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Horizon Blue Cross Blue Shield of New Jersey Horizon Healthcare of New Jersey, Inc.

2021 Commercial Quality Improvement Program Description

Table of Contents




    1. 3.1 Program Evaluation


    1. 4.1. Governing Body
    2. 4.2. Committees
    3. 4.3. Inclusion of Participating Providers in the QI Program
    4. 4.4. Quality Program Organizational Structure
    5. 4.5. Quality Improvement Program Resources
    6. 4.6. External Quality Review
      1. 4.6.1. Data Sources
    7. 4.7. Behavioral Health


    1. 5.1. Member Safety

    2. 5.2. Disparities in Health

      1. 5.2.1. Cultural Competency and Health Literacy

      2. 5.2.2. Complex Health Needs

    3. 5.3. Quality Assurance

      1. 5.3.1. QI Program Components

      2. Preventive Health and Wellness

      3. Care Management

      4. Medical Management

        1. New Initiatives & Opportunity for Improvement

      5. Pharmacy Management

      6. Credentialing & Recredentialing

      7. Network

      8. Customer Service

      9. Delegate Vendor Oversight

      10. Behavioral Health (BH) Care Management Programs

      11. Education and Training

      12. Nondiscrimination

      13. Value Based Programs





Quality Improvement Committee Structure - Attachment A

Quality Management Organizational Structure - Attachment B


    The Horizon Quality Improvement Program is a coordinated and comprehensive program designed to monitor, assess and improve the quality and appropriateness of care and services provided to members/covered persons with coverage within the respective lines of business. This is accomplished by creating an infrastructure and set of business processes to make the achievement of high quality outcomes and service an integral part of the way Horizon does business. This document serves as a summary description of the Horizon Quality Improvement Program. It does not include the quality activities of Government Programs; however, it is cross shared to ensure collaboration and consistency. More detailed descriptions of program components are described in other Policies, Procedures, and Workflows. The Horizon Quality Improvement Program is revised as needed and reviewed at least annually. It is available for review by the various regulatory and accreditation entities (e.g. – Department of Banking and Insurance and Centers for Medicare and Medicaid Services and NCQA) upon request. It is also made available to our members and network providers.


    The Quality Improvement Program provides a mechanism for the coordination of both quality improvement and quality management activities. The scope of this program includes the objective and systematic monitoring of the quality and safety of health care services provided to Horizon members. In an effort to improve organization performance, collaborative and specific indicators of both processes and outcomes of care are developed, measured and assessed by all appropriate departments in a timely manner.

    The membership served by the Quality Improvement Program is from the following product lines: Commercial including Qualified Health Plans, HMO, POS, Direct Access, EPO, PPO, FEHBP, and self-funded accounts (e.g. SHBP). It does not include products aligned to the Government Programs division (e.g. Medicare, MLTSS, FIDE SNP and Medicaid).

    The program has two major components: clinical and service. The range of the clinical activities is extensive, encompassing preventive care, acute care, chronic care, and care provided for special populations, including behavioral health. It monitors provider credentialing and compliance, member education, health outcomes, screening, practice guidelines, delegation and medical record documentation. The service component of the program monitors availability and accessibility of care, network adequacy, member/provider satisfaction, and member complaints and appeals.


    The Quality Improvement Program monitors the availability, accessibility, continuity and quality of care for both medical and behavioral health services on an ongoing basis.

    1. Goal:

      Monitor the quality of care and services provided by participating providers, practitioners, and independently contracted delegates to Horizon.


      • Evaluate and maintain a high quality provider network through a formalized credentialing and recredentialing process.
      • Maintain a structured, ongoing oversight process for quality improvement functions performed by practitioners, providers, and independently contracted delegates.
      • Implement activities to monitor and address continuity and coordination of care between medical and behavioral health specialties and within the medical care system.
      • Establish long-term collaborative relationships with the provider network to consistently improve the quality and cost effectiveness of care and services delivered to our members.
      • Specify standards of care, criteria and procedures as well as assess compliance with such standards and adequacy and appropriateness of health care resources utilized.
      • Monitor member satisfaction with quality of care and services received from network providers, practitioners and delegates.
    2. Goal:

      Maintain a systematic approach to monitor, evaluate, improve and ensure provider and member access to utilization management services.


      • Assure that adequate resources are arranged to provide available, appropriate, accessible and timely health care services to all members according to evidence based rules.
      • Evaluate new medical technology and the new application of existing technologies and determine their coverage status in the context of Horizon’s benefit packages.
      • Continually monitor, evaluate, and improve Horizon’s performance using benchmarks and goals based on local and national data.
      • Ensure appropriate coordination of care between clinical settings.
    3. Goal:

      Act on opportunities for improvement of the health status of members through the development and implementation of population health programs addressing health promotion, preventive health education, and disease and case management programs.


      • Continually identify and outreach to members at risk and/or with gaps in care.
      • Identify healthcare disparities in order to develop appropriate intervention tools including staff cultural competency education.
      • Establish programs focused on the chronic conditions of our members in order to empower members to actively participate in and take responsibility for their own health through the provision of education, counseling, and access to quality health care providers and tools.
      • Expand planned interventions in existing health management programs and strengthen coordination between clinical and behavioral health management activities, and appropriate discharge planning.
      • Develop, distribute and maintain preventive health guidelines that are: age, gender, culture, and risk status appropriate; describe the prevention or early detection interventions along with the recommended frequency and conditions under which the interventions are required; document the source upon which it is based, review and update bi-annually or as needed.
      • Develop population based programs that address our member’s needs in the areas of wellness, members with emerging risk, multiple chronic conditions and patient safety and outcomes across medical setting. Promote member engagement/participation in these programs.
    4. Goal:

      Maximize safety and quality of health care delivered to members through the continuous quality improvement process.


      • Provide members with semiannual publications and access to a website that contains information to improve their knowledge about clinical safety issues.
      • Collaborate with providers and practitioners to establish a means of promoting and maintaining safe clinical practices.
      • Address patient safety through continuous review of quality care issues and require corrective action from providers involved.
      • Evaluate and reward provider (physicians and hospitals) performance with respect to the quality of care delivered to members.
      • Utilize evidence based practice guidelines, monitor and assess the extent to which members receive care consistent with the guidelines.
      • Provide members with 24/7 access to clinical staff for informational questions and education about help with assessing their basic health care needs.
      • Evaluate patient safety through continuous monitoring of polypharmacy utilization.
      • Assess the over and under-utilization of services.
    5. Goal

      Maintain a high level of satisfaction in members, providers and customers on the services provided by Horizon.


