Quality management Maintaining standards of care

The Quality Management (QM) program monitors and objectively evaluates the quality and effectiveness of care for our members.

Jump to:

• Quality Management program
• Access and availability standards
• Member rights and responsibilities
• Privacy and confidentiality
• Utilization management decisions
• NCQA accreditation
• Medical record-keeping standards

AmeriHealth Quality Management program

AmeriHealth Quality Management (QM) program provides a formal process to systematically monitor and objectively evaluate the company’s quality, efficiency, and effectiveness.

Program activities:

• Provide tools and information to assist network providers in developing and maintaining a standard of care
• Manage partnership with network providers
• Monitor and evaluate care
• Suggest improvement to medical policies
• Oversee credentialing
• Oversee various processes for hearing grievances and appeals
• Collect member suggestions for quality initiatives
• Monitor aspects of care based on the demographics of members served (i.e., age, gender, and health status)
• Investigate and track potential quality of care concerns through the recredentialing, grievance and appeal, and peer review processes

Member safety

We use plan–wide activities that increase member safety initiatives and reduce medical/medication errors. These activities include communicating information through mailings and newsletters.

Quality improvement

Members can request information about the Quality Improvement Program by calling the Member Services number on the back of the ID card.

Download more AmeriHealth Quality Management Program information for members

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.

Office hours, patient scheduling, and waiting times

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

The maximum number of patients scheduled per hour per physician should not exceed four for primary care providers or most specialists.

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

More information

Providers can view the Provider Manual for Participating Professional Providers, available on 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.

Member rights and responsibilities Commercial member rights and responsibilities statement

Commercial member rights

The members have a right to receive information about the health plan, its benefits, services included or excluded from coverage policies, participating practitioners/providers, and members’ rights and responsibilities. Written and Web-based information that is provided to the member will be readable and easily understood.

The members have a right to be treated with respect and recognition of their dignity and right to privacy.

The members have a right to participate in decision-making regarding his/her health care. This right includes candid discussions of appropriate or medically necessary treatment options for their condition, regardless of cost or benefit coverage.

The members have a right to voice complaints or appeals about the health plan or care provided and to receive a timely response. The members have a right to be notified of the disposition of appeals/complaints and the right to further appeal as appropriate.

The members have a right to make recommendations regarding the organization’s member rights and responsibilities policies by contacting Customer Service in writing.

The members have a right to confidential treatment of personally identifiable health/medical information. The members also have the right to have access to their medical record in accordance with applicable federal and state laws.

The members have a right to reasonable access to medical services.

The members have a right to receive health care services without discrimination based on race, ethnicity, age, mental or physical disability, genetic information, color, religion, gender, gender identity, sexual orientation, national origin, or source of payment.

The members have a right to formulate advance directives. The Plan will provide information concerning advance directives to members and practitioners/providers and will support members through its medical record-keeping policies.

The members have a right to obtain a current directory of participating practitioners/providers in the Plan’s network, upon request. The directory includes addresses, telephone numbers, and a listing of practitioners/providers who speak languages other than English.

The members have a right to file a complaint or appeal about the health plan or care provided with the applicable regulatory agency and to receive an answer to those complaints within a reasonable period of time and to be notified of the disposition of an appeal or complaint and further appeal, as appropriate.

The members have a right to appeal a decision to deny or limit coverage, first within the Plan and then through an independent organization for a filing fee as applicable. The members also have the right to know that their doctor cannot be penalized for filing a complaint or appeal on the member’s behalf.

The members have a right to choose a primary care provider within the limits of covered benefits and availability within the Plan network. The members also have the right to refuse care from specific practitioners/providers.

For members with chronic disabilities, they have the right to obtain assistance and referrals to practitioners/providers who are experienced in treating their disabilities.

The members have a right to candid discussions of appropriate or medically necessary treatment options for their condition, regardless of cost or benefit coverage, in terms that members understand, including an explanation of their medical condition, recommended treatment, risks of treatment, expected results, and reasonable medical alternatives. If the members are unable to easily understand this information, they have the right to have an explanation provided to their next of kin or guardian and documented in their medical record. The Plan does not direct practitioners/providers to restrict information regarding treatment options.

The members have a right to have available and accessible services when medically necessary, including availability of care 24 hours a day, seven days a week for urgent and emergency conditions.

The members have a right to call 911 in a potentially life-threatening situation without prior approval from the Plan; the right to have the Plan pay per contract for a medical screening evaluation in the emergency room to determine whether an emergency medical condition exists.

