Quality management Maintaining standards of care

The Quality Management (QM) program is organized around a vision of supporting optimal health outcomes and satisfaction with care for our members, as well as meeting all applicable regulatory and accreditation requirements. The QM program monitors and evaluates quality of care for our members and engages with the provider community to ensure standards of care are maintained across the network.

Jump to:

• Program goals and activities
• NCQA accreditation
• Access and availability standards
• Medical record-keeping standards
• Member rights & responsibilities
• Privacy & confidentiality
• Utilization management decisions

AmeriHealth Quality Management Program

Program goals

• Assess and improve the safety of medical and behavioral health care and services our members receive
• Evaluate the adequacy of the plan networks for members to ensure access to qualified providers for timely and appropriate care
• Ensure evidence-based, effective care and services are provided to members for their medical and behavioral health conditions
• Promote efficient care and reduce health care waste by facilitating communication, continuity, and coordination of care among providers while supporting a focus on prevention and appropriate level of service
• Promote health equity among diverse populations by identifying and addressing social needs, including access to care that fits cultural and linguistic preferences, while supporting cultural humility and the reduction of disparities
• Assess and address the members' with their health care plan as well as services to support patient-centered system improvements

Program activities

The QM Program supports continuous quality improvement throughout the organization and across all plans. The QM Program monitors, evaluates, and acts to improve the quality and safety of clinical care and the quality of service provided to our members by participating practitioners and providers as well as delegates. It supports analysis of quality indicators through a quality committee structure to identify and prioritize organizational opportunities to improve member safety and quality of care, population health, network quality, member experience, utilization management quality, and compliance.

The QM Program implements a Member Safety Program, facilitates the organizational Population Health Management Strategy, and supports activities which ensure a quality network of practitioners and providers. It also ensures delegation oversight and implements policies and procedures to ensure plan compliance with established standards of practice, NCQA accreditation standards, and other regulatory requirements.

Member Safety Program:

• Reviewing and addressing member safety occurrences, quality complaints, and concerns about the health care they have received;
• Reviewing quality, claims, and safety data sources to identify and respond to member safety or quality of care concerns;
• Educating network providers about effective safety practices, resources, and AmeriHealth's standards of care and access for our members;
• Notifying network providers about gaps in members’ health care, errors, complaints, and adverse occurrences;
• Coordination with other internal departments to identify providers, patterns, and practices that could pose member safety and quality of care issues;
• Ensuring provider compliance with Plan quality standards through appropriate measurement, audit, and hearing processes;
• Overseeing processes for provider recognition in the provider directory for high-quality care;
• Producing quality review reports to inform Plan provider credentialing process;
• Working with regional coalitions to bring providers together through collaborative patient safety initiatives and information sharing.

Population Health Management Strategy:

The Population Health Management Strategy describes:

• Goals and populations targeted for each of the following four areas of focus:
  • Keeping members healthy
  • Managing members with emerging risk
  • Addressing patient safety or outcomes across settings
  • Managing multiple chronic illnesses
• Programs or services offered to members identified in the four areas of focus
• Activities that are not direct member interventions
• How member programs are coordinated
• How members are informed about available PHM programs
• How the organization promotes health equity

Ensuring a quality network:

The Population Health Management Strategy describes:

• Evaluating the sufficiency of the plan networks for members to access qualified medical and behavioral health providers for timely and appropriate care;
• Monitoring the capacity of the network to offer access to high volume and high need specialties and linguistically and culturally appropriate medical and behavioral health care;
• Verifying and monitoring the credentials and good standing of all network providers;
• Recognizing high-performing providers and identifying providers with unsafe practices or non-compliance for education and corrective action plans;
• Assessing and supporting initiatives around change to level of care and scope of practice changes to coverage;
• Assessing and addressing the satisfaction of members with their health plan and care.

Additional information about our Quality Management program, including a description of our yearly plan or a report on progress, is available to members and providers upon request. Members can call the Member Services number listed on back of their ID card to request additional information. Providers can visit the Provider News Center or call 1-800-275-2583 for additional information.