      • Ensure easy and timely access to accurate information through customer service representatives, phone lines, internet or website.
      • Resolve inquiries, complaints and appeals in a timely manner.
      • Measure member and provider satisfaction through analysis of complaints and survey data  Identify areas for improvement and develop improvement action plans.
    6. Goal:

      Maintain compliance with local, state, and federal regulatory requirements and accreditation standards.


      • Monitor and update workflows and processes to continuously meet regulatory requirements for quality improvement and compliance as needed.
      • Initiate and monitor quality improvement activities which meet or exceed accreditation standards.
      • Fulfill the quality related reporting requirements of applicable state and federal statutes and regulations, as well as standards developed by independent external review and accreditation bodies.
    1. 3.1. Program Evaluation

      Policies and procedures supporting the Quality Improvement Program are reviewed and approved annually by the appropriate committee and updated as needed. Based on the annual program evaluation, the prior year’s QI Work Plan is revised, and a new QI Work Plan for the coming year is developed to guide and focus the work for the next year.

      The program evaluation includes information about the following:

      • Review of progress and status of annual goals.
      • Monitoring of previously identified issues.
      • Evaluation of the effectiveness of each quality improvement activity.
      • Review of trends of clinical and service quality indicators.
      • Evaluation of the improvements occurring as a result of quality improvement efforts.
      • Evaluation of the overall effectiveness of the Quality Improvement Program.
      • Evaluation of adequacy of staff resources.
      • Evaluation of program structure and processes.
      • Goals and recommendations for the work plan for the following year.

    1. 4.1. Governing Body

      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.

    2. 4.2. Committees

      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

      1. Function

        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.

      2. 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: A. Senior Medical Director, Medical Management (tie breaker).

        • Executive Medical Director, Quality 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 Improvement Operations (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)
        • Behavioral Health Medical Director (1 voting member)
      3. 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.

      4. Others Attending

        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.

      5. Frequency of Meetings/Voting/Quorum

        The QIC meets quarterly. Attendance records are maintained. Committee meetings are scheduled by the Chairperson. 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) pre- scheduled 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.

      6. Minutes/Agenda

        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.

      7. Confidentiality

        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.

      8. Responsibilities:

        • 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 time tables 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 is warranted 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 Committees 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 is in compliance with appropriate accrediting organizations and regulatory requirements.

        The following represents a list and description of the committees:

      Quality Peer Review Committee

      1. Function

        The Quality Peer Review Committee (QPRC) reviews potential quality of care issues which are referred to the QPRC. The goal is to ensure that Horizon BCBSNJ 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 as a result 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. The committee is chaired by a Horizon Medical Director or designee. 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 on 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
        • Quality Management Manager Clinical Operations
        • Quality Risk Manager
        • Quality Management Nurses
        • Care/Case Disease Management Nurses
        • Managed Long Term Services and Supports (MLTSS)
        • Dual Special Needs (DSNP)
      2. Accountability

        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)
      3. Frequency ofMeetings

        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

      1. Function

        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.

      2. Accountability

        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, 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.
      3. Frequency ofMeetings

        The Medical Management Committee meets no less than six (6) times per year

      4. CommitteeComposition

        • Senior Medical Director, Health Affairs (Chairperson and tie breaker voting member)
        • Medical Director - Medical Management (1 voting member).
        • Medical Director - Medical Management (1 voting member).
        • Director - Quality Management (1 voting member).
        • Senior Medical Director, Medical Policy (1 voting member).
        • Manager, Medical Management Appeals (1 voting member).
        • Directors, Health Affairs with UM/CM/Prior Authorization (2 voting members).
        • Medical Director (Behavioral Health) (1 voting member).
        • Manager, Clinical & Quality Reporting (1 voting member)
        • External Physicians (1-2 voting members).
        • Other representatives as requested by Chairperson or person officially in “acting position” for any of the above positions – (non-voting).

      Provider Appeals Committee

      1. Function

        The Committee review is the final authority within Horizon in settling facility appeals related to medical necessity/appropriateness. The Committee’s voting membership consists of a Medical Director Chair (tie breaker), Manager or designee, and Utilization Management Appeals representatives (2 voting RN’s).

      2. Accountability

        • The Provider Appeals Committee (PAC) issues a determination and communicates the decision within 30 calendar days of receipt of the level two (2) appeals; 15 calendar days for Facility on behalf of the Member Appeals; provided the Committee does not require additional medical information. If the Committee does require additional medical information, a letter to this effect must be sent to the appellant within five (5) business days from the presentation at the Provider Appeal Committee.
        • The Provider Appeals Committee reports bi-monthly to the Medical Management Committee (MMC) and quarterly to the Quality Improvement Committee (QIC) and Quality Committee of the Board. The report includes a statistical summary on all written appeals filed, procedures used and dispositions handed down.
        • The Provider Appeals Committee convenes at least once each year to evaluate and update its role, procedures and effectiveness.
        • The Provider Appeals Committee complies with any applicable state and/or federal regulations and accreditation requirements as applicable.
      3. Frequency of Meetings

        The Provider Appeals Committee meets at least once a month. Additional meetings are scheduled on an as needed basis.

      Member Appeals Committee

      1. Function

        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 (2-4 voting members), Participating Physicians practicing in the appropriate specialties, as needed (non-voting members).

      2. Accountability

        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 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.
      3. Frequency ofMeetings

        The member Appeals Committee meets at least once a month. Additional meetings will be scheduled as needed.

      Delegate and Vendor Oversight Committee

      1. Function

        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, Delegate Vendor Contract Management/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, Manager, Vendor Compliance (1 voting member), Manager, Sourcing & Supplier Management (1 voting member), Manager, Physician Data Management (1 voting member), Director Network Programs (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).

      2. Accountability

        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.
      3. 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.

      Credentials Committee

      1. Function

        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, Quality Management (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 regards to the credentialing and re-credentialing, certification and re-certification of specialist physicians, healthcare professionals and ancillary providers and facilities.

      2. Accountability

        • 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.
      3. 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

      1. Function

        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.

      2. Accountability

        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.

      3. Frequency ofMeetings

        The MAC-BIC Committee meets at least once a week, with additional meetings scheduled as needed.

      Pharmacy and Therapeutics Committee

      1. Function

        The Pharmacy and Therapeutics Committee (the “P&T Committee”) of Horizon BCBSNJ 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 BCBSNJ. 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 BCBSNJ 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.

      2. Accountability

        • 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 BCBSNJ, the P&T Committee will provide input on recommendations Horizon BCBSNJ may make to the Horizon BCBSNJ physician networks regarding the appropriate use of pharmaceuticals, methods to measure the quality of drug prescribing and educational programs for Horizon BCBSNJ members and providers.
        • All actions of the P&T Committee are reported to the Quality Improvement Committee on a quarterly basis.
      3. Frequency ofMeetings

        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

      1. Function

        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.

