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, utilizing
appropriate statistical analyses. Sampling methodology is developed and the frequency of data collection is determined
based on the nature of the quality indicators and/or committee recommendations. Studying aspects of care and service
includes setting goals, comparing indicators to benchmarks, establishing thresholds for the outcomes of required actions,
and tracking measures over time. Performance indicators are established and measured periodically to monitor multiple
dimensions of performance. These indicators correlate directly to the scope of the program and are developed based on
scientific evidence or are adopted from authoritative sources.
The responsibility for monitoring and managing the improvement of these rates has been assigned to the Quality Management
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.