Skip to main content

Quality Management

The Quality Management Program consists of two major components: clinical and service activities. The range of clinical activities is extensive, encompassing preventive care, acute care, chronic care and care provided for special populations. It monitors member education and screening, provider credentialing, practice guidelines, medical record documentation, delegation and compliance. The service activities of the program monitors accessibility of care, member satisfaction and member complaints and appeals. Contract, regulatory requirements and accreditation standards determine the applicability of a specific program element.

The Quality Management Program further monitors the availability, accessibility, continuity and quality of care on an ongoing basis.

The Quality Management Program monitors the availability, accessibility, continuity and quality of care on an ongoing basis. Indicators of quality care used to evaluate the health care services provided by all participating health care professionals include:

  • A mechanism for monitoring patient appointments and triage procedures, discharge planning services, linkage between all modes and levels of care and appropriateness of specific diagnostic and therapeutic procedures, as selected by the Quality Improvement Committee;
  • A mechanism for evaluating all providers of care; and
  • A system to monitor physician and member access to utilization management services.

More specific program objectives include:

  • Specifying standards of care, criteria and procedures for the assessment of the quality of services provided and the adequacy and appropriateness of health care resources used.
  • Monitoring member satisfaction and participating network physicians’ response and feedback on plan operations.
  • Empowering members to actively participate in and take responsibility for their own health through the provision of education, counseling and access to quality health care professionals.
  • Maximizing safety and quality of health care delivered to members through the continuous quality improvement process.
  • Evaluating and maintaining a high-quality participating network through a formalized credentialing and recredentialing process.
  • Establishing long-term collaborative relationships with individuals and organizations committed to continuously improving the quality of care and services that they provide.
  • Maintaining effective communications systems with members and health care professionals to evaluate performance with respect to their needs and expectations.
  • Monitoring the utilization of medical resources using medical management processes as defined in the Utilization Management Program Description.
  • Maintaining a structured, ongoing oversight process for quality improvement functions performed by independently contracted entities and/or delegates.
  • Fulfilling the quality-related reporting requirements of applicable state and federal statutes and regulations, as well as standards developed by private outside review and accreditation agencies that Horizon BCBSNJ chooses to adhere to.

To receive a more detailed plan, please call the Quality Management Department at 1-877-841-9629.

Horizon BCBSNJ is required to investigate member complaints, including those that allege inadequate care was received from a participating hospital. Complaints that include potential medical quality-of-care issues will be referred to our Quality Peer Review Committee (which is comprised of Horizon BCBSNJ medical directors and participating physicians) for further review.

Upon receipt of a member complaint that includes a potential medical quality-of-care issue, you may be asked to submit medical records and documentation to help the committee investigate the complaint. You are required to respond to such requests under the terms and conditions of your Participation Agreement and an obligation to follow our policies and procedures.

Failure to comply with a request for medical records and/or additional documentation required to investigate a medical quality-of-care complaint is a very serious issue and may result in termination for cause from Horizon BCBSNJ’s networks.

Hospitals who do not respond to such requests in a timely manner will have a notation placed in their credentialing file for consideration at the time of recredentialing.

We also advise impacted members of their provider’s failure to comply with requests for medical records and make these members aware of their right to file a complaint with the New Jersey State Board of Medical Examiners.

We acknowledge and appreciate that the great majority of our medical record requests are responded to promptly and efficiently.

As the National Committee for Quality Assurance (NCQA) gathers data from health plans for its nationwide comparisons, Horizon BCBSNJ gathers data from your medical offices. Contracted practitioners/providers are encouraged to cooperate with the collection and evaluation of data and participate in Horizon BCBSNJ’s quality improvement activities. Performance data may be used for quality improvement activities. A provider’s diligence in ensuring his or her patients are appropriately treated or screened will be reflected in the plan’s report card made available to the general public through the NCQA’s website.

HEDIS® (Healthcare Effectiveness Data and Information Set) is the measurement tool used by the nation’s health plans to evaluate their performance in terms of clinical quality and customer service. It is a set of standardized performance measures designed to ensure that purchasers and consumers have the information they need to reliably compare health care quality.

We appreciate your cooperation in helping us to meet the requirements of these measurements.

Note: You may not charge Horizon BCBSNJ for copies of medical records when they are requested for medical review, claim review or as part of a medical record or HEDIS audit.