      2. Accountability

        The Committee focus is oversight and direction of enterprise-wide 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.
        • Develop service QI goals and activities.
        • 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.

      3. Frequency ofMeetings

        The MPSSC meets quarterly throughout the year.

      Clinical Policy Committee

      1. Function

        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.

      2. Accountability

        Review and advise on the content and quality of medical, 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.
      3. Frequency of Meetings

        The Clinical Policy Committee meets no fewer than ten (10) times per year.

      Value Based Programs Quality Advisory Committee

      1. Function

        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) Chairperson, (voting member); Director, Partner Transformation, 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).

      2. Accountability

        • Forms a QAC sub-committee when necessary for the efficient functioning of the Value Based Programs to meet project deadlines or as otherwise directed.
        • Reports all actions to Horizon’s Quality Improvement Committee following all QAC meetings.
        • On an annual basis, documents Horizon’s enterprise-wide value based programs’ strategies for the year.
        • Evaluates quality as an integral component of shared savings opportunities with partners in value based programs.
        • Reviews and monitors quality performance of Value Based Programs partners including but not limited to recommending corrective action plans if appropriate
        • Assesses and advises the organization’s value based quality metrics on a quarterly or ad hoc basis as needed.
      3. Frequency ofMeetings

        The Value Based Programs Quality Advisory Committee Team will meet on a quarterly basis, additional communications may occur as required.

    3. 4.3. 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 Utilization Management/Case Management Committee, Physician Advisory Committee, Pharmacy and Therapeutics Committees, Dental Advisory Committee 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.

    4. 4.4. Quality Program Organizational Structure

      An organizational chart of the QIC is available in Attachment A.

      An organizational chart of the Quality Management Department is available in Attachment B.

    5. 4.5. 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

      The President and CEO is responsible for the overall operations of the Quality Improvement Program.

      Vice President and Chief Medical Officer (CMO)

      The Vice President and Chief Medical Officer reports to the Executive Vice President of Healthcare Management, chairs the Quality Committee of the Board and is responsible for design and implementation of the Quality Improvement Program. He/she ensures that quality activities are prioritized based on membership needs and integrates the Medical Management (including population health management activities) and Credentialing programs with the Quality Improvement Program.

      VP and Chief Pharmacy Officer

      The Chief Pharmacy Officer plans and directs pharmacy benefit management activity, including specialty pharmacy management. This includes oversight of the P&T Committee, clinical development activity, utilization and quality management and medication safety, benefit administration, operations, sales and marketing support and business development. The Chief Pharmacy Officer is responsible for the contracted PBM. Performance measurement is managed in conjunction with the Delegate and Vendor Oversight Committee which is part of the Quality structure and reports to the Quality Improvement Committee.

      Senior Medical Director

      Senior Medical Directors may be assigned specific oversight of key functions and areas of importance as determined by the Chief Medical Officer, including designated chair of the Quality Improvement Committee, and also chairs/or participates in Medical Management Committee, Provider Appeals Committee, Member Appeals Committee, and the Quality Committee of the Board. His/her roles include, overseeing the implementation of the QI program that involve or affect clinical care, patient safety, and the overall development and evaluation of the QI program.

      Medical Directors

      The Medical Directors are responsible for conducting peer and utilization management review, and may be delegated to chair various committees.

      Behavioral Health (BH) Sr. Medical Director

      The BH Medical Director is the designated behavioral health care practitioner who is actively involved in the behavioral health care aspects of the QI program. Some of his/her responsibilities consist of coordination of the and development of the BH activities included in the Quality Improvement Program Description, Quality Work Plan, mid-year Quality Work

      Plan Update, and the annual QI Program Evaluation. The Medical Director is also responsible for the implementation and review of the behavioral health safety program and adherence to corporate compliance policies and procedures.

      Quality Assurance & Improvement Operations Director

      The designated Quality Improvement Director plans and directs the quality improvement and assurance activities. The director oversees initiatives related to all quality improvement programs as well as participates in the provider quality improvement process including provider credentialing. The Director oversees the development of an annual quality improvement work plan and is responsible for the annual quality improvement program evaluation. He/she reviews and revises the Quality Improvement Program Description annually, and is a member of the Quality Improvement Committee, Medical Management Committee, Member Provider Service Satisfaction Committee, Credentials Committee, and the Delegate and Vendor Oversight Committee.

      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.

    6. 4.6. External Quality Review

      The National Committee for Quality Assurance, NCQA provides accreditation for Horizon’s healthcare plans. This accreditation certifies Horizons systems, policies and procedures are aligned with high quality care and service. The Quality Management Department is responsible for Horizon’s biannual preparation, the submission of documentation and the coordination of the onsite/virtual NCQA assessment. The Division of Baking and Insurance, DOBI monitors member enrollments, regulation compliance and market structure to ensure product availability in the New Jersey marketplace.

      1. 4.6.1. Data Sources

        Horizon collects, stores, groups, analyzes and uses the following data in order to identify opportunities for improvement, and 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 such as nurses, business analysts, reporting analysts and clinical auditors with the appropriate background and qualifications required by the task such as data management, computer programming, data analysis and clinical expertise.

        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 corporate policy “Records Management Policy” reviewed annually that clearly describes processes.

    7. 4.7. Behavioral Health

      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 medical 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, as needed, with the development

      of BH specific activities that are incorporated into the QI annual 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 between behavioral and medical services, BH clinicians and business owners participate in the applicable committees noted in the QI organizational structure.

      Additionally, the Provider Contracting & Strategy 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.


    Detailed processes and methodology are used to determine the overall efficacy of performance improvement activities and programs. The monitoring of specific indicators is designed, measured and assessed by all appropriate departments, disciplines and services to reveal trends and performance improvement opportunities in an effort to improve organizational performance. These indicators are objective, measurable, based on current scientific knowledge and clinical experience, broadly recognized in the industry and are structured to produce statistically valid performance measures of care and services provided.


