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 in the following committees that advise the QIC:
- Quality Improvement Committee
- Behavioral Health QualityManagement Subcommittee
- Care Management Committee
- Medical Policy Committee
- Behavioral Health Utulization Management Subsommittee
- Credentialing/Re-credentialing Committee
- Delegation Oversight Committee
- Pharmacy & Therapeutics Committee
- HARP Medicaid BH Advisory Subcommittee
- Children’s Medicaid Health and Behavioral Health Advisory Committee
A main aspect of the Children’s Health and Behavioral Health Benefit is the expansion of existing Quality Management committees and Behavioral Health Quality Management sub-committee functions to ensure they meet the quality requirements and standards for the populations, benefits, and services for children under 21 years of age, including those in the following subpopulations: Medically Fragile Children with physical, emotional, or developmental disabilities diagnosis; behavioral health diagnosis(es); and children in voluntary foster care agencies. This includes expanding the membership of the Behavioral Health Quality Management sub-committee to include in an advisory capacity: members, family members, youth and family peer support specialists, and child-serving providers. The Behavioral Health Quality Management sub-committee is responsible for carrying out the planned quality activities for the children’s membership with behavioral health conditions, including those in the following subgroups: seriously emotionally disturbed children and children with diagnoses across multiple HCBS categories who access behavioral health benefits and/or HCBS services.
A detailed chart of the QIC Structure can be found at the end of this chapter.
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.
Services available to a member as defined in his or her contract. Benefit design includes the types of benefits offered, limits (e.g., number of visits, percentage paid or dollar maximums applied) and subscriber responsibility (cost sharing components).
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.
The process by which the organization permits another entity to perform functions and assume responsibilities covered under these standards on behalf of the organization, while the organization retains final authority to provide oversight to the delegate.
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.
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.
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.
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
- Doctor of podiatric medicine
- Physical therapist
- Nurse midwife
- Certified and registered psychologist
- Certified and qualified social worker
- Nurse anesthetist
- Speech-language pathologist
- 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.