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  • Quality Improvement > Overview

    EmblemHealth's corporate mission is to provide access to affordable, quality health care services in ways that respect and respond to members' fundamental needs. In line with our corporate mission, the Quality Improvement Program (QIP) establishes a framework and processes that will facilitate the continuous improvement in medical (including pharmaceutical and dental)and behavioral health care and service to EmblemHealth’s complex, culturally and language-diverse membership. As a result of this ongoing improvement and monitoring process, the Plan will better serve the needs of members, employers, employees, participating practitioners, providers, accounts, service partners, brokers, consultants and regulatory and accreditation bodies.

    2016 Primary Care Physician (PCP) Incentive Award Program

    EmblemHealth has launched its 2016 PCP Incentive Award Program to recognize the efforts you take to provide high quality care to our members. When you encourage and provide well visits, preventive screenings, and appropriate follow-up care, you help improve patient outcomes and satisfaction. By continuing to do so, EmblemHealth will thank you with an incentive award. What’s more, the greater percentage of our members receiving this quality care, the larger the potential incentive award.

    The program tracks performance on quality measures, which will be calculated using claims and other administrative data. Your incentives are paid on a per member, per measure basis.

    PCPs are eligible if they care for EmblemHealth members with Medicare, Medicaid/Child Health Plus, or Health Exchange plans. Enrollment is automatic for those meeting the eligibility criteria. For more details on the program, please refer to the materials below.

    We want to acknowledge your dedication to quality patient-centered care and look forward to incentivizing you for your commitment to the health and well-being of our members. If you have any questions, please call Provider Services at 1-866-447-9717.

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    Glossary terms found on this page:

    An evaluative process in which a health care organization undergoes an examination of its policies and procedures to determine whether the procedures meet designated criteria as defined by the accrediting body, and to ensure that the organization meets a specified level of quality.

    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 itemized statement of health care services and their costs provided by a hospital, physician's office or other health care facility. Claims are submitted to the insurer or managed care plan by either the plan member or the provider for payment of the costs incurred.

    A determination of whether or not a person meets the requirements to participate in the plan and receive coverage under the plan.

    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.

    A nationwide insurance program for the disabled and people age 65 and over, created by the 1965 amendments to the Social Security Act and operated under the provisions of the Act. It consists of two separate but coordinated programs, Part A and Part B.

    An individual and each of his or her eligible dependents, including Medicare beneficiaries who are enrolled or participate in a benefit program and who are entitled to receive covered services from the practitioner pursuant to such benefit program and the terms of the practitioner's agreement.

    A family physician, family practitioner, general practitioner, internist or pediatrician who is responsible for delivering or coordinating care. Also called a primary care physician.

    A family physician, family practitioner, general practitioner, internist or pediatrician who is responsible for delivering or coordinating care. Also called a PCP.

    A medical practitioner or covered facility recognized by EmblemHealth for reimbursement purposes. A provider may be any of the following, subject to the conditions listed in this paragraph:

    • Doctor of medicine
    • Doctor of osteopathy
    • Dentist
    • Chiropractor
    • Doctor of podiatric medicine
    • Physical therapist
    • Nurse midwife
    • Certified and registered psychologist
    • Certified and qualified social worker
    • Optometrist
    • Nurse anesthetist
    • Speech-language pathologist
    • Audiologist
    • Clinical laboratory
    • Screening center
    • General hospital
    • Any other type of practitioner or facility specifically listed in the member's Certificate of Insurance as a practitioner or facility recognized by EmblemHealth for reimbursement purposes

    A provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider's license or certification.

    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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