Unit 6: Quality Management
The Highmark Quality Management Program is designed to ensure that members receive the best quality health care, in the most appropriate setting, in the most cost-effective manner.
Quality Management follows a Continuous Quality Improvement Process model for the ongoing monitoring and analysis of relevant clinical and service quality measures. The model focuses on the early identification of problems, with the development and implementation of interventions that focus on any issues that are identified. The member is at the heart of all activities.
The purpose of the Quality Management Program is to provide the framework and the formal processes within which the organization continually assesses and improves the quality of clinical care, safety, and service to members.
Definitions
Quality improvement processes are those activities that the health plan undertakes to improve the quality and safety of clinical care (including behavioral health care) and the quality of service to members.
Quality management is the integrative process that links knowledge, structure, and processes together throughout the organization to assess and improve quality.
Highmark Quality Management
Highmark's Health Plan Clinical Quality area, part of the Health Plan Chief Medical Officer (CMO) Organization division of Highmark, is responsible for corporation-wide coordination of clinical and service-related improvement initiatives focused on clinical care, member satisfaction, access and availability, and performance measures and outcomes for both physicians and facilities.
Quality Management is also accountable for compliance with all applicable external accrediting and regulatory entities such as the:
- Centers for Medicare and Medicaid Services (CMS)
- National Committee for Quality Assurance (NCQA)
- Office of Personnel Management (OPM)
- State health and insurance departments
Organizational Structure
The organizational structure of Highmark's Health Plan Quality Management divides staff responsibilities into these distinct functional areas:
- HEDIS®/CAHPS®/FEP
- Clinical Outcomes, Guidelines, and Quality of Care
- Clinical Quality Assurance
The Risk and Compliance Management area – which is part of the Enterprise Risk and Governance division – also supports the quality management program from an accreditation and regulatory compliance perspective.
These areas work together with the support of staff from other departments in Highmark, as well as external support from primary and specialty care providers to continually assess and improve the quality of clinical care, safety, and service to members.
Overall Objectives of the Quality Program
The objectives of the Quality Program are as follows:
- Continuously improve client and member experience of care, as well as their health, by anticipating and evaluating their needs and proactively aligning those needs with appropriate programs and services that reduce and/or control clinical risk.
- Support and promote the delivery of care by providing a high-quality network of practitioners and providers.
- Offer data-informed, evidenced-based, and comprehensive health care services and programs that are continuously improved based on outcomes.
- Build effective partnerships with members and their caregivers/families, clients, providers, facilities, payers, and the community to understand their objectives and needs while adapting products and/or services accordingly to create positive and lasting change and a differentiated member and provider experience.
- Utilize advanced analytics and proven quality improvement strategies and tools to measure and improve outcomes of care and service and achieve meaningful and sustainable improvement.
- Enhance transparency efforts to promote member engagement and customer intimacy, while supporting members in making appropriate decisions about care.
- Continue to work toward achieving health equity through reducing health care disparities, enhancing health literacy, and providing culturally and linguistically appropriate services.
Data Sources
The Highmark Quality Program provides a framework for continuous assessment and improvement of all aspects of health care delivery and services for its membership. This involves the collection and quantitative/qualitative analyses of relevant data to identify barriers or causes for less-than-optimal performance, identification of opportunities for improvement, and implementation of interventions to improve results.
Examples of the various data sources that may be collected and analyzed include, but are not limited to, the following:
- Medical/treatment records
- Claims
- Enrollment reports
- Pharmacy data
- Condition management reports
- Health risk appraisals
- Member service data
- Healthcare Effectiveness Data and Information Set (HEDIS®) results
- Consumer Assessment of Healthcare Providers and Systems (CAHPS®) results
- Health Outcome Survey results
- Utilization Management (UM) statistics
- Member/practitioner surveys
- Current literature
Behavioral Health
The coordination of behavioral health programs is based on an analysis of the demographic, cultural, clinical, and risk characteristics of Highmark members who utilize behavioral health services.
