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  • Quality Improvement > Activities and Performance Indicators

    EmblemHealth uses appropriate processes and methodology for conducting and evaluating quality improvement activities through appropriate study design that includes baseline measurement, root cause analysis, development and implementation of appropriate interventions and re-measurement to determine the impact of the interventions.

    A sampling methodology is developed and the frequency of data collection is determined based on the nature of the quality indicators and/or committee recommendations. Once goals are set for each aspect of care, indicators are compared against performance goals. These indicators are tracked over time and enable the Quality Improvement department to establish thresholds for the outcomes of required actions.

    Performance indicators are established based on sound scientific evidence or adopted from authoritative sources and are measured periodically to monitor multiple aspects of performance.

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    Glossary terms found on this page:

    An activity of EmblemHealth or its subcontractor that results in:

    • Denial or limited authorization of a service authorization request, including the type or level of service
    • Reduction, suspension or termination of a previously authorized service
    • Denial, in whole or in part, of payment for a service
    • Failure to provide services in a timely manner
    • Failure of EmblemHealth to act within the time frames for resolution and notification of determinations regarding complaints, action appeals and complaint appeals

    Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.

    The process to objectively and systematically monitor and evaluate the quality, timeliness and appropriateness of covered services, including both clinical and administrative functions, to pursue opportunities to improve health care and resolve identified problems in any of these services.


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