Organizational Structure of The QI Program
The Horizon Board of Directors holds the final authority and accountability for the quality of care and service provided to Horizon members. The Board of Directors of Horizon Blue Cross Blue Shield of New Jersey and Horizon Insurance Company have delegated quality improvement responsibility and authority to the Quality Committee of the Horizon Healthcare of New Jersey, Inc. Board. The Quality Committee of the Horizon Healthcare of New Jersey, Inc. Board meets at least three times a year and provides oversight to the Quality Improvement Program through reviewing and approving annually, the Quality Improvement Program Description, Work Plan, and Evaluation. In turn, the Boards of Directors of the Horizon companies also review and approve annually the Quality Improvement Program Description, Work Plan and Evaluation. The Quality Committee of the Horizon Healthcare of New Jersey, Inc. Board has designated full responsibility for the Horizon Quality Improvement Program to the Quality Improvement Committee (QIC). The QIC provides oversight and evaluation of the Quality Improvement Program.
Quality Committee of the Board
The Quality Committee of the Horizon Healthcare of New Jersey, Inc. Board is chaired by the VP and Chief Medical Officer for Horizon Blue Cross Blue Shield of New Jersey, who has full responsibility and authority for the quality of care provided to Horizon members.
The Quality Committee of the Horizon Healthcare of New Jersey, Inc. Board meets at least three times a year and provides oversight to the Horizon Quality Improvement Program through reviewing and approving annually the Quality Improvement Program Description, Work Plan and Evaluation. The Quality Committee of the Horizon Healthcare of New Jersey, Inc. Board reports to the Board of Directors of Horizon Healthcare of New Jersey, Inc. Annually, the Horizon Board reviews and approves the Quality Improvement Program Description, Work Plan and Evaluation. The Quality Committee of the Horizon Healthcare of New Jersey, Inc. Board has delegated full responsibility for Horizon’s Quality Improvement Program to the QIC.
Quality Improvement Committee
The QIC is an interdisciplinary committee that reviews, analyzes, recommends and approves all Quality Improvement activities for the following lines of business: Commercial HMO, POS, Omnia, Direct Access, EPO, PPO, FEHBP, Traditional, self-funded accounts, including SHBP, and QHP products.
The QIC reports at least three times per year to the Quality Committee of the Horizon Healthcare of New Jersey, Inc. Board of Directors. The Board of Directors of the Horizon companies have the ultimate final authority and accountability for all Quality Improvement activities relating to the health plans mentioned above that are operated under their direction.
The Vice President and Chief Medical Officer (CMO) of Horizon Blue Cross Blue Shield of New Jersey, or their designee, serves as Chairperson. The CMO has designated the Senior Medical Director, Medical Management, to serve as Chairperson of the Quality Improvement Committee.
QIC Committee Composition
The Committee consists of the chairpersons of the reporting committees and directors from functional areas involved in service and clinical quality improvement initiatives. At a minimum, this includes:
- Senior Medical Director, Medical Management (tie breaker)
- Chairpersons of all of the reporting Committees (up to 12 voting members). Chairpersons must be Medical Directors or at the Director level or above to be members of the QIC however, they may appoint a designee to attend in their absence. If a Committee Chairperson is not at the Director level, that Chairperson’s Director is the designated voting member for the QIC.
- Participating Physicians (up to 5 as voting members including external network physicians)
- Director, Quality Performance and Stars (1 voting member)
- Director, Service Operations (1 voting member)
- Director, Market Business Units (1 voting member)
- Director, Clinical Operations (1 voting member)
- Director, Pharmacy Programs (1 voting member)
- Assistant General Counsel (non-voting member)
- Director, Compliance Services (1 voting member)
- Director, Clinical Initiatives (1 voting member)
- Executive Medical Director of Population Health & Transformation (1 voting member)
- Director, Network Management (1 voting member)
- Director, Clinical Behavioral Health Services (1 voting member)
- Medical Director, Behavioral Health (1 voting member)
Terms of Office
The QIC Chairperson appoints committee members to serve a one (1) year term of office. Members will be considered for re-appointment annually. There is no limitation on the number of terms of reappointment a committee member may have.
Other medical and non-medical personnel and consultants may attend and participate without vote as needed.
Participating physicians, as necessary, will be invited on a regular basis to ensure involvement of the medical community.