Highmark developed a Quality Program Description that outlines in greater detail activities to monitor and improve the quality and safety of behavioral health care and the quality of service provided to members. The document outlines the behavioral health aspects of the Quality Program and is reviewed and approved annually by the Highmark Board and appropriate Quality-related committee.
Highmark manages the inpatient utilization of behavioral health services for all members who have behavioral health care coverage through Highmark. Outpatient behavioral health services are authorized in accordance with the behavioral health benefits available for each product.
Behavioral Health Activities
Behavioral health activities have continued to include:
- Access to care and service availability for behavioral health services
- Communication standards to improve communication between behavioral health practitioners and primary care physicians to enhance continuity and coordination of care
- New and ongoing preventive behavioral health clinical initiatives
- Depression Condition Management Program
As a way for Highmark to promote objective and systematic monitoring, evaluation and continuous quality improvement, various Highmark Program Committees have been established. The Program Committees are made up predominantly of health care professionals and are established by Highmark's Board of Directors.
Enterprise Quality, Safety, and Value Committee (EQSV)
The Enterprise Quality, Safety and Value (EQSV) Operating Committee supports the Highmark Health and Highmark Inc. EQSV Board Committee on matters impacting quality, safety, and value for the enterprise’s patients, members, and other customers. The committee’s work is to transform the enterprise’s approach to QSV from one that is focused on discrete problem solving into one that establishes and maintains a “Blended,” outcomes-driven and patient-clinician centric model across the full set of enterprise capabilities, products, and services. The Committee membership represents QSV clinical and operational expertise across all care settings, all populations, all product lines and all applicable markets. The Committee is chaired by an appointed chairperson approved by the Highmark Nominations and Governance Committee. The QSV committee provides strategic oversight to dedicated workgroups, each focused on a high-value family of measures. These specialized workgroups include Preventive Care, Pediatric Care, Cardiometabolic, Continuity and Care Coordination, among all other measures as needed, ensuring comprehensive attention to critical areas of health care quality.
Care Management and Quality Committee (CMQC)
The Care Management and Quality Committee is a multi-disciplinary committee representing Delaware; western and northeastern New York; western, central, and northeastern Pennsylvania; and West Virginia that is dedicated to continuous improvement of quality and care management services provided to members. The Senior Medical Director chairs the CMQC. Medical Directors and actively practicing physicians, including behavioral health and physicians in administrative positions with involvement in care management functions in hospitals, are active voting members.
The CMQC has responsibility for the review and approval of the quality, utilization management, and population health management program descriptions, evaluations, and action plans; relevant policies and procedures; utilization core performance indicators/trends; clinical criteria sets used by the plan and its delegates; review, leadership, and direction over Highmark’s care management activities and initiatives; relevant quality improvement activities; oversight/monitoring of all delegated utilization functions, credentialing policies, and desktop procedures as revised; and quality committee reports.
The CMQC is also responsible for recommending policy decisions, analyzing and evaluating the results of quality activities, ensuring provider participation in the quality program, instituting needed actions, and ensuring follow-up, as appropriate. This includes, but is not limited to, the results of quality monitoring activities completed specific to clinical outcomes, member experience, health care equity, member access to services, practitioner and provider availability, continuity and coordination of care, credentialing and recredentialing, delegation and business arrangement oversight, ongoing regulatory and accrediting body compliance, and review and input on clinical practice and preventive health guidelines.
Clinical Policy Management Committee (CPMC) and Specialty Subcommittees
The Clinical Policy Management Committee (CPMC) is responsible for evaluating medical and surgical procedures and techniques, developing policy guidelines for new and evolving technology and injectable drugs, determining the medical policy coverage positions, and recommending medical necessity guidelines for covered procedures.
Specialty subcommittees are utilized to review and gather recommendations regarding medical policy coverage and criteria. The specialty subcommittees are made up of external practicing physicians. The subcommittees include but may not be limited to Cardiology, Hematology/Oncology, Musculoskeletal, Neurosciences, and Pediatrics.
