Quality management
Anthem Blue Cross and Blue Shield (Anthem) maintains a comprehensive quality management (QM) program to objectively monitor and systematically evaluate the care and service provided to members. The scope and content of the program reflects the demographic and epidemiological needs of the population served. Studies are planned across the continuum of care and service, with ongoing proactive evaluation and refinement of the program.
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
- Develop 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
- Ensure adequate accessibility to care and services
- Monitor and ensure members receive seamless, continuous, and appropriate attention throughout the continuum of care
- Ensuring members have access to appropriate care management programs, including Care 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 the following year.
If you would like more information on our QM Program, please call 844-912-1226. 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 we try to find a way to implement that feedback.
Contact Us
Please contact us at 844-912-1226 to provide feedback or request training.
844-912-1226
Related information
Documents
- Clinical Practice Guidelines Matrix (coming soon)
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
Provider tools & resources
- Log in to Availity Essentials
- Launch Provider Learning Hub Now
- Learn about Availity
- Prior Authorization Lookup Tool
- Prior Authorization Requirements
- Claims Overview
- Member Eligibility & Pharmacy Overview
- Provider Manuals and Guides
- Provider Search Tool
- Forms
- Training Academy
- Pharmacy Information
- Electronic Data Interchange (EDI)