Frequency of Meetings/Voting/Quorum
The QIC meets quarterly. Attendance records are maintained. Voting privileges are not assigned to alternates attending in place of committee members. A majority of the committee’s membership must be present to meet the quorum requirement (50% + 1). Members not in attendance at four (4) prescheduled meetings in any twelve-month period may be removed / replaced through action by the chairperson. Action is taken by the majority vote of members present.
Minutes are recorded under the direction of the chairperson. Copies of the minutes are distributed to committee members. All preliminary research on agenda items is completed prior to the meeting and documentation released with the agenda one week in advance of the meeting. Members review all materials prior to the meeting date. The approved actions are forwarded to the Quality Committee of the Board of Directors. Approved committee minutes are maintained in a binder and in an on-line database.
Member, physician and provider confidentiality is maintained. All external, non-employee members of the QIC must sign a confidentiality agreement annually. All internal members must comply with Horizon policies.
- The QIC is responsible for the annual development and implementation of the Quality Improvement Program, oversight of the QI Work Plan (QIWP) and analysis and approval of the QI Program Evaluation.
- The QIC monitors on a quarterly basis the QIWP, which details goals and objectives with established timetables and criteria for completion. These goals will involve specific medical policy, practice guidelines, health care evaluation and utilization, clinical and service quality assessments, as per applicable regulatory and accreditation requirements and in alignment with Horizon’s quality metrics.
- The QIC conducts a more focused review of any topics that it deems necessary by tracking and trending performance indicators.
- The QIC is responsible for annual approval of the Quality Improvement and Medical Management Program Descriptions, Work Plans and Program Evaluation.
- The QIC serves as the coordinating body that reviews and approves the recommendation of the committees that report to it: Clinical Policy Committee, Quality Case Review Committee, Medical Management Committee, Provider Appeals Committee, Member Appeals Committee, Delegate and Vendor Oversight Committee, Credentials Committee, Member Appeals Committee-Benefit Issues Complaints Committee, Pharmacy and Therapeutics Committee, Member Provider Service Satisfaction Committee and Quality Advisory Committee.
- The QIC is responsible for approval of all committee actions, whether submitted on an annual work plan or in the quarterly reports. The QIC may request or recommend action plans from the committees as needed.
- The committees will report to QIC on a quarterly basis. Items requiring action on a more frequent basis will be presented to the QIC as needed.
- The QIC delegates the approval of policies, procedures, workflows and guidelines to the respective committees.
- The QIC directs and evaluates all statewide ongoing activities pertaining to the quality of clinical care, services to members and utilization of resources.
- The QIC recommends, approves and oversees new Quality Improvement activities.
- The QIC ensures that Horizon complies with appropriate accrediting organizations and regulatory requirements.
The following represents a list and description of the committees:
Quality Peer Review Committee
The Quality Peer Review Committee (QPRC) reviews potential quality of care issues that are referred to the QPRC. The goal is to ensure that Horizon members are receiving quality medical, behavioral health care and excellent service. The Quality Peer Review Committee reports to the Quality Improvement Committee (QIC) for each respective line of business.
The committee reviews quality of care and service issues that were referred because of an issue that directly affects the quality of care members receive. Referrals may be received from members, providers and external agencies as well as internal departments. The Quality Peer Review Committee addresses deviations from accepted standards of professional practice through education, requests for plans of correction and when indicated, sanctions. The committee reviews, trends, and analyzes data concerning the QPRC Program and reports findings to the Quality Improvement Committee. A Horizon Medical Director or designee chairs the committee. Participants consist of voting members, presenters and Legal Counsel when needed. A quorum is 3 voting members. Voting members are identified at the start of the meeting.
Voting members of QPRC action items include:
- Horizon Medical Director(s)
- At least one external board certified participating physician not employed by Horizon with an unrestricted license to practice medicine in the State of New Jersey
In the event of a sanctioning appeal, voting members include:
- Three (3) physician members who have not participated in the original sanctioning determination, including one external board certified participating provider.
In order to guarantee peer representation on the QPRC, ad hoc members will be added to the committee for specialized circumstances as deemed necessary.
Other medical and non-medical personnel may attend and participate without vote.
