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2. Program Scope

The QI Program oversees all quality-related activities for Horizon NJ Health (Medicaid & MLTSS), Horizon NJ TotalCare (HMO D-SNP), Medicare Supplement and Medicare Advantage HMO and PPO plans.

The scope of the QI Program encompasses the clinical and service aspects of the care that members receive. The Program oversees Horizon's efforts to monitor and improve preventive, acute, chronic, behavioral and rehabilitative aspects of care. The Program also reviews the Plan's initiatives and outcomes related to member and provider satisfaction and education, access and availability of care, disparities in health care, continuity and coordination of care, member appeals/grievances, quality-of-care concerns, clinical and service quality metrics and the credentialing of providers. The Program effects changes to improve Horizon's performance on Healthcare Effectiveness Data and Information Set (HEDIS), Stars, Consumer Assessment of Healthcare Providers and Systems (CAHPS) and Health Outcomes Survey (HOS). Accreditation efforts and audits completed by the Quality Management Department and other departments are also reviewed by the Program. The following Quality Assurance activities are developed and monitored on an ongoing basis:

  • Adoption of guidelines for the management of selected diagnoses and basic health maintenance, and distribution of all standards, protocols, and guidelines to all providers and to enrollees and potential enrollees upon request.

  • Ensuring treatment protocols allow for adjustments based on the enrollee's medical condition, level of functioning, and contributing family and social factors.

  • Monitoring the quality and adequacy of medical and behavioral health care including assessing the use of the distributed guidelines, assessing possible over-treatment/over-utilization of services and assessing possible under-treatment/under-utilization of services.

  • Evaluation of procedures for focused medical care evaluations that will be employed when indicators suggest that quality may need to be studied, including procedures for conducting problem-oriented clinical studies of individual care.

  • Evaluation of timeliness of decision-making and notification of Utilization Management decisions and appeals.

  • Review of procedures for prompt follow-up of reported problems and grievances involving quality of care issues. Timeframes for prompt follow-up and resolution that meet the standard described in Article 5.15B.

  • Monitoring of Hospital Acquired Conditions and Provider-Preventable Conditions, including the implementation of a no payment policy and a quality-monitoring program consistent with guidance from the Centers for Medicare and Medicaid Services (CMS).

  • Review of inpatient hospital mortality rates.

  • Ensure corrective action procedures are in place to inform subcontractors and providers of identified deficiencies or areas of improvement, conducting ongoing monitoring of corrective actions, and taking appropriate follow-up actions, such as instituting progressive sanctions and appeal processes.

  • Review of discharge planning procedures to ensure adequate and appropriate discharge planning, including coordination of services for enrollees with special needs.

  • Monitoring of providers for compliance with state and federal laws and regulations including but not limited to; advance directives, family planning services for minors and other issues as identified. Reports are submitted annually or within thirty (30) days to the Division of Medical Assistance and Health Services (DMAHS).

  • Ensuring methods to track emergency care utilization and to take follow-up action, including individual counseling, to improve appropriate use of urgent and emergency care settings.

  • Review of medical technology policies and procedures for evidence-based criteria for the evaluation of the appropriate use of new medical technologies or new applications of established technologies, including medical procedures, behavioral health, drugs, devices, assistive technology devices and durable medical equipment.

  • Maintaining policies and procedures related to informed consent, which requires that all participating providers comply with the informed consent forms and procedures for hysterectomy and sterilization as specified in 42 C.F.R. Part 441, Sub-part F, and shall include the annual audit for such compliance in its quality assurance reviews of participating providers.

  • Collecting data and acting on opportunities to improve continuity of care for all members including collaborative care between behavioral health and medical health providers.