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  • Quality Improvement > Authority and Responsibilities

    The Board of Directors of the EmblemHealth companies has delegated ultimate authority for the QIP, QIP Work Plan (QIPWP) and QIP Evaluation to the Board's Quality Committees. Responsibility for the strategic and tactical management of the QIP resides with EmblemHealth’s chief medical officer or that person's designee.

    The Quality Improvement Committee (QIC) is responsible for policy decisions, planning, designing, implementing, coordinating, analyzing, and evaluating QI activities, instituting needed actions and ensuring follow up as appropriate.

    The QIC also ensures practitioner participation in the QIP through planning, design, implementation, committee participation and review. Various committees and subcommittees support the functions of the QIP and report their activities to the QIC at least quarterly.

    Network practitioners, including behavioral health care practitioners and consumers participate on the following committees that advise the QIC:

    • Health Status Improvement Committee
    • Credentialing/Recredentialing Committee
    • Peer Review Subcommittee
    • Medical Policy Subcommittee
    • Pharmacy & Therapeutics Committee
    • Customer Experience and Satisfaction Improvement Committee
    • Medicaid BH UM Subcommittee
    • Medicaid BH QM Subcommittee
    • HARP Medicaid BH UM Subcommittee
    • HARP Medicaid BH QM Subcommittee
    • HARP Medicaid BH Advisory Subcommittee

    A detailed chart of the QIC Structure can be found at the end of this chapter.

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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

    Conditions that affect thinking and the ability to figure things out that affect perception, mood and behavior.

    An individual person who is the direct or indirect recipient of the services of the organization. Depending on the context, consumers may be identified by different names, such as "member," "enrollee," "beneficiary" or "patient." A consumer relationship may exist even in cases where there is not a direct relationship between the consumer and the organization. For example, if an individual is a member of a health plan that relies on the services of a utilization management organization, then the individual is a consumer of the utilization management organization.

    An entity contracted with EmblemHealth to perform various services including utilization review, credentialing and claims processing. Also called managing entities and carve outs.

    A person authorized by the insured to assist in obtaining access to, or payment to, the insured for health care services. If the insured has already received health care services and has no liability for payment of services, a designee will not be authorized for the purpose of requesting an external appeal.

    A health care benefit arrangement that is similar to a preferred provider organization in administration, structure and operation but does not cover out-of-network care. Also called an Exclusive Provider Organization.

    An organization comprised of individual physicians or physicians in group practices that contracts with the managed care organization on behalf of its member physicians to provide health care services. Also called an Independent Practice Association.

    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.

    A jointly funded federal and state program that provides hospital and medical coverage to the low-income population and certain aged and disabled individuals.

    The group of physicians, hospital, and other medical care providers that a specific plan has contracted with to deliver medical services to its members.

    A health plan that offers benefits in-network and out-of-network. In-network services are available to enrollees at lower out-of-pocket cost than the services of non-network providers. In addition, PPO enrollees may self-refer to any network provider at any time. Also called a Preferred Provider Organization.

    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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