Non-voting members or their designee, down to a manager level, who attend the meetings on a regular basis include:
- Assistant General Counsel
- Director, Quality Management Clinical Operations
- Director, Behavioral Health Clinical Operations
- Manager, Quality Management & Administration
- Quality Risk Manager
- Quality Management Nurses
- Care/Case Disease Management Nurses
- Behavioral Health Quality Auditors
- Managed Long Term Services and Supports (MLTSS)
- Dual Special Needs (DSNP)
QPRC is charged with the following responsibilities:
- Review potential deviations from accepted standards of professional practice
- Determine if a deviation of care exists
- Assign a level of care sanction as appropriate
- Recommend actions to address the deviation to include, but not limited to; education, Corrective Action Plan (CAP), or sanctions
- Review and approve policies related to the scope of QPRC
- Track quality indicators quarterly
- Serve as a forum for education and discussion regarding Quality of Care (QOC)
- Refer Quality of Service issues to the appropriate internal Horizon Committee(s)
Frequency of Meetings
This committee meets a minimum of six (6) times per year. In addition, this committee may meet on an ad hoc basis if necessary.
Medical Management Committee
The Medical Management Committee serves as a supporting committee to the QIC. This committee is responsible for reviewing, analyzing and trending Horizon Medical Management and Complex Case Management data and their respective lines of business, Commercial (HMO, POS, Direct Access, EPO, PPO, Indemnity), Horizon’s Marketplace Products, FEHBP and self-funded accounts, such as SHBP, that elect to participate in the Medical Management and Complex Case Management Programs, but excluding Government Programs products.
The responsibilities of the Medical Management Committee include, but are not limited to:
- Annual approval of the Medical Management Program Description, Program Evaluation and Work Plan, including the Complex Case Management Program.
- Annual evaluation of the Medical Management Work Plan.
- Annual approval of the Pharmacy Medical Management Program Description and Evaluation.
- Approval of Medical Management Programs and Program Evaluations as applicable to the delegates.
- Annual review of clinical criteria.
- Monitoring of inpatient hospitalization data.
- Annual review of administrative policies pertaining to Medical Management/Case management (MM/CM).
- Monitoring of appeals data.
- Monitoring of utilization data, including patterns of over and underutilization.
- Review of program and / or product specific initiatives (e.g. – FEP).
- Selection and monitoring of MM and CM initiatives.
- Monitoring of the Prior Authorization Process.
- Evaluation of Physician, Nurse, Behavioral Health Clinician, and Physical Therapist Inter-rater reports.
- Monitoring of Delegate utilization data.
- Monitoring of Case Management Program outcomes.
- Monitoring of MM and CM compliance with external accreditation standards and regulatory requirements.
- Assessment of member/covered person and provider satisfaction with the Medical Management and Complex Case Management process.
- Identification and referral of data, policy, and quality issues, as appropriate, to the Quality Improvement Committee, Appeals Subcommittee, Clinical Issue Subcommittee, Medical Policy Subcommittee, Delegate and Vendor Oversight Subcommittee, Quality Case Review Subcommittee and/or Credentialing Subcommittee.
- Follow-up for Medical Management and Complex Case Management activities, as appropriate.
Frequency of Meetings
The Medical Management Committee meets no less than six (6) times per year.
- Senior Medical Director, HCM&T (Chairperson and tie breaker voting member)
- Medical Director – HCM&T (2 voting members)
- Director – Quality Assurance (1 voting member)
- Executive/Senior Medical Director, Medical Policy (1 voting member)
- Manager, Utilization Management Appeals (1 voting member)
- Directors/Managers, Clinical Operations and other Clinical Directors/Managers, (3 voting members)
- Medical Director (Behavioral Health) (1 voting member)
- Director/Manager, Delegate & Vendor Oversight (1 voting member)
- External Participating Physicians (1-2 voting members)
- Director Clinical Behavioral Health (1 voting member)
- Manager, Manager Pharmacy (1 voting member)
- Other representatives as requested by Chairperson or person officially in “acting position” for any of the above positions – (non-voting)
Member Appeals Committee
The Committee reviews Stage 2 medical appeals brought by members/covered persons pursuant to Horizon’s Member Medical Appeals policy. The Committee’s voting membership consists of a chairperson (tie breaker), participating physicians who are board-certified with valid unrestricted licensure to practice in New Jersey (up to 3 voting members), at least two (2) but no more than four (4) community representatives/non-Horizon employees or providers; a minimum of 1 must be a Horizon member, and participating physicians practicing in the appropriate specialties, as needed (nonvoting members).