*Members who have a concern or complaint about the quality of care or service they received from a provider may call the Member Services number listed on back of the ID card and request filing a quality-of-care complaint.

NCQA accreditation

NCQA is an independent, not-for-profit organization dedicated to assessing and reporting on the quality of managed care plans, managed behavioral healthcare organizations, preferred provider organizations, new health plans, physician organizations, credentials verification organizations, disease management programs, and other health-related programs.

NCQA Health Plan Accreditation evaluates how well a health plan manages all parts of its delivery system — physicians, hospitals, other providers, and administrative services — in order to continuously improve the quality of care and services provided to its members. NCQA sends a team of trained health care experts, including physicians, to conduct a rigorous on-site survey of the health plan. NCQA uses information from health plan records, consumer surveys, interviews with plan staff, and performance on selected HEDIS^® measures.

Learn more about AmeriHealth’s accreditation statuses and other health care quality information on NCQA’s website at https://www.ncqa.org.

Access and availability standards

AmeriHealth is committed to maintaining an adequate network of primary and specialty care providers to meet the needs and preferences of its members. To ensure access and availability to care, AmeriHealth has established standards for the number and distribution of providers in our networks as well as timeliness of care. Each year, AmeriHealth assesses how effectively our networks ensure appropriate access and availability of care to our members.

Our access and availability standards, which participating providers should adhere to, are summarized below:

Appointment availability

In the event of an emergency or immediate need, members should call 911 or go to the nearest emergency room.

For non-life-threatening urgent care needs, an urgent care center, retail health clinic, or telemedicine visit may be an appropriate alternative for care if a primary care provider is unavailable. Members can use the Find a Doctor tool or visit MDLIVE’s website to learn more about these alternatives.

Maximum number of patients scheduled per hour per physician

Waiting times in the office should not exceed 30 minutes from the time of the scheduled appointment.

Minimum number of office hours per practice per week

Practices are encouraged to have at least one weekend day or evening session per week.

Maximum number of patients scheduled per hour per physician

Waiting times in the office should not exceed 30 minutes from the time of the scheduled appointment.

After-hours care

Providers should respond to after-hours urgent/emergency problems within 30 minutes. Coverage must be provided 24 hours per day, 7 days per week for our members. Providers who use answering machines for after-hour services are required to include:

• Urgent/emergent instructions as the first point of instruction
• Information on contacting a covering provider
• Telephone number for after-hours physician access

Access to behavioral health care

Access to language assistance services

Free language assistance services are available, and your AmeriHealth patients (or their friends or family members) can call the Customer Service number on the back of their member ID card to request telephone interpretation for a preferred spoken language or video interpretation for sign language. Free telephone relay services are available at TTY/TDD: 711.

Access to behavioral health care

• In the case of a life-threatening emergency, you should be seen immediately or be directed to your nearest emergency department.
• If the emergency is not life threatening, you should be seen within six hours of your crisis call.
• For an urgent situation, you should be offered an appointment within 48 hours.
• For a routine visit, you should be offered an appointment within 10 business days.
• Maximum wait time for scheduling mental health and SUD care for the initial and follow-up visit should not exceed 7 business days.

More information

Providers can view the Provider Manual for Participating Professional Providers, available through the Provider News Center, for additional information on appointment availability requirements, the minimum number of office hours per week, and the maximum number of patients scheduled per hour per provider by practice and provider type.

Medical Record-Keeping Standards

Medical records facilitate the delivery of quality health care through the documentation of past and current health status, diagnoses, and treatment plans. As such, AmeriHealth has established standards for medical records to promote efficient and effective treatment by facilitating communication and the coordination and continuity of care.

The AmeriHealth medical record standards policy is reviewed annually. The policy addresses confidentiality of medical records, medical records documentation standards, an organized medical record-keeping system, standards for availability of medical records, maintenance and auditing of medical records, and performance goals to assess the quality of medical record keeping. AmeriHealth’s standards for medical record documentation are in addition to state and federal laws, including the requirements of the Health Insurance Portability and Accountability Act (HIPAA).