    • Identification of important issues that reflect significant aspects of care and service.
    • Selection and/or development of adequate metrics.
    • Selection of goals and/or benchmarks for each measure/metric.
    • Measurement, tracking and trending.
    • Identification of opportunities for improvement based available data.
    • Root cause analysis.
    • Implementation of interventions or corrective actions referring to the identified opportunities for improvement.
    • Re-measure to determine the effectiveness of the interventions based on statistical significant improvement and/or reaching a goal or benchmark.
    1. 5.1. Member Safety

      Horizon has a dedicated commitment to patient safety; it is of the utmost importance to Horizon and its membership. Promoting patient safety encompasses a wide range of activities in the Quality Improvement domain:

      • Drug-Drug Interaction Reject (DDIR) Program to identify potential serious drug interactions at the point of service.
      • Reducing prescribing errors by encouraging and supporting e-prescribing.
      • Retrospective analysis and evaluation of clinical data through Drug Utilization Reviews (DUR) Program.
      • Identification of potential drug-drug interactions through Point of Service edits.
      • Prior authorization Program: This is a program in which certain prescription drugs require Horizon’s prior authorization before the prescription drug can be dispensed. If prior authorization is not obtained for the requested prescription drug, the requested drug rejects at the point-of-service. Specific prescription drugs may require prior authorization due to any of the following factors:
        • The drug has the potential for significant inappropriate use or abuse
        • Use of the drug carries a significant safety concern (adverse events could occur or patient monitoring needed)
      • Quantity Limit and Age Limit Programs are safety edits in the adjudication system based on FDA approved product labeling and clinical pivotal trials to allow dispensing of the drugs up to the FDA recommended maximum dosage and to not allow drug coverage for certain populations, such as pediatrics, based on limited clinical data.
      • Dose Optimization Program: This program is part of the dispensing limit requirements, for drugs that are FDA approved for once a day dosing. This program encourages the use of higher strengths once a day and discourages the use of lower strengths which require multiple dosing throughout the day, thus generally improving the likelihood of patient compliance.
      • Drug Recalls, Black Box Warnings and Safety Alerts: When a drug is withdrawn / recalled from the market or when a drug has a new black box warning, Horizon’s Pharmacy Benefit Manager on behalf of Horizon BCBSNJ Pharmacy Services, will notify participating providers and affected members.
      • Duplicate Therapy: Through this program a licensed pharmacist retrospectively reviews member and pharmacy claims for potential duplicate therapies dispensed in the previous quarter to help ensure safe and appropriate utilization.
      • Clinical programs with a focus on safety, underutilization and overutilization.
      • Opioid Management Program, to reduce inappropriate prescribing and utilization through case based reviews and physician outreach. The purpose of the narcotic management program is to reduce inappropriate prescribing and inappropriate utilization through case based reviews. Different Horizon BCBSNJ departments, such as case management and investigations, collaborate to assist in making effective interventions.
      • Horizon BCBSNJ maintains a website with a drug to drug interaction tool and a drug database that informs members regarding drug therapy, how to take drugs, potential side effects, etc.
      • Newsletters: Pharmacy related topics are published in the member and provider newsletters on various drug information such as, drug coverage and other clinical programs annually and quarterly respectively.
      • Gaps in Care Program to promote appropriate drug therapy and improve quality of life for our members through avoidance of medical complications and slowing disease progression.
      • The use of HEDIS results to identify areas for improvement and to ensure that our members are continuously receiving safe and appropriate care (i.e. Diabetes treatment, Rheumatoid Arthritis, Adherence and High Risk Medications.)
      • Maintaining a safety conscious provider network through diligent credentialing.
      • Monitoring continuity of care across treatment sites and between medical and behavioral health.
      • Monitoring adherence to clinical practice guidelines at the provider level.
    2. 5.2. Disparities in Health

      Disparities in health reduce the overall quality of care provided within the health care system while adding to overall health care costs. In 2020, to address the multiplicity of the needs of the membership, the QI Program will conduct an analysis of the needs and characteristics of the entire health plan population. Identify sub-populations that require assistance and determine whether the current population health program services and resources are adequately meeting those needs. Compile a report that demonstrates process to at least annually segment and stratify the entire enrolled population into subsets for targeted intervention based on their health needs. Disparities identified will be addressed through the quality improvement process.

      1. 5.2.1. Cultural Competency and Health Literacy

        As part of the onboarding for all new Horizon employees, cultural diversity, cultural competency and health literacy are key components of the mandatory curriculum. This training is ongoing and recurrent for existing staff.

        Members speaking a language other than English have access to the AT&T language line whenever they need to interact with Horizon, and they can look for a provider speaking their language in the provider directory. Horizon Blue Cross Blue Shield of New Jersey also has a bilingual website dedicated to Spanish speaking members

        All members and those specifically enrolled in Case Management and Care Management Programs have translation services and materials available in Spanish, which is the predominant non-English language among Horizon’s members, as well as other languages, as needed.

      2. 5.2.2. Complex Health Needs

        Offerings vary by line of business.

        The Chronic Care Program services are primarily telephonic, with on-site services provided at the discretion of the Chronic Care program management team. The team includes Registered Nurses, Registered Dieticians, Social Workers, Managed Care Coordinators and Medical Directors. The Chronic Care Program is an “opt-out” program and participation is voluntary.

        Member Identification

        Members are identified for participation from the following sources:

        • Horizon’s own clinical identification algorithms based on medical, laboratory and pharmacy claims data. Health Risk Assessment survey
        • Member self/ caregiver/ Practitioner referral
        • Hospital discharge data
        • 24/7 Nurse line referral
        • Internal Horizon referral
        • Facility Case Managers
        • Employer Group referrals

        Member Interventions

        The methods of member interventions include: educational mailings, telephonic educational coaching, assessing member readiness to change, assisting the member to understand treatment options, appropriate use of medications, appropriate nutrition, avoiding disease exacerbations, improving communication with his/her physician, and connecting members with community resources.

        Provider Interventions

        The Chronic Care Program staff is dedicated to supporting the treating physician’s efforts to improve health status and interact with the physician on behalf of the member by informing them of the member’s participation in the program through phone, mail, e-mail and or fax including the member’s decision to opt out of the program or when the member denies the disease. The care manager will involve the provider in determining mutually agreed upon goals for the members enrolled in the program and to request clinical metrics to support any identified gaps in care for the member. Participating physicians are encouraged to use the physician-restricted online portal of Horizon BCBSNJ’s website that provides them access to Clinical Practice Guidelines that are developed based on national standards of care and also provides information about the Chronic Care Program as well as resources for their members.


        Clinical outcomes metrics may include but are not limited to objective clinical findings such as lab results, immunization rates, and prescription filling/use of disease-specific medications. Clinical outcome metrics are specific to each Chronic

        Care Program and are measured quarterly and annually using medical, pharmacy claims, HEDIS and assessment collected data.

        An annual assessment of the program is conducted, including a review of all clinical and operational metrics including member satisfaction and provider feedback. Feedback on the program including need for program revisions or new/revised clinical practice guidelines is evaluated. Improvement areas are identified and actions are developed. Ongoing monitoring is conducted quarterly/biannually and plans are reviewed for improvement or revision.