The member, provider acting on behalf of a member with the member’s consent, and/or duly authorized representative receives notice of a final determination and confirmation, in writing, within the timeframes provided for in the Member Appeals policy and procedure. The written notification documents the reasons for the decision and advises members on how they can file an external appeal, if applicable.
- Urgent medical appeals are reviewed by the Expedited Member Appeals Committee and communicated via telephone to the appellant. Written confirmation will follow. The whole process does not exceed the timeframes set forth in the Member Medical Appeals policy and procedure.
- The Member Appeals Committee reports quarterly to the Quality Improvement Committee (QIC).
- The Member Appeals Committee complies with applicable state or federal regulations and/or requirements.
- The Committee chair, Sr. Medical Director of Utilization Management (UM) or his/her designee appoints committee members to serve a one (1) year term of office. The members may be re-appointed annually. All prospective members are subject to approval by a majority vote of current members.
Frequency of Meetings
The member Appeals Committee meets at least once a month. Additional meetings will be scheduled as needed.
Delegate and Vendor Oversight Committee
The Delegate and Vendor Oversight Committee (DVOC) of the QIC is an interdisciplinary committee that provides oversight of vendor healthcare contracts and selected vendor non-healthcare contracts. The Delegate and Vendor Oversight Committee reports quarterly to QIC. The Committee’s voting membership consists of the Director, Network Program and DVO (tie breaker), Manager, ICI DVOD (1 voting member), Manager, Horizon Medical Policy Medical Director (1 voting member), Manager, Customer Service Operations (1 voting member), Director, Clinical Operations (1voting member), Director/Manager, Utilization Management (UM) Appeals (1 voting member), Director/Manager, Network Contracting (1 voting member), Director, Pharmacy Operations (1 voting member), Manager, Quality/Accreditation Management (1 voting member), Manager, Services and Partner Management (1 voting member), Manager, Sourcing & Supplier Management (1 voting member), Manager, Physician Data Management (1 voting member), Director Delegate Vendor Contract Management/Vetting and Implementation (1 voting member), Director, Clinical SNP, Director, Managed Care Long Term Services and Support (MLTSS) (1 voting member) and Medical Director, Dental Operations (1 voting member).
The annual QI work plan approved by the QIC may include action items assigned to the Delegate and Vendor Oversight Committee. The committee is then responsible for the creation of a committee work plan that will include the QIC assignments and other issues identified within the committee. Updates to this plan are given to the QIC on a quarterly basis, and/or on as needed.
- The committee is responsible for the annual review of policies that fall within its scope of responsibility.
- The committee ensures that all new delegates have received a pre-delegation review.
- The committee reviews, makes recommendations and votes to approve or disapprove quarterly reports for each delegated function (i.e. Continuous Quality Improvement, Utilization Management, Case Management, Customer Service and Provider Credentialing activities) and for vendors and providers as appropriate.
- The committee reviews annual audits of the delegates’ clinical and administrative policy and procedures manuals, committee minutes, Quality Improvement studies and corrective action plans, operational results (claims, correspondence, complaints and customer service), and periodically participates in the delegate’s quality meetings.
- The committee is the primary body charged with carrying out the Delegate and Vendor Oversight Policy. Recommendations, including corrective action plans made by the Committee, will be addressed by the Delegate and Vendor Oversight Department. In addition, the committee is responsible for ensuring that all delegates comply with external accreditation standards, compliant with State and Federal regulations, and meet contractual performance measures.
- The committee reviews, makes recommendations and votes to approve or disapprove reports submitted by contracted delegates, certain vendors, and certain ancillary providers as defined in the Delegate and Vendor Oversight Policy.
- The committee reviews, makes recommendations and votes to approve or disapprove quarterly reports of certain non-healthcare and healthcare vendors with whom Horizon contracts. The delegate/vendor oversight process will monitor vendor performance and compliance with contractual and regulatory requirements on an enterprise-wide basis.
Frequency of Meetings
The Delegate and Vendor Oversight Committee meets at least quarterly and more frequently as needed. Committee meetings may be scheduled on an ad hoc basis as needed.
