The scope of activities within the Quality Improvement Program provides a framework to monitor and evaluate significant aspects of care and service provided to health plan members and their service delivery systems. EmblemHealth takes an active position in helping its members stay healthy, get better quickly, and live effectively with illness. Measures for monitoring important aspects of medical care, behavioral health care, and quality of service, including patient safety, have been developed and implemented. These activities include:
- Quality of Care
- Quality of Service
- Patient Safety
- Utilization Management
- Member and Physician Satisfaction
- Member Complaints, Grievances and Appeals
- Member Decision Support Tools
- Cultural Diversity
- Care for the Family Caregiver
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.
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.
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 request to change an adverse determination that was based on administrative policies, procedures or guidelines.
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.
Professional services rendered by a physician for the treatment or diagnosis of an illness or injury.
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 type of health benefit plan that allows enrollees to go outside the health plan's provider network for care, but requires enrollees to pay higher out-of-pocket fees when they do. Also called Point of Service.
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.
A review to determine whether covered services that have been provided or are proposed to be provided to a member, whether undertaken prior to, concurrent with or subsequent to the delivery of such services are medically necessary. Also called Coordinated Care.