Each medical record should comply with the following standards:

Medical record content

• History and physicals
• Significant illnesses and medical conditions indicated on the problem list
• Documentation of medications — current and updated
• Prominent documentation of medication allergies and adverse reactions; if there are no known allergies or history of adverse reactions, this is appropriately noted
• Food and other allergies, such as shellfish or latex, which may affect medical management
• Past medical history (for patients seen three or more times), including serious accidents, operations, and illnesses. For children and adolescents (18 years and younger), past medical history relates to prenatal care, birth, operations, and childhood illnesses
• For patients 12 years and older, appropriate notations concerning use of cigarettes, alcohol, and substances (for patients seen three or more times, query substance abuse history)
• History and physical documentation includes subjective and objective information for presenting complaints
• Working diagnoses consistent with findings
• Treatment or action plans consistent with diagnoses
• Laboratory and other studies are ordered as appropriate
• Unresolved problems from previous office visits are addressed in subsequent visits
• Documentation of clinical evaluation and findings for each visit
• Appropriate notations regarding the utilization of consultants
• No evidence that the patient is placed at inappropriate risk by a diagnostic or therapeutic procedure
• Documentation of preventive services and risk screening
• Immunization record for children is up to date, or an appropriate history is made for adults
• Preventive services and risk screenings are offered and documented
• Records of hospital discharge summaries and emergency room/department visits

Medical record organization

• Each page in the record contains the patient’s name, date of birth, and ID number.
• Personal/biographical data include address, employer, home and work telephone numbers, marital status, race, ethnicity, primary language, sexual orientation, and gender identity.
• All entries contain the author’s identification; author identification may be a handwritten signature, a unique electronic identifier, or initials.
• All entries are dated.
• The record is legible to someone other than the writer.

Information filed in medical records

• All services provided directly by a primary care practitioner
• All ancillary services and diagnostic tests ordered by a practitioner
• All diagnostic and therapeutic services for which a member was referred by a practitioner (such as home health nursing reports, specialty physician reports, hospital discharge reports, and physical therapy reports)
• Laboratory and other studies ordered
• Encounter forms or notes have a notation when indicated, regarding follow-up care, calls, or visits; the specific time of return is noted in weeks, months, or as needed
• If a consultation is requested, there is a note from the consultant in the record
• Specialty physician, other consultation, laboratory, and imaging reports filed in the chart are initialed by the practitioner who ordered them to signify review; review and signature by professionals other than the ordering practitioner do not meet this requirement
• If the reports are presented electronically, or by some other method, there is representation of review by the ordering practitioner
• Consultation: abnormal lab and imaging study results have an explicit notation in the record of follow-up plans
• The existence of an Advance Directive is prominently documented in each adult (older than 18 years of age) member’s medical record; information as to whether the Advance Directive has been executed is also noted

Retrieving medical records

• Medical records are to be made available to the Plan as defined in the Professional Provider Agreement
• Medical records are organized and stored in a manner that allows easy retrieval

Confidentiality of medical records

• Protected Health Information (PHI) is protected against unauthorized or inadvertent disclosure
• Medical records are safeguarded against loss or destruction and are maintained according to state requirements
• At a minimum, medical records must be maintained for at least ten (10) years, or age of majority plus six years, whichever is longer
• Records are stored securely, and only authorized personnel have access to records
• Staff receive periodic training in member information confidentiality

Maintenance of records and audits

Providers must maintain all medical and other records in accordance with the terms of their Professional Provider Agreement and the Provider Manual for Participating Professional Providers. When requested by AmeriHealth or its designated representatives or designated representatives of local, state, or federal regulatory agencies, the provider shall produce copies of any such records and will permit access to the original medical records for comparison purposes within the requested time frames and, if requested, shall submit to examination under oath regarding the same. If a provider fails or refuses to produce copies and/or permit access to the original medical records within 30 days as requested, AmeriHealth reserves the right to require Selective Medical Review before claims are processed for payment to verify that claims submissions are eligible for coverage under the benefits plan.