The Credentials Committee is a committee of the QIC established for the purpose of implementation and oversight of a program for credentialing and re-credentialing of physicians, healthcare professionals, facilities, and ancillary providers who fall under the scope and authority of the Credentials Committee Charter and Credentialing and Recredentialing Administrative Policies. Voting members consist of the Medical Director / chair (tie breaker), physicians and/or other healthcare professionals that are participating in the Horizon Managed Care Network, Horizon PPO Network and/or Horizon NJ Health Medicaid Networks (between 2 and 5 voting members), medical directors (between 3 and 7 voting members) representing the following Department: Healthcare Management, Government Programs, Transformation and Behavioral Health.
Consultant voting members of the Credentials Committee may be appointed, as necessary, to conduct the business of the Credentials Committee with regard to the credentialing and re-credentialing, certification and re-certification of specialist physicians, healthcare professionals and ancillary providers and facilities.
- The Credentials Committee reports to the QIC regarding credentialing and re-credentialing decisions which are made, and advises and makes recommendations to the QIC with respect to the following:
- The establishment of criteria for participation in the Horizon Managed Care, Horizon PPO, Horizon NJ Health and Horizon Casualty Services Networks (collectively “Networks”).
- The establishment of guidelines for submission and review of initial and renewal applications for participation in the Networks.
- The establishment and annual review of policies and procedures as may be appropriate for the Credentials Committee to carry out its purpose and function.
- Monitoring of Credentialing and Re-credentialing compliance with accreditation and regulatory requirements.
- The Credentials Committee engages in other activities designated by the QIC and/or as may be necessary for the Credentials Committee to carry out its responsibilities.
- The Credentials Committee determines the eligibility of initial applicants and renewal applicants for participation in the Networks, and certification and/or re-certification as required by Horizon.
- The Credentials Committee provides guidance to organization staff on the overall direction of the credentialing program.
- The Credentials Committee evaluates and reports to organization management on the effectiveness of the credentialing program.
Frequency of Meetings
The Credentials Committee meets no less than ten (10) times per year, at least every 45 days.
Member Appeals Committee-Benefit Issues/Complaints Committee
The role of the Member Appeals Committee-Benefit Issues Complaints (MAC-BIC) relates to the review of a Member appeal regarding a benefit-based adverse benefit determination. The MAC-BIC is an interdisciplinary Committee that reviews unresolved benefit-related appeals received by Horizon. Committee composition shall consist of up to 8 voting members with at least a minimum of 4 Committee members attending each meeting. For expedited meetings, the Committee shall consist of at least 3 voting members. Attendance consists of any combination of the following: Chairperson (attendance required/tie breaker), a Manager from Service Operations, a Network Relations Representative, a Medical Director, and a Medical Management Team Representative. The Committee may also contract with up to three (3) external consumer advocates.
The MAC-BIC Committee hears benefit appeals per the procedures described in the Members/Covered Persons Inquiries, Complaints and Appeals Policy. The member/covered person or authorized representative receives a final written determination following the MAC-BIC Committee meeting. The written notification documents the reason for the decision and advises members of any additional appeal rights if the outcome is not favorable to the member. If the member or their authorized representative participates in the meeting via teleconference or in-person, they will be informed of the decision via telephone by close of business the day after the MAC-BIC Committee meets. On a quarterly basis, the summary information pertaining to the Committee’s determinations submitted to the QIC.
Frequency of Meetings
The MAC-BIC Committee meets at least once a week, with additional meetings scheduled as needed.
Pharmacy and Therapeutics Committee
The Pharmacy and Therapeutics Committee (the “P&T Committee”) of Horizon is a multi-disciplinary committee of health care professionals that is charged with identifying opportunities for quality improvement and cost-effectiveness by reviewing therapeutic classes of drugs and new drug therapies, developing medical guidelines and a process to work with those practitioners licensed to prescribe in achieving quality and appropriate prescribing patterns within the health plans underwritten or administered by Horizon. The P&T Committee also makes tiering decisions, and develops and documents procedures to ensure appropriate drug review and inclusion. Additionally the P&T Committee will ensure that the formulary drug list covers a range of drugs across a broad distribution of therapeutic categories and classes and regimens that does not discourage enrollment by any group. The committee will also provide appropriate access to drugs that are included in broadly accepted treatment guidelines and that are indicative of general best practices at the time of the analysis. Additionally, the committee conducts a quarterly evaluation of treatment protocols, policies and procedures related to the plan's formulary and its operations, which includes, but is not limited to, the medical necessity criteria for formulary drugs, which drugs on the formulary are subject to prior authorization or other utilization review activities, and the procedures associated with such activities. As part of such evaluation process, the P&T and Horizon will implement any necessary updates to its treatment protocols, policies and procedures.