    3. 5.3. Quality Assurance

      1. 5.3.1. QI Program Components

        The following are brief descriptions of the various components of the Quality Improvement Program. For a full description of the programmatic elements as well as to which lines of Horizon’s business they apply, see the relevant administrative policies relating to that function.

        1. Preventive Health and Wellness

          The goal of Horizon’s Preventive Health and Wellness Program is to improve the member’s quality of health by encouraging them to pursue healthy lifestyles and maintain optimal wellness. Key components of the Program include assisting members/covered persons to obtain needed immunizations and screening tests, and educating members on preventive health care, known to reduce illness, and accidents, and promote the early detection of potential disease conditions. The Program uses a variety of reminder techniques for this purpose such as automated reminder telephone calls; health risk appraisals, interactive tools through the member portal; newsletters targeted to a specific populations; mailings, and preventive health calendars. The aim is to reach members in a manner to which they can easily relate.

          Horizon’s Preventive Health Program is based on preventive health care guidelines that are developed and maintained by Horizon. These guidelines were adopted from national organizations such as the Advisory Committee on Immunization Practices, the American Academy of Pediatrics; the American Academy of Family Physicians; the Agency for Health Care Policy and Research; American Cancer Society and the American Diabetes Association. The guidelines are age, gender, and risk-status specific that describe the prevention or early detection interventions recommended along with frequency and conditions under which the interventions are required. Target preventive health activities include, but are not limited to: childhood and adult immunizations, women’s health needs, nutrition, high blood pressure, smoking cessation, and depression.

          Internal users who utilize Clinical Practice Guidelines (CPG’s) access information through the Lotus Notes database. Horizon distributes the preventive health guidelines and updates to participating physicians and members via newsletters. Providers can also access information via the provider portal.

        2. Care Management

          Care Management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet a member’s medical and psychological needs. Its primary focus is the coordination of appropriate quality health care in the most cost-effective manner for members with complex medical and behavioral conditions. The intensity of care management activities varies based on a multitude of factors including, but not limited to:

          • Clinical features of the individual case as reported by a member or attending/treating provider;
          • Evaluation/treatment setting resources available
          • The member’s clinical needs and situation; and
          • The opportunity for case management intervention to have a positive impact on the member’s circumstances. Care Management activities and the result of these activities are summarized and reported to the Medical Management Committee.

          The objectives of the Care Management Program are as follows:

          • To assure timely patient access to the appropriate type and level of care as early as possible.
          • To manage health care benefits as effectively as possible while pursuing all members needs from a patient advocacy perspective.
          • To identify needs that follow an acute care episode and assists with interventions for long –term health problems.
          • To identify members who may benefit from educational programs, materials and other services that can be offered, including community services and provides evidence-based tools and resources.
          • To identify members, based upon eligibility under their benefits contract, which might benefit from referral to Horizon internal or contracted services such as the Complex Case Management Program which includes specialty care management services, Primary Nurse Program, Case Management Plus, Behavioral Health Services, eviCore, CareCentrix, Magellan RX, Pharmacy assistance, and referrals to Horizon par external vendors. To integrate member’s services with all those providing care through ongoing collaboration in treatment planning, discharge planning, transition of care in such venues as Interdisciplinary Community Based Care Model meetings, hospital and post-acute facility discharge planning meetings, Case Rounds, and individual outreaches to providers and vendors.
          • To achieve optimum cost efficiency while assuring delivery of quality of care.
          • To improve population health through population health management strategies.
          • To identify and address social determinants of health.
          • To promote and manage safe transitions in care.
        3. Medical Management

          The Medical Management (MM) Program evaluates clinical necessity, access, appropriateness, and efficiency of services. This includes, but is not limited to the following programmatic components: prior authorization, concurrent review, discharge planning, retrospective review, care management, and chronic care management. The MM Program also generally seeks to coordinate, when possible, emergent, urgent and elective health care services. The MM Program evaluates overall utilization such as ER, admission and readmission rates, coordination of services, over and underutilization, and evaluation of new technology. In addition, oversees all Medical Managed delegated functions. Refer to Medical Management (MM) Program Description for more detailed information.

          1. New Initiatives & Opportunity for Improvement

            Opportunities for improvement that are identified in the 2020 QI Program Evaluation are incorporated into the following year’s QI Program activities for implementation and monitoring by the QIC. These opportunities may require new initiatives to be developed that will yield a positive impact on the quality of care and service. Horizon will track these opportunities for improvement in 2021 and include updates to activities in the QI Program Evaluation. Activities may include: analyze member experience with accessing the network through review of member complaints, appeals, member survey data about access and out-of-network utilization for behavioral health and non-behavioral health services to identify network gaps which could impact member ability to access care. Develop new initiatives to address identified areas.

        4. Pharmacy Management

          The purpose of the Pharmacy Utilization Management Program is to identify different patterns of medication utilization and identify variables in treatment patterns for different disease states. The goal of this program is to improve patient outcomes and to utilize various interventions, including physician and member education, to ensure medically appropriate cost-effective prescription drug therapy in accordance with all applicable state and federal laws and regulations.

          Goals of the Pharmacy Utilization Management Program are as follows:

          • To assure that adequate and appropriate resources are available to provide accessible health care services.
          • To design interventions that improve clinical outcomes, optimize patient compliance, and maximize safety.
          • To provide pertinent education to members, physicians and healthcare professionals.
          • To identify medication utilization issues.
          • To identify patterns of inappropriate prescribing based on recommended prescribing guidelines.
          • To evaluate the impact of interventions.
          • To augment the drug selection process for formulary inclusion.
          • To further integrate Pharmacy Utilization Management activities with Medical Utilization Management and Quality Improvement processes.
          • To audit retail pharmacies and the pharmacy benefit manager to ensure appropriate utilization and reporting.
          • To differentiate drugs based on medical versus pharmacy
          • To review quarterly utilization reports to monitor drug use patterns.
          • To perform outcomes research based on pharmacy, medical and laboratory data.
        5. Credentialing & Recredentialing

          A significant part of Horizon’s Quality Improvement Program is the appropriate and regular credentialing of providers. The Credentials Committee establishes standards for identifying competent physicians and other providers in accordance with regulatory requirements and accreditation standards. The Committee uses the standards to determine eligibility for participation in one or more of Horizon’s networks. The goal is to develop a network of participating physicians and providers that demonstrates Horizon’s commitment to continuously improve the quality of health care delivered to its members.

          All physicians and providers participating with the health plan must submit their qualifications for review and approval by the Credentials Committee. Qualifications for physicians include, but may not be limited to, current licensure(s), education and training, work history, board certification, hospital/facility privileges, and malpractice history.