New York Quality Improvement Program
The focus of the Quality Improvement Program is to continuously assess and improve the care delivered by our participating practitioners/providers and the service delivered by Highmark staff to its members. The organization has the responsibility of designing, measuring, assessing, and continually improving its performance. The result is enhanced health and well-being of the populations we serve.
New York Quality Improvement Program Scope
The scope of the Quality Improvement Program is comprehensive. It includes all Highmark members for all New York operating areas, as well as practitioners and providers who participate in the network. This includes Commercial (HMO, POS, PPO, EPO, ASO, Federal Employees Program/FEP), Medicare Advantage, and Exchange/Qualified Health Plan products and oversight of Child Health Plus, Essential Plan, and Medicaid Managed Care.
The Quality Program includes organization-wide activities, a focus on trend analysis, and development of interventions that improve the quality of care and service provided to members. The activities include clinical, service, and patient experience.
The Enterprise Risk and Governance (ERG), Quality Management (QM), Utilization Management (UM), Health Engagement Operations (HEO), and Population Health Management (PHM) teams and programs provide a framework for continuous assessment and improvement of various aspects of the health care delivery system. Cross-functional teams interface across the continuum to achieve shared goals, such as improving clinical outcomes and member experience, implementing a more robust quality strategy, supporting clinician-led care delivery and driving operational excellence.
The Health Plan Quality area's functions and responsibilities, outlined below, represent a core component of the broader Quality Management Program. This area actively integrates with other Highmark departments, expanding the program's scope throughout the organization.
Health Plan Quality
HEDIS/CAHPS/FEP
- Annual HEDIS reporting to meet NCQA, QARR (NYSDOH), CMS, QRS, OPM, Pennsylvania, and New York State regulatory requirements used to assess member effectiveness of care, access to care, patient experience and utilization of preventive/chronic care services and provider compliance with national standards of care.
- Annual NCQA HEDIS Compliance Tool (Roadmap) for all applicable products which includes a review of record of administration, data management, and processes which serve to collect information about how the plan’s information and management practices comply with HEDIS reporting requirements and associated on-site audit activities. One roadmap and audit process will be completed for the Commercial, Medicare Advantage, and Marketplace products. This audit includes a review of the health information system that is maintained to support data collection and analysis efforts for quality improvement activities. A separate roadmap and audit process for the State of Pennsylvania Children's Health Insurance Program (CHIP) product is also conducted and analyzed for quality improvement activities.
- Completion of the NYSDOH Prenatal Medical Record Documentation Review to include medical record retrieval, data entry, analysis, and annual evaluation.
- Quality Initiatives related to Quality Improvement Strategies (QIS) and Quality Rating Systems (QRS) for all ACA Exchange (Health Insurance Marketplace) products. NYSDOH Essential Plan Quality Incentive and Quality Improvement Strategy (QIS) to support NY Marketplace products (managed by Wellpoint, oversight by Highmark Western and Northeastern New York).
- Clinical QARR/HEDIS outcome monitoring, analysis, and planning/design of initiatives focused on improving the care via the monthly HEDIS/Quality Oversight meeting with Wellpoint and the Clinical POEM Workgroup.
- Annual vendor selection/management for administration and analysis of CAHPS and EES for all applicable products are maintained for identification of improvement opportunities.
- Clinical outcome monitoring, analysis, and planning/design of initiatives focused on improving the care provided to the Federal Employee Program [Federal Employee Health Benefits (FEHP) and Postal Service Health Benefits (PSHB)] membership, with focus on targeted measures selected by the OPM for their performance improvement program.
- Year-round medical record reviews are systematically performed to support prospective reporting, providing continuous data for performance measurement and intervention planning.
Clinical Outcomes and Guidelines (COG) and Quality of Care (QOC)
- Clinical outcome monitoring, analysis, strategizing and planning/design of initiatives focused on improving the care provided to members, with targeted focus on NCQA HEDIS scored measures.
- Program Outcomes Evaluation and Measure Clinical Workgroup (POEM-CWG). Preventive initiatives are developed and implemented by Clinical Quality staff through the work of the POEM-CWG. HEDIS data is reviewed, barrier analysis performed, and opportunities for improvement identified to identify gaps in care that need closing, and to improve outcomes through interventions targeted towards members and providers.