Member rights and responsibilities

Member rights

• The right to receive information about AmeriHealth, its benefits, services included or excluded from coverage, policies and procedures, participating practitioners/providers, and member rights and responsibilities. Information provided will be in a manner and format that is easily understood and readily accessible.
• The right to obtain a current directory of participating providers in the plan’s network, upon request. The directory includes addresses, telephone numbers, and a listing of providers who speak languages other than English.
• The right to prompt notification of terminations or changes in benefits, services, or provider network.
• The right to be treated with courtesy, consideration, respect, and recognition of their dignity and right to privacy.
• The right to confidential treatment of personally identifiable health/medical information. Members also have the right to access their medical record and ask that it be amended or corrected, in accordance with applicable federal and state laws.
• The right to receive health care services without discrimination based on race, ethnicity, age, mental or physical disability, health status, genetic information, color, religion, gender, sexual orientation, national origin, source of payment, utilization of medical or mental health services or supplies, or the filing by such member of any complaint, grievance, appeal or legal action against Professional Provider, a Group Practice Provider (if applicable), or AmeriHealth.
• The right to participate with practitioners in making decisions about their health care.
• The right to formulate and have advance directives implemented.
• The right to candid discussions of appropriate or medically necessary treatment options and alternatives for their conditions, regardless of cost or benefit coverage, in terms that the member understands, including an explanation of their complete medical condition, recommended treatment, risks of treatment, expected results, and reasonable medical alternatives. If the member is not capable of understanding this information, an explanation shall be provided to his or her next of kin or guardian and documented in the member’s medical record.
• The rights afforded to members by law or regulation as a patient in a licensed health care facility, including the right to refuse medication and treatment after possible consequences of this decision have been explained in language the member understands.
• The right to voice and file complaints (sometimes called grievances) or appeals about AmeriHealth or the care it provides and receive a timely response about the disposition of the appeal/complaint and the right to further appeal through an independent organization for a filing fee or the applicable regulatory agency, as appropriate. A doctor cannot be penalized for filing a complaint or appeal on a member’s behalf.
• The right to make recommendations regarding our member rights and responsibilities policy by contacting Customer Service.
• The right to choose practitioners/providers within the limits of covered benefits, availability, and participation within the AmeriHealth network.
• The right to a choice of specialists among participating providers following an authorized referral, as applicable, subject to their availability to accept new patients.
• For members with chronic disabilities, the right to obtain assistance and referrals to providers with experience in treatment of their disabilities.
• The right to continue receiving services from a provider who has been terminated from the AmeriHealth network (without cause) in the timeframes defined by the applicable state requirements of the member’s benefit plan. This does not apply if the provider is terminated for reasons which would endanger the member, public health or safety, breach of contract, or fraud.
• The right to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation by contracted providers of AmeriHealth.
• The right to available and accessible services when medically necessary, including availability of care 24 hours a day, seven days a week for urgent and emergent conditions.
• The right to call 911 in a potentially life-threatening situation without prior approval and have AmeriHealth pay per contract for a medical screening evaluation in the emergency room to determine whether an emergency medical condition exists.
• The right to be free from balance billing by providers for medically necessary services that were authorized or covered, except as permitted for copayments, coinsurance, and deductibles by contract.
• The right to be free from lifetime or yearly dollar limits on coverage of essential health benefits.
• The right to be free from unreasonable rate increases and to receive an explanation of rate increases of 15% or more before your premium is raised.
• The right to choose an individual On-Exchange health plan rather than the one offered by an employer and to be protected from employer retaliation.