          Re-credentialing is performed on every network physician (excluding those to whom credentialing is not applicable per the Credentialing and Re-credentialing policy) and provider every three years.

          To ensure the quality and safety of care between credentialing cycles, the program performs continuous monitoring for sanctions, limitations on licensure, potential quality of care issues including member complaints and compliance with Horizon’s performance standards, such issues are brought to the Credentials Committee, which takes action as warranted.

        6. Network

          Network Management focuses on exploring and implementing opportunities to improve member access to care and services. Data is continuously gathered and analyzed throughout the Horizon organization to ensure that our Network(s) meet these needs and is able to deliver quality healthcare to our members.

          Some examples of analysis include but are not limited to the following: Our quarterly geo-access reporting that identifies any potential network deficiencies within provider specialties that we would need to recruit into our network(s). We also conduct an appointment availability analysis to ensure that members have access to needed providers and that they are getting desired appointments within the required timeframes. Additionally, we conduct several annual in-service education seminars for our network providers to inform them of updates to our various programs, services, products and requirements. We use the provider feedback from these seminars to plan future programs.

        7. Customer Service

          Horizon Member Services seeks to establish and maintain effective communication with members and providers in order to deliver the highest level of service. Member and Provider satisfaction are evaluated from data which includes phone performance, member/provider complaint handling, and member/provider satisfaction surveys (CAHPS and other internally developed surveys). Survey data is reviewed quarterly, and continuous process improvements are developed to optimize service levels in areas such as first call resolution, Average Speed of Answer, information accuracy and content of written materials (health literacy).

          Member/Provider satisfaction reports and complaint and appeal information are used to identify opportunities for improvement, review root cause / “end to end” processes and develop action plans as warranted.

        8. Delegate Vendor Oversight

          The Delegate and Vendor Oversight Department (DVOD) performs the formal process by which Horizon monitors, directs, and evaluates a set of activities by contractors who are responsible for the performance and/or implementation of any of Horizon’s quality improvement activities. Horizon maintains oversight responsibility of delegated activities and retains the right to modify or withdraw the nature of the contractual relationship, including the termination of the contract and/or the delegation of activities as specified in the relevant contract or delegation agreement.

          The Delegate and Vendor Oversight Committee (DVOC) also seeks to ensure that the vendor or delegate’s activities adhere to Horizon’s policies and procedures, regulatory and accreditation standards and meet performance goals as required in the relevant contract or delegation agreement. In the event a delegate and/or vendor is not meeting performance goals or expectations, the committee requires improvement and requests a corrective action plan, which is monitored until the issue(s) is remediated.

        9. Behavioral Health (BH) Care Management Programs

          The mission of the Horizon Blue Cross Blue Shield of New Jersey Care Management Program is to promote the well-being of our members by empowering them with the tools they need to better manage their disease and lead a better quality of life. The BH Integrated Care Management Program provides members with education and support utilizing a collaborative management approach with the Medical Care team to help manage behavioral health conditions such as but not limited to depression, anxiety, alcohol, and other substance abuse or dependence, eating disorders, schizophrenia, and bipolar disorder. The program encourages the member to actively participate and empower the member to be able to manage their own health conditions. Through the provision of education, support and motivation, we encourage member adherence to provider recommended treatment regimens, thereby improving member quality of life and preventing unnecessary complications. Horizon Blue Cross Blue Shield of New Jersey supports and partners with the interdisciplinary health team and employers to ensure access to high quality, cost effective behavioral health management programs.

          The BH Integrated Care Management Programs include the following goals:

          • Providing Behavioral Health support to members that are identified at risk or with diagnosis of depression, anxiety, bipolar, schizophrenia, autism disorders, alcohol or other substance abuse and eating disorders. Also identifying members with comorbid behavioral health and chronic medical conditions with symptoms that complicate adherence to prescribed treatment plan and self-management of their conditions.
          • Assisting members with behavioral health referrals by linking them to network providers.
          • Support the transition of members who are in medical inpatient units to behavioral health services as appropriate.
          • Assisting members with primary or secondary diagnosis of substance abuse or dependence with appointments within 14 days of diagnosis, establishing initiation of treatment and two (2) subsequent appointments (HEDIS Substance Abuse Treatment Initiation and Engagement).
          • Improving community tenure, functioning and treatment compliance for members with behavioral health issue through complex case management (CCM).
          • Prevent use of the ER for behavioral health reasons through proactive identification and providing assistance with referrals to specialty programs, appropriate authorizations and community resources.
          • Improving communications between primary care providers and behavioral health providers.
          • Performing diagnostic assessment of symptoms to determine the severity of the conditions (Patient Health Questionnaire).
          • Providing all enrolled members with education about behavioral health conditions.
          • Assisting members with depression and other behavioral health conditions to overcome barriers to treatment.
          • Focus on behavioral health conditions as barrier to adherence with self-management.
          • Monitoring the member’s condition through assessment of treatment response.
          • Collaborating, with the member’s consent, routinely with behavioral health providers and medical providers, as needed.
          • Identifying and promoting an optimal, realistic level of an individual’s wellness and functionality.
          • Improving overall member and provider satisfaction with Horizon Blue Cross Blue Shield of New Jersey.
          • Identifying needs following an acute care episode and assisting with interventions for long term behavioral health needs.
          • Providing follow up after hospitalization support.
          • Provide support via consultation to Horizon PCPs and pediatricians to improve the identification, evaluation and treatment of behavioral health conditions such as depression, anxiety and bipolar disorders. PCPs are afforded access to telephonic consultations with a behavioral health medical director (psychiatrist) to consult on psychotropic medication management and appropriateness of their Horizon member’s current behavioral treatment plan.
          • Post-partum support for member with comorbid Behavioral health symptoms and or diagnosis to assist in navigation for provider needs as well as community resources.
        10. Education and Training

          A team of clinical and non-clinical training professionals from the Clinical Operations Training team will create and deliver educational and training materials. Trainings are provided in either a classroom setting, by WebEx or via Horizon University to employees across the Enterprise. All courses are reviewed annually to ensure information is current. Education includes but is not limited to:

          • Medical Management
          • Health literacy
          • Cultural competency
          • Ethics
          • Regulatory and key industry guidelines
          • Accreditation
          • Safety
          • Quality reporting

          Training modules are provided to Clinical Operations staff and include a knowledge check or attestation to assess completion. General orientation training is conducted for new employees. Focused/specialized ad hoc training, including system upgrades, and trainings identified by departmental leadership are created and offered. Areas receiving education include:

          • Utilization Management
          • Case/Care Management
          • Quality Management
          • Appeals
          • Medical Directors
          • Other Departments as requested

          An annual review of process flows and pre-review screening is conducted in partnership with the appropriate teams to provide consistency of information to new and existing employees. Monthly chart review audits are conducted to ensure compliance with NCQA requirements and standards. Gaps identified in the audit process are addressed with each respective team for remediation.

