The data sources used for quality improvement measurement, analysis of barriers, and determining appropriate interventions include, but are not limited to, encounters, claims, utilization review, pharmacy, laboratory, enrollment, behavioral health, medical records, and appeals data. Additionally, provider and member complaints, applicable case management and disease management databases, and telephone response data are also utilized. Other sources of data include HEDIS®/QARR data, Quality Compass®, national and regional epidemiological, demographic, and census data about EmblemHealth’s membership, and practitioner, provider and member surveys. Provider surveys include, but are not limited to, provider satisfaction surveys, GeoAccess studies, and Access and Availability surveys. Member surveys include, but are not limited to, the following: CAHPS®, EES, Health Outcomes Survey (HOS), new member surveys, member satisfaction with and assessment regarding the network, member loyalty surveys, disease management surveys, and case management surveys.
Integrated data systems collect member, practitioner and provider information, utilization, population-based and/or specific member information, and practitioner/provider specific information. Software includes, but is not limited to, claims systems, NCQA-approved HEDIS® software, credentialing and re-credentialing software, Microsoft products, and other systems to support both clinical and service interventions.
CMS Stars Ratings Data Sources: EmblemHealth complies with the annual Medicare HEDIS®, HOS, and CAHPS® reporting requirements, and other administrative measures required by CMS. This information forms the basis of the CMS Star Ratings used to assess the quality of Medicare Advantage plans.
HEDIS® Reporting Requirements
EmblemHealth submits audited summary-level HEDIS® data to NCQA and to the Centers for Medicare & Medicaid Services-designated contractor. The data collection methodologies are either administrative or hybrid types. The administrative method is from transactional data for the eligible populations, and the hybrid method is from medical record or electronic medical record and transactional data for the sample.
Because of the critical importance of ensuring accurate data, EmblemHealth is required to participate in an external audit of the HEDIS® measures before public reporting. EmblemHealth contracts with an NCQA-licensed organization for the Compliance Audit. Following receipt of the Final Audit Report, EmblemHealth makes available a copy of the complete final report to CMS.
Medicare HOS Survey Process Requirements
EmblemHealth is required to report results for a baseline HOS and a follow-up survey. EmblemHealth contracts with an NCQA-certified vendor for administration of both the baseline and follow-up surveys. Each year, baseline cohorts are drawn and the CMS identifies a number of randomly selected members per contract to be surveyed. Additionally, each year the cohort measured two years previously at baseline is resurveyed. The results of this re-measurement are used to calculate a change score for the physical health and emotional well-being of each respondent.
Individual member level data is not provided to EmblemHealth until approximately a year after the entire baseline/followup cohort study is completed. CMS provides EmblemHealth with a HOS Baseline Report and HOS Performance Measurement Report and Data containing the results of the follow-up survey. The survey vendor provides EmblemHealth with details of the survey administration.
Medicare CAHPS® Requirements
EmblemHealth is required to report results of the CAHPS® Survey. EmblemHealth contracts with an approved MA & PDP CAHPS® vendor for survey administration. This vendor adheres to CMS requirements for fielding, collecting, and reporting CAHPS® data, thereby ensuring valid and reliable results.
Children’s Health and Behavioral Health Medicaid Benefit
The Plan’s Children’s Health and Behavioral Health Medicaid Benefit integrates physical health and behavioral health for children under 21 years of age to create better quality of care and lay the groundwork for better health outcomes for adults. This includes addressing the needs of Medically Fragile Children, children with behavioral health diagnosis(es), and children in Foster Care (FC) with developmental disabilities. This benefit also includes Home and Community Based Services to address the membership’s complex needs.
Reporting Requirements for Children’s Health and Behavioral Health Medicaid Benefit:
- Children’s Consumer Perception Survey
The Plan will participate in a consumer perception survey for the children’s population 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 agencies in adherence to New York State guidance. The Plan will also report results according to New York State guidance.
- Home and Community Based Services (HCBS)
The Plan will comply with the federal HCBS quality assurance performance measure reporting requirements for children under 21 years of age receiving HCBS as defined by New York State.
The Plan will report on required outcome measures for the children’s population 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 agencies, as specified by New York State.
- Performance Improvement Project
The Plan will participate in an internal performance improvement project as defined by New York State on a topic affecting the children’s population 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 agencies.
- Quality Assurance Reporting Requirements (QARR)
The Plan will continue to submit reports to New York State as specified in the Quality Assurance Reporting Requirements (QARR) within the time frames provided by the Medicaid Managed Care Model Contract.
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
Oral or written request from a member or their designee for EmblemHealth to review or reconsider a decision made by the plan.
Conditions that affect thinking and the ability to figure things out that affect perception, mood and behavior.
A program that assists the patient in determining the most appropriate and cost-effective treatment plan, including coordinating and monitoring the care with the ultimate goal of achieving the optimum health care outcome.
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.
The government agency responsible for administering the Medicare and Medicaid programs.
Initial oral or written communication from a member or their designee or provider that expresses discontent with any aspect of their care or coverage with EmblemHealth. Specifically, it is dissatisfaction with:
- A determination made by the plan, other than a determination of medical necessity or a determination that a service is considered experimental or investigational
- Treatment experienced through the plan, its providers or contractors
- Any concern with the plan, its benefits, employees or providers.
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.
A legal agreement between an individual member or an employer group and a health plan that describes the benefits and limitations of the coverage.
A business entity that performs delegated functions on behalf of the insurer or managed care organization.
A coordinated system of preventive, diagnostic and therapeutic measures intended to provide cost-effective, quality health care for a patient population who have or are at risk for a specific chronic illness or medical condition.
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.
A permit (or equivalent) to practice medicine or a health profession that is: 1) issued by any state or jurisdiction in the United States and 2) required for the performance of job functions.
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.
Any form of health plan that uses selective provider contracting to have patients seen by a network of contracted providers and that requires prior approval of certain services.
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 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. Also known as MA.
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 nonprofit organization that performs quality-oriented accreditation reviews of HMOs and similar types of managed care plans. Also called National Committee for Quality Assurance.
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.
A formal evaluation (prospective, concurrent or retrospective) of the coverage, medical necessity, efficiency or appropriateness of health services and treatment plans. Also called Coordinated Care.