The Quality Management (QM) Program provides a formal process to objectively and systematically monitor and evaluate the quality, appropriateness, efficiency, safety, and effectiveness of care and service. A multidimensional approach enables Anthem Blue Cross and Blue Shield Healthcare Solutions (Anthem) to focus on opportunities for improving operational processes as well as health outcomes and satisfaction of members and providers. The QM Program is essential to ensure all medical care and service needs of our members are met and also ensure continuous improvement occurs with the quality of care and services being provided. QM Program promotes the accountability of all employees and affiliated health personal for the quality of care and services provided to our members.
The QM Program addresses issues related to quality management
The QM Program addresses issues related to quality management and quality performance measures to ensure both state and national compliance. Annually, the health plan evaluates the effectiveness of the QM and Utilization Management Programs identifying specific opportunities for improvement.
The general quality goals:
- Develop and maintain quality improvement processes, structures and resources in support of the organization-wide commitment to provision of quality healthcare for all members
- Development of effective methods to measure outcome of care and services provided to members, as well as interventions to achieve continuous and measurable improvements
- Continuous collaboration with appointed entities to develop and implement structures and programs fostering coordination and continuity of care
- Compliance with applicable federal, state, regulatory, contractual and accreditation requirements
- Ensuring adequate accessibility to care and services
- Monitor and ensure members receive seamless, continuous and appropriate attention throughout the continuum of care
- Ensure members have access to appropriate care management programs, including Case Management and Condition Care
- Coordinate, monitor and report QM activities to appropriate committees
- Conduct root cause analysis for benchmarks or goals unmet
- Implement and monitor programs designed to improve the quality and safety of members through member and provider education
- Ensure effective credentialing and recredentialing processes for providers who comply with state, federal and accreditation requirements
- Ensure the confidentiality of members is maintained at all times
- Analyze member and provider satisfaction survey results and implement effective interventions to address areas of dissatisfaction
- Oversight of all delegated activities to ensure compliance with all state, federal and accrediting organizations
- Promote improved continuity and coordination of care between medical and behavioral healthcare
- Develop and implement programs based on population analysis and incorporate culturally and linguistically appropriate services into Anthem
The QM Program implements and tracks a variety of QI activities
In an effort to meet these general goals, the QM Program implements and tracks a variety of QI activities that address the quality and safety of clinical care and quality of service throughout the year. These activities are described within the program evaluation including results compared to performance goals, trending of measures when appropriate, barrier analysis, opportunities for improvement and interventions.
Anthem evaluates the overall effectiveness of the QM Program
Anthem evaluates the overall effectiveness of the QM Program utilizing the aforementioned findings to determine the adequacy of QM Program resources, QM committee structure, practitioner participation and leadership involvement. Where needed, changes to the QM Program for the subsequent year are made. The content of this report is reviewed by the medical advisory committee, quality management committee, quality improvement committee and the board of directors. Findings included serve as the framework for developing the QM Work Plan for following year.
If you would like more information on our QM Program, please call 1-702-228-1308 (TTY 711). It is very important to us that all members get access to the highest quality care and services possible. We want providers to know that not only do we listen to their feedback but try to find a way to implement that feedback.
Please contact us:
Please contact us at 1-702-228-1308 (TTY 711) to provide feedback or request for training.
1-702-228-1308 (TTY 711)
- Electronic Clinical Data Systems coding booklet
- HEDIS Coding Booklet 2023
- HEDIS Cat II Coding Bulletin 2023
- HEDIS ECDS Prenatal and Postpartum Care Coding Bulletin 2023
- HEDIS Well Child and Immunizations Coding Bulletin 2023
- HEDIS Desktop Reference Guide 2023 NV
- HEDIS Preventive Care Tool — adults
- HEDIS Preventive Care Tool — children
- AHC Process For Provider Office
- Quality Patient Visit Summary Form — English
- Quality Patient Visit Summary Form — Spanish
- CHESS Health/Connections App: Recovery Support for members
- HEDIS Desktop Reference Guide 2024
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
Provider tools & resources
- Log in to Availity
- Launch Provider Learning Hub Now
- Learn about Availity
- Precertification Lookup Tool
- Precertification Requirements
- Claims Overview
- Member Eligibility & Pharmacy Overview
- Provider Manuals and Guides
- Training Academy
- Pharmacy Information
- Electronic Data Interchange (EDI)