Member responsibilities

• The responsibility to communicate, to the extent possible, information AmeriHealth and participating providers need in order to provide care.
• The responsibility to follow plans and instructions for care agreed to with their practitioners. This includes consideration of the possible consequences of failure to comply with recommended treatment.
• The responsibility to understand their health problems and participate in developing mutually agreed upon treatment goals, to the degree possible.
• The responsibility to review benefits and member materials carefully, follow the policies and procedures of the health plan, and advise AmeriHealth of any questions or concerns.
• The responsibility to be considerate and act in a way that helps the smooth running of providers’ offices and facilities.
• The responsibility to pay premiums and any cost-sharing owed (deductibles, coinsurance, or copayments, as appropriate) and meet other financial responsibilities described in the member’s contract/Evidence of Coverage.
• The responsibility to pay for charges incurred that are not covered under, or authorized under, the member’s benefit policy or contract.
• For point of service contracts, the responsibility to pay for charges that exceed what the plan determines as customary and reasonable (usual and customary, or usual, customary and reasonable, as appropriate) for services that are covered under the out-of-network component of the member’s benefit contract.

Additional Medicare Advantage member rights

• The right to get information in a way the member understands from Medicare, health care providers, and, under certain circumstances, contractors.
• The right to get information in a way the member understands about Medicare and get answers to questions to help him or her make health care decisions, including what is covered, how doctors are paid, what Medicare pays, and how much they have to pay.
• The right to see AmeriHealth providers and get covered health care services and drugs within a reasonable period of time, in a language the member can understand and in a culturally sensitive way.
• The right to get a decision about health care payment, coverage of items or services, or prescription drug coverage before getting services. If you disagree with the decision of your claim, you have the right to file an appeal.

Additional Medicare Advantage member responsibilities

• The responsibility to notify providers that they are enrolled in our health plan when seeking care (unless it is an emergency).
• The responsibility to notify the health plan if they have additional health insurance or prescription drug coverage.
• The responsibility to notify the health plan if they move.

Privacy and confidentiality

Protection of privacy in all settings

AmeriHealth has taken numerous steps to see that the personal information of our members is kept confidential and to prevent the unauthorized release of, or access to, this information. All employees complete annual training regarding the importance of protecting member information. All contracted providers are required to maintain confidentiality of member information and records in accordance with applicable laws

Access to medical records

AmeriHealth does not maintain members’ medical records. The providers who create the records are responsible for maintaining them. Members can access and obtain such medical records from their providers. AmeriHealth does maintain designated record sets that contain personal health information as it relates to medical, enrollment, claims, and billing records, as well as other records that we may use to make decisions about health care benefits. Upon a member’s request, we will provide a summary of any personal information maintained by us, such as telephone number, address, etc. At any time, a member may request that we modify, correct, change, or update their personal information that we maintain by contacting us by mail or telephone.

Inclusion in routine consent

In certain situations, it may be necessary for us to maintain and release a member’s records, claims-related information, or health-related information to third parties for health care operations in accordance with applicable laws and regulations. Once enrolled with us, we may maintain and release member records to third-party vendors to ensure that quality health care coverage is provided to the member, to perform our contractual obligations, or to fulfill a regulatory mandate.

Right to approve release of information

Member information will only be released to qualified recipients and in accordance with applicable state and federal laws. Members may request the release of their personal information by completing the AmeriHealth Authorization Form.

Use of measurement data

At times we may use membership data to develop or enhance health benefits and services. Member identity will be kept anonymous wherever possible.

Utilization management decisions

It is the policy of AmeriHealth and its affiliates (“plans”) that all utilization review decisions are based on the appropriateness of health care services and supplies in accordance with the plans’ definition of medical necessity and the benefits available under the member’s coverage. Only physicians can make denials of coverage of health care services and supplies based on lack of medical necessity.

The nurses, medical directors, other professional providers, and independent medical consultants who perform utilization review services for the plans are not compensated or given incentives based on their coverage review decisions. Medical directors and nurses are salaried employees of the plans, and contracted external physicians are compensated on a per-case-reviewed basis, regardless of the coverage determination. The plans do not specifically reward or provide financial incentives to individuals performing utilization review services for issuing denials of coverage. There are no financial incentives for such individuals that would encourage utilization review decisions that result in underutilization.

Contact us

If you have any questions or concerns about the quality of care received, you can reach us by calling the Member Services number on the back of your ID card.