- Preventive Health Guidelines (PHGs) are developed, published and reviewed annually to comprehensively address age-specific needs and considerations. These guidelines, which include recommendations, screenings, and interventions, are grounded in evidence-based sources, practitioner input, and Federal and Regulatory guidance, with the aim of preventing illness, detecting disease early, and improving health outcomes.
- Facilitate the Preventive Health Workgroups (PHWG) to ensure the health plan is compliant with mandates and regulatory guidelines and complete the annual Medicare Advantage and Commercial Preventive Schedules (PS).
- Member and provider interventions to improve health literacy.
- Continuity and coordination of care monitoring for transitions within medical care, between medical and behavioral health care, identifying opportunities for improvement, and acting as appropriate.
- Quality Improvement Strategy (QIS) for ACA Exchange (Health Insurance Marketplace) members.
- Collaboration with Government Quality on the development and reporting of the Chronic Care Improvement Program (CCIP). Collaboration is also with Clinical Services on interventions that support the CCIP. The CCIP incorporates at least one activity into the Quality Program to reduce disparities in health/health care among enrollees that are broadly accessible to address relevant disparity.
- Patient safety activity monitoring through the review of all internal and external QOC complaints.
Clinical Quality Assurance
- Highmark Western and Northeastern New York Quality Program implementation, documentation, monitoring, analysis, and planning under the authority of the Highmark Western and Northeastern New York Quality Management Committee and the Board of Directors of Highmark Western and Northeastern New York.
- Oversight and coordination of various quality committees including the Care Management and Quality Committee (CMQC), and the Mental Health Parity Compliance Committee.
- Coordination of Regulatory requirements and documentation for New York Utilization Management regulatory requirements.
- Support Utilization Management operations compliance with regulatory and accreditation requirements through monitoring, analysis, and remediation planning, including but not limited to conducting clinical quality audits to validate appropriateness of UM review, approval and medical record documentation, as well as inter-rater reliability testing and reporting for UM medical, behavioral health, and pharmacy.
- Support Population Health Management operations compliance with regulatory and accreditation requirements through monitoring, analysis, and remediation planning.
Other Health Plan Clinical/Service Quality Activities (Medical and Behavioral Health)
The functions below are performed by various departments within the health plan/enterprise.
- Vendor selection/management for administration and analysis for behavioral health experience.
- Network adequacy plan maintenance and monitoring, including Marketplace products.
- Member preventative health status assessments via claims data analysis, health-risk assessment (HRA) data, PRA-plus surveys, Medicare Health Outcomes survey (HOS) results, Personal Health Records (PHRs), etc.
- Behavioral Health Preventive Program management, such as those proponents focused on alcohol use screening and depression screening post cardiac event.
- Practitioner/provider interventions designed to encourage participation in CMS and HHS QI initiatives as applicable.
- The Center for Inclusion Health and the Institute for Strategic Social and Workforce programs partner in owning the work to maintain Civil Rights Act compliance, including arrangements for language assistance services as needed; demographic analysis; Language Assistance Plan monitoring, identification of opportunities for improvement, implementation, and re-measurement.
- Provider peer review/performance monitoring occurs through the Quality of Care/Access to Care complaint process as well as credentialing/re-credentialing functions, with regular reporting to the Quality Management Committee.
Enterprise Risk and Governance (ERG)
The scope of Enterprise Risk and Governance functions and responsibilities are described below. The functions below are maintained within the appropriate ERG teams or Highmark business areas.
- Ongoing monitoring and continuous audit preparedness for applicable regulatory and accrediting bodies.
- NCQA Health Plan accreditation program management for Commercial and Exchange products.
- NCQA contract, project management, and audit coordination: coordinate, prepare, and submit documents for, and participate in, on-site and off-site quality reviews and audits conducted by applicable accrediting and regulatory bodies.
- Delegation oversight assessment/monitoring: participate in centralized delegation oversight assessment process and ongoing monitoring specific to NCQA requirements.
