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Use of Practitioner Performance Data

Administrative Policy:
Use of Practitioner Performance Data

Effective Date:
March 22, 2013

Last Revised Date:
September 2, 2022

This policy applies to physicians and healthcare professionals participating in the Horizon Managed Care Network and/or the Horizon PPO Network, including participation in plans that utilize tiering and/or a subset of an existing Horizon Network.

To define instances when Horizon BCBSNJ may use practitioner performance data.

Physicians and healthcare professionals shall cooperate with Horizon BCBSNJ's Quality Improvement (QI) activities and allow Horizon BCBSNJ to use performance data for various initiatives including but not limited to: Value Based Programs, any products that consist of a subset of Horizon BCBSNJ's managed care and/or PPO networks, quality improvement activities and member cost sharing initiatives.

Examples of performance data that may be utilized by Horizon BCBSNJ include: compliance with HEDIS measures, use of generic drugs on Horizon BCBSNJ formulary, complaints, grievances, patient reviews of practitioners or other similar programs.

NCQA - Current Standards and Guidelines for the Accreditation of Health Plans