There must be at least ten (10) voting members, excluding the Chairperson and Co-chair. At least two-thirds (2/3) of the P&T Committee members shall be practicing physicians and pharmacists.
- The P&T Committee shall objectively review the medical usefulness of all available pharmaceuticals for safety and effectiveness and provides input into drug utilization review activities and the analysis of adverse reactions of drug therapy Cost analysis of the available pharmaceuticals must also be considered. In addition, when requested by Horizon, the P&T Committee will provide input on recommendations Horizon may make to the Horizon physician networks regarding the appropriate use of pharmaceuticals, methods to measure the quality of drug prescribing and educational programs for Horizon members and providers.
- All actions of the P&T Committee are reported to the Quality Improvement Committee on a quarterly basis.
Frequency of Meetings
The P&T Committee holds quarterly meetings. Special meetings may be held if the chairperson determines it to be necessary and appropriate.
Member Provider Service Satisfaction Committee
The Member Provider Service Satisfaction Committee (MPSSC) reports to the QIC and reviews, approves and oversees improvement activities that have an impact on provider and member services and satisfaction. The committee consists of at least 15, but not more than 20 members. The MPSSC reports quarterly to the QIC.
The committee focus is oversight and direction of provider and member service improvement initiatives. The committee:
- Monitors provider and member service quality data.
- Identifies quality improvement opportunities.
- Conducts root cause analyses and barrier analyses.
- Measures and analyzes results with respect to overall goals.
- Monitors ongoing QI activities for improvement and recommends revisions as necessary.
The committee oversees collection, reporting and trending of member and provider service quality data including but not limited to the following:
- NCQA and other accreditation information.
- Focus is on HMO, POS/DA, PPO, EPO, and Horizon’s Marketplace Products.
- Member and provider contact volume.
- Member and provider call Average Speed of Answer rates.
- Member and provider call abandonment rates.
- Member complaints and appeals volume, status and turnaround time.
- Provider complaints and appeals volume, status and turnaround time.
- Annual and on-going member and provider satisfaction data (CAHPS – Office Managers-Member Experience – First Call Resolution – Member Touchpoint Measures).
The committee reviews all activities pertaining to member/provider service quality issues, except clinical care issues. A quarterly summary of actions, recommendations and process improvement activities are reviewed and approved. The committee reviews recommended activities and reports submitted and appoints appropriate staff or workgroup from:
- Service Division
- HealthCare Management
- Market Business Units
The committee ensures appropriate resources are assigned and accountable for approved and recommended activities.
The co-chairpersons of the committee appoint work teams to develop action plans and proposals related to specific issues. The committee annually oversees and approves all policies and procedures related to compliance with regulatory and accreditation requirements. Member’s rights and responsibilities are also reviewed annually and updated as appropriate.
Frequency of Meetings
The MPSSC meets quarterly throughout the year.
Clinical Policy Committee
The Clinical Policy Committee (CPC) is responsible for the following functions:
- Identify, prioritize and develop medical policies for the commercial products underwritten by Horizon Blue Cross Blue Shield of New Jersey, Horizon Healthcare of New Jersey, Inc. and Horizon Insurance Company, and for the self-insured products, as applicable. Medical policies, as approved by the commercial Horizon Clinical Policy Committee, may also apply to Government Programs products if Government Programs has no comparable medical policy or other guidance.
- Provide medical expertise and experience in policy development.
- Assist in researching medical issues, obtaining specialty consultations and feedback from the medical community on policy issues.
- Review and update existing medical policies, as necessary.
The CPC reports to the Quality Improvement Committee (QIC) and reviews and advises the QIC on the clinical content, validity and appropriateness of medical and pharmacy policies. Voting members consist of the chairperson, who is the Medical Director for Medical Policy or his/her designee (tie breaker voting member), at least one (1) but no more than three (3) participating providers, at least two (2) but no more than four (4) Horizon medical directors from the Health Care Management Division, one (1) Medical Director of Major/National Accounts and one (1) Horizon Behavioral Health Medical Director.