          A semi-annual (May and November) MCG interrater reliability IRR testing is administered to Care Management (CM), Behavioral Health and Utilization Management (UM) staff RN’s, Medical Directors, and professionals who participate in clinical decision making. In addition, a 3rd quarter IRR is administered solely to the Commercial RNs to assess consistency of case management skill.

        11. Nondiscrimination

          Horizon Blue Cross Blue Shield of New Jersey complies with applicable Federal and State civil rights laws and does not discriminate against nor does it exclude people or treat them differently on the basis of race, color, gender, national origin, age, disability, pregnancy, gender identity, sex, sexual orientation or health status in the administration of the plan, including enrollment and benefit determinations. For further information, see the Notice of Nondiscrimination and Information in Other Languages Sections of the Horizon Blue Cross Blue Shield of New Jersey website.

          New Jersey is a diverse state and so is the membership at Horizon Blue Cross Blue Shield of New Jersey. Horizon collaborates with numerous institutions, community centers, hospitals and practitioners implementing programs to decrease health care disparities, training staff on cultural competency and developing programs on health literacy. The Horizon Foundation, through the yearly award of grants, helps to demonstrate our compassion, social responsibility and commitment to New Jersey.

        12. Value Based Programs

          Value-Based Programs are administered by the Healthcare Management and Transformation division of Horizon Blue Cross Blue Shield of New Jersey HBCBSNJ with the following goals based on the Triple Aim:

          • To improve the health of the population.
          • To achieve a sustainable trajectory in health care spending.
          • To improve the patient experience.

          To achieve these goals, Horizon works to establish collaborative provider relationships and looks to streamline processes to reduce clinician burnout, with clinician experience often called the Quadruple Aim. To reach these goals, Value-Based Programs has focused on:

          • Redefining care delivery to emphasize population health management and delivery system alignment.
          • Creating accountable consumers and purchasers.
          • Enhancing data exchange.
          • Enforcing clinical quality standards.
          • Providing coaching and insights to identify care barriers and fragmentation.

          Value-Based Programs Models

          EpisodesofCare (EOC) is the primary model that Horizon BCBSNJ uses to engage specialty care physicians in our value- based strategy. In an Episode of Care, a practice, doctor, or hospital acts as the conductor orchestrating the full spectrum of care for a specific medical condition, procedure or illness within a defined period of time.

          The goal of EOC is to standardize and optimize quality and cost of care, with the patient at the center of decision-making. Quality and utilization measures are part of program evaluation.

          Episodes of Care:

          • Promote physician-directed medicine;
          • Creates accountability to the patient for all care related to their particular procedure, diagnosis or health care event;
          • Promotes collaborative, comprehensive “best-in-class” care for Horizon BCBSNJ members across the full continuum;
          • Supports the view that health care is about best outcomes;
          • Promotes clinical outcomes and cost transparency to inform optimal care delivery decisions;
          • Enhances collaboration of all care providers across multiple care settings.

          Value Based Programs

          SharedSavingsPrograms – An organization of health care providers agrees to assume joint accountability for a patient’s entire care. The program is comprised of hospital and practice based Accountable Care Organizations (ACO), large multispecialty groups, and a Virtual aggregation of smaller practices. The program offers a reimbursement model that accounts for both quality and total cost of care.

          RiskSharingPrograms – For more functionally advanced provider partners, Horizon offers risk-sharing options that yield enhanced financial rewards for high performers. These programs include upside/downside risk by both parties and seek to encourage those providers performing well on cost, quality, and member experience goals to earn increasing year-end compensation tracked to enterprise and program goals.

          The program’s clinical goals are:

          • Providing active management of chronic and complex conditions to optimize treatment plans, drive care coordination and ensure patient self-management.
          • Identifying and managing patients at risk for high cost or morbidity in the future
          • Providing proactive care for a patient population to drive health promotion, disease prevention and patient engagement.
          • Empowering providers to make appropriate care decisions for their patients inclusive of referral management and patient education.

          AlliancePartnerships – Value-Based partnerships with select health systems and large providers designed as enhanced partnerships to increase the quality of care, patient/member experience with care and reduce costs. The goal is to achieve measured quality improvement and increase affordability for the provider’s patient population. The program is designed similarly to the shared savings programs but with increased provider/plan collaboration and synergy.


    An annual Quality Improvement (QI) Work Plan is developed and approved by QIC. The purpose of the QI Work Plan is to focus on the specific activities that Horizon will undertake to meet established goals planned for the year. The annual

    work plan includes time frames for monitoring and completing quality improvement activities, clearly defined and measurable objectives for the year, individuals responsible for those activities, time frames for monitoring and completing each activity, and serves as an action plan for previously identified issues. The Quality Improvement Committee annually presents an evaluation of the QI Work Plan and the Quality Improvement Program to the Quality Committee of the Board, and in turn to the Board of Directors of Horizon Healthcare Services, Inc., Horizon Insurance Company and Horizon Healthcare of NJ, Inc. Updates to the work plan are presented quarterly or as needed, based on the effectiveness of the program and the ability to reach established goals and objectives, membership demographics and utilization experience. The QI work plan allows tracking of activities over the calendar year


    Process and Outcome Measures

    The following process and outcome measures are collected and reported with various frequencies from monthly to annually depending on the nature of the indicator as per what it measures and the availability of data.

    These measures are collected, analyzed and reported by a team of professionals with knowledge in data management, analysis and clinical expertise. Benchmarks and/or goals are developed for all measures. For those publicly reported measures, national and regional benchmarks are utilized and then goals set based on differences between the plan’s performance and benchmarks. For internal developed measures or measures with no benchmarks available, goals are set based on plan’s trends and objectives.

    Results are presented at various committees (see section VIII Organizational Structure) and shared with members and providers as appropriate via newsletter and the member and provider portal.

    A.Healthcare Effectiveness Data & Information Set (HEDIS)®

    Annually, Horizon participates in Healthcare Effectiveness Data & Information Set (HEDIS)® reporting for its Combined HMO/POS/DA, PPO, and Marketplace products. Data is collected, analyzed, evaluated, and compared to regional and national benchmarks. Based on the results and comparison against national benchmarks, Horizon, through the Quality Management team is able to recognize areas of strength as well as identify opportunities for improvement.