The members have a right to continue receiving services from a practitioner/provider who has been terminated from the Plans’ network (without cause) in the timeframes as defined by the applicable state requirements. This continuation of care 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 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 they understand.

The right to be free from balance billing by practitioners/providers for medically necessary services that are authorized or covered by the Plan except as permitted for copayments, coinsurance, and deductibles, by contract.

The right to prompt notification of terminations or changes in benefits, services, or practitioner/provider network.

Commercial member responsibilities

Members have the responsibility to communicate, to the extent possible, information the Plan, participating practitioners, and practitioners/providers need in order to care for the member.

Members have the responsibility to follow the plans and instructions for care that they have agreed on with their practitioners/providers. This responsibility includes consideration of the possible consequences of failure to comply with recommended treatment.

Members have the responsibility to understand their health problems and participate in developing mutually agreed upon treatment goals to the degree possible.

Members have the responsibility to review all benefit and membership materials carefully and to follow the rules pertaining to the health plan.

Members have the responsibility to ask questions to assure understanding of the explanations and instructions given.

Members have the responsibility to treat others with the same respect and courtesy expected for oneself.

Members have the responsibility to keep scheduled appointments or to give adequate notice of delay or cancellation.

The responsibility to pay deductibles, coinsurance, or copayments, as appropriate, according to the member’s contract.

The responsibility to pay for charges incurred that are not covered under or authorized under the member’s benefit policy or contract.

The responsibility to pay for charges that exceed what the plan determines are 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 with respect to point-of-service contracts.

Privacy and confidentiality

Contracted providers are required to maintain confidentiality of member information and records in accordance with applicable laws.

Member consent and confidentiality

We have implemented numerous initiatives to safeguard the confidentiality of member’s personal health information. Employees are required to sign the Code of Ethics and Business Conduct when hired and each year thereafter. This document specifically addresses the confidentiality of member information and unauthorized release or access to these data. In addition, physician contracts stress the importance of maintaining the confidentiality of individual medical records, and physician consultants are required to sign confidentiality statements. These policies (“A Word About Confidentiality”) are in place to heighten the awareness of protecting the privacy of personal health information.

Protection of privacy in all settings

The Plan 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 these data. All Plan employees sign confidentiality statements regarding member information annually. All Plan contracted practitioners and providers are required to maintain confidentiality of member information and records in accordance with applicable laws.

Members unable to give consent

When the Plan needs to obtain consent for the release of personal health information, authorization of care and treatment, or to have access to information from a member who is unable to provide it, the Plan will obtain consent from the parent, legal guardian, next of kin, or other individual with appropriate legal authority to make decisions on behalf of the member.

Access to medical records

The Plan does not maintain member medical records. Medical records are maintained by the practitioners and providers who create them, and members can access such medical records from such practitioners and providers. Upon a member’s request, the Plan will provide the member with a summary of any of his or her personally identifiable information maintained by us. At any time, any member may request that we modify, correct, change, or update his or her personally identifiable information that we maintain by contacting us by postal mail, email, or telephone.

Inclusion in routine consent

It may be necessary for us to maintain and release a member’s records, claims-related information, or health-related information to third parties (e.g., regulatory agencies). By enrolling with us, each member gives his or her consent to us to maintain and release member’s records to see that health care is provided to the member or is paid for, to perform our contractual obligations to the member, or to assist us in doing so, or to fulfill a legal mandate.

Right to approve release of information

In certain circumstances, it is required by law to obtain a member’s consent before releasing unique member health information. If the member gives consent for us to release the information, the member has the right — at any time — to revoke his or her consent (except to the extent we relied on the consent while it was in effect). There could be circumstances, however, such as a subpoena issued by a court or a request from a regulatory agency, where a member’s consent is not required before releasing such information.

Use of measurement data

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

Utilization management decisions

Affirmative statement regarding physician incentives for 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 and other professional consultants 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.

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.

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

• 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 substance abuse (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
• 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

Medical record organization

• Each page in the record contains the patient’s name or ID number
• Personal/biographical data include address, employer, home and work telephone numbers, and marital status
• 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 field 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 are ordered, as appropriate
• 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 also 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

Confidentiality of medical records

• Protected Health Information (PHI) is protected against unauthorized or inadvertent disclosure
• At a minimum, medical records must be maintained for at least ten years, or age of majority plus six years, whichever is longer
• Records are stored securely
• 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.