Review and advise on the content and quality of physical, behavioral and pharmacy policies including but not limited to:
- Evidence based data from clinical trials, studies and articles, published in peer-reviewed literature.
- Accessibility to health care for members.
- Utilization and medical necessity, indication or appropriateness of medical services.
- Provider and member education.
The Clinical Policy Committee shall also have the accountability for the following:
- Developing medical policies that reflect evidence-based best medical practice, promote high standard of quality care, promote efficient and appropriate use of resources, and minimize risk to our members.
- Evaluating emerging and new technologies.
- Identifying services that result in improved clinical outcomes.
- Assisting in the education of internal and external customers regarding medical policy.
Frequency of Meetings
The Clinical Policy Committee meets no fewer than ten (10) times per year.
Value Based Programs Quality Advisory Committee
The Value Based Programs’ Quality Advisory Committee (QAC) is comprised of members representing various disciplines within Horizon Blue Cross Blue Shield of New Jersey whose diverse knowledge will provide clinical and healthcare administration expertise representation from a variety of specialties relating to the development of Value Based Programs’ initiatives. In addition, committee members will act as ambassadors to the Enterprise to communicate Value Based Programs’ goals and strategies. The committee consists of the Executive Medical Director, Population Health, Healthcare Management (HCM) Vice Chairperson, (voting member); HCM Committee Administrator (non-voting member); Director, New Models and Episodes of Care (EOC) (voting member); Director Healthcare Marketplace Innovations, (voting member); Medical Directors, including the following Healthcare Management and Transformation (HCM & T) areas: Quality Management, Medical Policy, Population Health, Partner Transformation (voting members); Directors, including the following Healthcare Management and Transformation areas: Partner Transformation Value Based Programs and Community Health (voting members) and various Representatives, including but not limited to the following areas: Pharmacy Analytics, Value based contracting, Quality Management, Medical Policy, Healthcare Management and Transformation, (non-voting members).
- Assesses and advises Horizon’s value based programs quality metrics on a quarterly or ad hoc basis as needed.
- Reviews and monitors quality performance of Value Based and Episode of Care provider partners including but not limited to recommending corrective action plans if appropriate.
- Evaluates quality as an integral component of shared savings opportunities with partners in value based programs.
- On an annual basis, documents Horizon’s enterprise-wide value based programs’ strategies for the year.
- Reports all actions to Horizon’s Quality Improvement Committee following all QAC meetings.
- Forms a QAC sub-committee when necessary for the efficient functioning of the Value Based Programs to meet project deadlines or as otherwise directed.
Frequency of Meetings
The Value Based Programs Quality Advisory Committee Team will meet on a quarterly basis, additional communications may occur as required.
Inclusion of Participating Providers in the QI Program
Participating providers are included as voting members of the QIC. Participating providers are also voting members of the Horizon Medical Management Committee, Pharmacy and Therapeutics Committees, and Quality Peer Review Committee. Participating physicians and other providers are kept informed about the written QI Program Description available in provider newsletters and on the plan’s website. Providers can also access information in the Provider Administrative Manual about how they can be included in the design, implementation, review and follow up of Commercial QI activities.
Quality Program Organizational Structure
Review the organizational structure of the QIC.
Quality Improvement Program Resources
Resources available to the Program that contribute to the Quality Improvement function include various Horizon departments, including Quality Management, Medical Management (Utilization Management, Case Management and Care Management Programs), Marketing, Service, Communications, Operations, Information Systems, Credentialing, Service Quality, Pharmacy and Network Management. Organizational charts are used to provide a more comprehensive description of the resources available within each department.
Roles and Responsibility-Individual
President and CEO
Vice President and Chief Medical Officer (CMO)
VP and Chief Pharmacy Officer
Senior Medical Director
Behavioral Health (BH) Sr. Medical Director
Director Quality Performance and Stars
Team Quality Managers
The Team Quality Managers oversee the day-to-day operations of the Quality Improvement programs. Additionally, they manage clinical quality complaints, adverse events, Member Advocacy, management of HEDIS® program, training and quality audits, and accreditation.
