Use of Practitioner Performance Data

Administrative Policy:
Use of Practitioner Performance Data

Effective Date:
March 22, 2013

Last Revised Date:
December 2, 2022

Scope:
This policy applies to internists, family practitioners, pediatricians, Ob/Gyns and specialists (collectively referred to as physicians and other health care professionals) that participate in the Horizon Managed Care Network and/or the Horizon PPO Network and provide care to members in the following products:

• Commercial including HMO, POS, Direct Access, Horizon Advantage EPO and PPO
• OMNIA
• Braven Health Medicare Advantage

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

Policy:
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.

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

HCM-PP-HCS-022-1222