Quality Management

Quality Assessment and Performance Improvement

Our goal at Anthem Blue Cross and Blue Shield (Anthem) is continuous, measurable improvement in our delivery of quality health care. Following federal and state guidelines, we have a Quality Assessment and Performance Improvement (QAPI) program in place to advance our levels of readiness, service and care. The QAPI program, aligned with the state of Wisconsin's quality standards, focuses on developing and implementing standards for clinical care and service, measuring conformity to those standards, and taking action to improve performance.

Healthcare Effectiveness Data and Information Set (HEDIS®)

HEDIS is a national evaluation and core set of performance measurements gauging the effectiveness of Anthem and providers in delivering quality care. We are ready to help when providers and their office staff need training to participate in required HEDIS evaluations.

Quality management

Twice a year, and in accordance with the National Committee for Quality Assurance (NCQA) standards, Anthem analyzes relevant utilization data against established thresholds for each health plan to detect current utilization levels. If our findings fall outside specified target ranges and indicate potential under-utilization or over-utilization, further analysis will occur based on the recommendation of Anthem’s Utilization Management committee. The follow-up analysis may include gathering the following data from specific provider and practice sites:

  • Case management services needed by members
  • Claims payments for covered services
  • Coordination with other providers and agencies
  • Focus studies
  • Investigation and resolution of member and provider complaints and appeals within established time frames
  • Retrospective reviews of services provided without authorization

Learn more about our quality initiatives, including scope and requirements, by viewing the Quality Assessment and Performance Improvement section of our provider manual.

Provider tools & resources

Interested in becoming a provider in the Anthem network?

We look forward to working with you to provide quality services to our members.