In the event a position becomes vacant, the Medical Director and/or Quality Management Director will delegate the responsibilities in coordination with other team members.
External Quality Review
Horizon’s healthcare plans are accredited by the National Committee for Quality Assurance (NCQA). Accreditation is a rigorous assessment of Horizon’s systems, clinical quality, member satisfaction, policies and procedures. The Quality Management Department is responsible for educating staff on annual updates to the standards, assisting teams with document preparation, completing gap analysis, the submission of documentation and the coordination of the NCQA survey. The Division of Banking and Insurance (DOBI) monitors member enrollments, regulation compliance and market structure to ensure product availability in the New Jersey marketplace.
Horizon utilizes data from the following sources to identify opportunities for improvement, track and measure process, outcomes and overall effectiveness. These data sources include, but are not limited to:
- Annual HEDIS® reports
- Quality Rating System (QRS)
- Member Satisfaction Survey (CAHPS®)
- Enrollee Experience Survey (EES)
- Provider satisfaction surveys (Office Manager/Physician)
- Hospital acquired conditions
- Member and provider files
- Medical record review data
- Access and availability data (GeoAccess)
- Continuity and coordination of care processes and data
- Clinical and preventive guidelines
- Credentialing and re-credentialing data and files
- Marketing information
- Member quality of care complaints
- Member complaints and appeals
- Provider complaints and appeals
- Chronic care program data and files
- Case management data and files
- Utilization management data and files
- Delegated entities’ performance data
- Internal audits of Quality Improvement processes data and reports
- Pharmacy utilization data
- Phone statistics (ASA, CAR)
- Employer satisfaction survey
- Concurrent review database
- 24/7 nurse line data and reports
- Online interactive tools/HRA data and reports
- Feedback from external regulatory and accrediting agencies
- Office site visits reports
All data is stored in Horizon’s electronic systems. Utilization and member/provider data is stored, updated and maintained in an Enterprise Data Warehouse that is backed up daily. Data resulting from surveys, interaction with members, mandatory reporting and specific analysis and monitoring are stored in independent databases supported by the enterprise IT Department, which in turn ensures data confidentiality in compliance with HIPAA regulations.
Data accuracy is assessed through periodic audits such as medical record reviews for performance monitoring and reporting, sharing of performance data with providers and other internal audit processes.
Data collection, management and analysis is carried out by Horizon’s staff including nurses, business analysts, reporting analysts and clinical auditors with the appropriate background and qualifications.
A comprehensive data recovery process is in place to ensure continuity of business in the event of a major adverse event. All data is backed-up daily and stored in an outside location. A recovery site is located 40 miles from the corporate headquarters in Newark where Horizon’s technology (telephone and computers) can be rerouted in the event of a major disruption of business. Horizon has a work-at-home policy and several locations which contribute to a fast restoration of services in the event of a major adverse event.
All data, documents, reports, materials, files and committee minutes are kept for a period of years (according to various regulatory, state and federal requirements), whether on site or achieved in a secured site. Horizon has a “Records Management Policy” reviewed annually that clearly describes these processes.
The Behavioral Health Program offers quality services to help members manage all aspects of their health and provides access to mental health and substance abuse services in a variety of settings by participating providers from several disciplines. Behavioral Health Case Managers provide assessment, development and implementation of individualized plans of care and offer coordination of integrated physical and behavioral health care services for members and their families. The program utilizes the Care Radius medical management system to support delivery and documentation of the case management process.
Horizon is committed to monitoring and improving the quality of Behavioral Healthcare (BH), as needed, with the development of BH specific activities that are incorporated into the QI work plan. They include core performance indicators, monitoring and intervention activities designed to focus on the safety and quality of services provided to members, and coordination of care for members. Work plan goals are evaluated annually with achievements and opportunities for improvement specified in the organization’s annual program evaluation. To ensure continuity and coordination of care/integration between behavioral and physical healthcare services, BH clinicians and business owners participate in the applicable committees noted in the QI organizational structure.
Additionally, the Network Contracting and Servicing and Network Operations Departments review geographical access reports that address the adequacy of the behavioral health provider network as well as reports which assess member ability to access behavioral services in a timely manner. Deficiencies are acted on to reduce barriers to care and ensure continuity of care for members.