiveness. The Medical Director decides if a drug, device or procedure is Experimental or Investigational.
Emergency		Meets statutory definition of emergency.
Urgent Care		Not specifically defined by the plan.
OTHER		Psychologically Necessary: Means mental health services provided for mental disorders that can be helped through short-term therapy. These are mental disorders that affect the person’s ability to perform daily activities at work, at home, or at school. It also includes periodic mental health services for a chronic mental disorder to prevent deterioration of function.
Primary Cary Providers, Referrals and Pre-Authorization Requirements
Types of providers who can serve as Primary Care Provider		The types of providers that can serve as a PCP include family practice physicians, internists, pediatricians, gynecologists and obstetricians.
What Happens if Member Fails to Choose a PCP?		If you fail to choose a PCP, you will not receive coverage for the HMO gatekeeper option (Option 1) services except emergency care.
Process to Change PCP		You may change your PCP by contacting the Customer Service Department on or before the 25th of the current month. The change will become effective on the first day of the following month and you will receive a new ID card.
referrals to Specialists		If you are using the HMO gatekeeper option (Option 1), your PCP must provide referrals to a specialist. You may not obtain care directly from them. Under the open access plan (Option 2) or point-of-service plan (Option 3), you may obtain care directly from specialists with additional cost sharing.
Can Specialists Serve as PCP?		Specialists may sometime serve as a PCP when medically necessary.
Non-Emergency Hospital preauthorization requirements		Your PCP must arrange your hospital admission or outpatient hospital services for non-emergency care. Second opinion: QualChoice will cover a second opinion if it is requested by the member and meets the following conditions: The second opinion is given by a physician who is a board-certified specialist and who, by reason of his or her specialty, is an appropriate physician to consider the surgery or treatment. The physician who gives the second opinion does not perform the surgery or treatment. Note: QualChoice will not cover both a second surgical opinion and a consultation with the same specialist for the same surgical procedure
Appeal and Grievance Procedures
Informal Reconsideration		Follows statutory definition. Note: QualChoice considers all written grievances to be formal in nature, and addresses them through the formal grievance process.
First Level Non-Certification Appeal Provisions		Follows statutory definition. Note: Members or their representatives must submit first level appeal in writing to QualChoice. No time limitations are specified in the Evidence of Coverage. Members will receive a response from QualChoice within 30 days of QualChoice’s receipt of the review request.
First Level Expedited Appeals		Follows statutory definition. Note: Responses to expedited appeals will be received within 4 days of the receipt of all necessary information.
First Level Grievance Hearings		Follows statutory definition. Note: Members or their representatives must submit a request for a first level grievance review in writing to QualChoice. No time limitations are specified in the Evidence of Coverage. Members will be notified of the decision within 30 days of QualChoice’s receipt of the request for review.
Second-Level Grievance Hearings (covers second- level appeals and grievances)		Follows statutory definition. Note: Requests for second level grievance hearings must be made following a first level grievance decision. No time limitations are specified in the Evidence of Coverage. The second level review meeting will be held within 45 days of QualChoice’s receipt a request for a second level grievance review. Member will be notified of the decision within 7 business days of the review meeting.
Second Level Expedited Appeals		Follows statutory definition. Note: Responses to expedited appeals will be received within 4 days of the receipt of all necessary information.
Other Avenues of Appeal		Members can obtain independent information about the appeals process and seek assistance from the N.C. Department of Insurance and the Office of Commissioner. Call 1-800-662-7777.
Notes		Limits: Appeals are limited to services offered and covered by the plan.
Enrollment Trends
Enrollment on December 31, 1999 (Financial Report, # 10)		73,167
Member months (1999) (Financial Report, #11)		858,545
Average 1999 monthly enrollment (member months/12)		71,545
Percentage of change in average monthly enrollment between 1998-1999		40.9%
Five year average enrollment trends		1999: 71.545 1998: 50,788 1997: 20,556 1996: 8,824 1995: 1,127
Percentage of Groups that Disenrolled (December 31, 1998-December 31, 1999)		11%
Percentage of Members that Disenrolled (December 31, 1998-December 31, 1999)		30%
Percentage of Primary Care Physicians who Resigned (Dec. 31, 1998 — Dec. 31, 1999)		6.3%
Percentage of Primary Care Physicians who Were Terminated (Dec. 31, 1998 — Dec. 31, 1999)		0.03%
Utilization Review Information
Number of reviews requested, 1999		61,051
Review rate per 1,000 members, 1999		1,546
Percentage of noncertifications, 1999		0.15%
Noncertification rate per 1,000 members, 1999		2.30
Appeal Rate per 1,000 Noncertifications, 1999		230.76
Percentage of appeals decided for the members, 1997		54.17%
Financial Data
Total 1999 revenues (Financial Report, #6)		$172,004,149
Average premium per member per month (1998) (Financial Report, #5 / #11)		$198.45
Five year premium per member per month trends		1999: $198.45 1998: $188.31 1997: $158.97 1996: $114.39 1995: $126.97
Medical/hospital expenses per member per month 1999 (Financial Report, #7 / #11)		$186.60
Medical Loss Ratio 1998 (% premiums spent on medical/hospital expenses) (Financial Report, #15)		90%
Five year medical loss ratio trends		1999: 90% 1998: 105.7% 1997: 108.9% 1996: 89.5% 1995: 127.0%
Operating profit margin, 1999 (Financial Report, #9 / #6)		(5.9%)
Five year operating profit margin trends		1999: 5.9% 1998: (14.5%) 1997: (51.8%) 1996: (26.7%) 1995: (107.2%) 1994: N/A
Sources of Information
Source of Information		QualChoice of North Carolina, Inc., Enrollee Coverage Certificate 100 Plan (Form QC 100 8/97); 1998 Annual Financial Report; NC DOI Managed Care and Health Benefits Division, "HMOs in North Carolina Status Reports: Analysis of 1995 Activity" January 1997; NC DOI, "1999 Managed Care Plan Handbook: A Comparison Guide for North Carolina Consumers." Data on Utilization Review and Appeals and Grievances from NC DOI.

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