    HEDIS® is a set of standardized performance measures designed to ensure that purchasers and consumers have the information they need to reliably compare the performance of managed health care plans. The performance measures in HEDIS® are related to many significant public health issues such as cancer, heart disease, smoking, asthma and diabetes. HEDIS® is sponsored, supported and maintained by the National Committee for Quality Assurance (NCQA).

    Horizon’s staff collects, consolidates and reports HEDIS hybrid and administrative rates. It contracts with an NCQA certified software vendor, Inovalon, to report HEDIS data through the use of Inovalon’s QSHR tool. Relevant data are extracted by experienced trained nurses using Inovalon’s QSHR data collection tool.

    Upon completion of all relevant chart audits, Inovalon has measure-specific logic to automatically consolidate data from multiple chart reviews and administrative data to determine a member’s compliancy to a measure or whether the member should be excluded from the denominator.

    To ensure all measures are accurately reported, data files and documentation are reviewed by an NCQA certified auditor. The Quality Management team then reviews and finalizes the interactive survey tools prior to submission to NCQA.

    HEDIS rates are reported via the IDSS (Interactive Data Survey System) to NCQA and/or Centers for Medicare and Medicaid Services (CMS).

    B.Consumer Assessment of Healthcare Providers and Systems (CAHPS)®

    CAHPS® (Consumer Assessment of Healthcare Providers and Systems) is a member satisfaction survey as well as a major component of HEDIS®. The CAHPS® survey is a measurement tool, used for all products which ask members to report and evaluate their experiences with health care in areas of customer service, access to care, claims processing and provider interactions. The products for CAHPS® surveys are grouped as HMO/POS, and PPO. The Direct Access product is considered a POS product and is included in one sample under the HMO/POS. The survey is conducted by an NCQA certified vendor.

    Quality Rating System (QRS)

    As part of the Quality Health Plan program for Marketplace products, Horizon participates annually in CMS’ Quality Rating System (QRS). CMS developed the Quality Rating System to: inform consumer selection of Qualified Health Plans (QHPs) offered through a Health Insurance Marketplace (Marketplace), facilitate regulatory oversight of QHPs, and provide actionable information to QHPs for performance improvement. CMS also developed the Qualified Health Plan Enrollee Experience Survey (QHP Enrollee Survey), which yields consumer experience data that will be used in the QRS.

    CMS has defined a set of QRS measures that consist of clinical measures and survey measures, the latter of which are based on a subset of QHP Enrollee Survey questions. The measures address areas of clinical quality management; enrollee experience; and plan efficiency, affordability, and management.

    Using a standardized methodology, CMS calculates QHP scores and ratings based on the QRS clinical and survey measure data that QHP issuers submit for each of their products in the Marketplace. The methodology includes rules for combining and scoring QRS measures through a hierarchical structure, resulting in one global score. Based on the scores, CMS will assign each QHP a star rating using a 1 to 5 scale.

    Public reporting of quality rating information will be displayed on Marketplace websites to allow consumers to compare plans.

    Quality Improvement Systems (QIS)

    Horizon participates in Quality Improvement Systems (QIS) initiatives for Marketplace members.

    The CMS QIS statutory requirements require the use of market-based incentives to improve the quality and value of health care and services specifically for Marketplace enrollees. CMS specifies two types of market-based incentives that issuers may include in their quality improvement strategies: (1) increased reimbursement or (2) other incentive

    Horizon reports annually to CMS on the status of their Marketplace QIS initiatives.

    C.Other Process/Outcome Measures

    Examples of other measures that would be utilized to assess effectiveness of the quality of care and services provided to Horizon members include the following:

    • Member satisfaction with Chronic Care Program
    • Analysis of the impact of population health management activities on member care process or outcome, utilization and member experience
    • Percent of referred members engaged in any form of behavioral health treatment
    • Timeliness of UM decisions and notifications
    • ALOS
    • Readmission rate 30 and 60 days
    • ER/1,000 members
    • Admits/1,000 members
    • Average number of primary and specialty visits per member per year
    • Access to primary care, specialty care and behavioral health services
    • Adequacy of primary care, specialty care and behavioral health network
    • Drug treatment adherence (percent of members refilling specific prescriptions)
    • ASA/Call abandonment rate for Customer Service phone unit
    • Timeliness of member appeals
    • Percent member appeals upheld

    Horizon is committed to protecting the confidential, proprietary and private information that our members, and employees share with us. Various federal and state laws and regulations including the Health Insurance Portability and Accountability Act (HIPAA) govern Horizon’s use and disclosure of members’ private information. Horizon is not allowed to access, use or disclose Private Information unless it is for a legitimate business need and to perform an appropriate business function. Horizon is committed to an effective compliance program and maintains privacy policies and procedures and training programs relative to the use and disclosure of its members’ private information.

    Horizon has in place appropriate administrative, technical and physical safeguards to protect the privacy of its members’ Private Information and to reasonably attempt to prevent any intentional or unintentional use or disclosure of Private Information in violation of Horizon’s privacy policies and procedures or other applicable state or federal law. Safeguards may include but are not limited to:

    • Shredding documents containing Private Information prior to disposal.
    • Securing all electronic and paper files against unauthorized use and disclosure.
    • Securing cabinets, drawers and rooms that house Private Information.
    • Ensuring when emailing Private Information to confirm the correct recipient.
    • Using Secure Blue button to encrypt emails when sending Private Information outside the Company.
    • Ensuring all proper agreements are in place when sharing Private Information with a third party.
    • Never taking photographs in the workplace.
    • Never sharing passwords with colleagues.
    • Never using or disclosing more than the Minimum Necessary information
    • All users who gain access to information Assets shall be uniquely identified and properly authenticated.
    • Placing laptops in areas not accessible to the general public or in high-traffic areas; shielding computer screens so that information is not viewable by others nearby.
    • Making certain that laptops are secured after-hours either in a locked cabinet or with the employee
    • Using secured methods of electronically transmitting Private Information such as data encryption.

    In addition, all new and existing employees will be trained on Horizon’s HIPAA privacy policies and procedures and applicable state and federal privacy law.

    All privacy policies and procedures are maintained and reviewed at least annually by Horizon’s Privacy Officer and are available to all employees through On-Line Information (OLI).


    NJAC 11:24-7.1, NJAC 11:24A-3.8.

    45 CFR Part 92: Nondiscrimination in Health Programs and Activities; Final Rule
    NCQA – Current Standards and Guidelines for the Accreditation of
    Health Plans


    Attachment A

    Attachment B

    Quality Improvement Committee Structure - Attachment A


    Quality Management Organizational Structure - Attachment B




    Quality Improvement Structure