- Highmark Population Health Management Strategy that aligns with the Highmark Health strategy.
- Communications to members and providers regarding QP goals/objectives, progress towards achieving goals, ability to provide input, etc.
- Communications to members and providers regarding QP goals/objectives, progress towards achieving goals, ability to provide input, etc.
- Health services contracting monitoring to ensure compliance with NCQA requirements.
- Compliance audits of member notification of practitioner termination and continued access to care to ensure continuity and coordination of care of membership.
- Oversight of Transition of Care (TOC) procedures to allow new enrollees of a managed care product who are currently in treatment with an out-of-network provider the opportunity to transition his/her care to a network provider.
- Oversight of process to help inform members and providers of the potential for benefit exhaustion as well as to educate members about available alternatives for continuing care, as appropriate.
- Mental Health Parity and Addiction Equity Act of 2008 (“MHPAEA”): Highmark applies the same network admission and provider credentialing standards to all providers in a comparable manner regardless of whether the provider renders medical services, behavioral health services or substance abuse treatment services. Further, Highmark utilizes the same processes, standards, factors, and strategies to develop provider reimbursement rates for providers that render medical services, behavioral health services and substance abuse treatment services.
- Oversight of appointment accessibility monitoring to ensure that members have appropriate access to primary care, behavioral healthcare, and specialty care services.
- Telephone accessibility monitoring to ensure that members have appropriate access to organization services.
- Member experience/satisfaction monitoring (e.g., dissatisfactions, complaints, appeals) and determination of service quality improvement opportunities to correct all problems identified through internal surveillance, complaints, or other mechanisms.
- Provider satisfaction monitoring (e.g., UM process) through the review and analysis of provider dissatisfactions. Opportunities to improve provider satisfaction are identified and a plan of action implemented, if required.
- Oversight of practitioner and provider availability monitoring to ensure an adequate network of primary care, behavioral health, and specialty care practitioners and providers is maintained, as well as how effectively the network meets the cultural, ethnic, racial, and linguistic needs and preferences of its membership.
- Oversight of continuity and care coordination monitoring of transitions between medical care settings, and between behavioral and medical healthcare, identifying opportunities for improvement, and acting as appropriate.
New York Quality Improvement Program Authority and Structure
The ultimate accountability for the Quality Program rests with the Board of Directors of Highmark Western and Northeastern New York, Inc.
The authority and responsibilities for administration and implementation of the Quality Program are vested in the Senior Medical Director. The Corporate Quality Management Committee regularly submits reports to the Board of Directors of Highmark in New York.
QI Committee Structure
To assure that the Quality Program is implemented appropriately, key critical responsibilities related to a successful Quality Improvement Program are the shared responsibility of a variety of the committees and subcommittees across the organization.
In support of this shared responsibility, the committees, subcommittees, ad hoc committees, etc. will analyze health care-related data from monitoring activities, software program output, and formal studies as appropriate.
These committees consider a variety of actions in relation to data and a number of other activities that are defined in corporate policies. These committees include the Quality Management Committee, Network Quality and Credentials Committee, Pharmacy and Therapeutics Committee, Medical Management Clinical Committee, Vendor Process Management, Mental Health and Substance Use Disorder Parity Compliance Committee, the Behavioral Health Advisory Board Committee, Wellpoint Joint Oversight Committee, and Highmark Inc./Highmark NY Utilization Management Master Service Agreement (MSA) Joint Oversight Committee.
Monitoring and Evaluation
Results are used to compare with other local plans and regional averages, to revise goals and to target areas of improvement.
- Healthcare Effectiveness Data and Information Set (HEDIS®) measures are primarily clinical in nature, collected annually, audited by an approved contracted vendor, and submitted to NCQA, CMS, and the Blue Cross Blue Shield Association.
- Consumer Assessment of Health Plan Study (CAHPS®) survey provides a measurement of how well the plan/practitioners met members' expectations.
- Quality Assurance Reporting Requirements (QARR) is a set of measures for Commercial HMO, Qualified Health Plans (Marketplace), and Medicaid/Child Health Plus populations based on HEDIS-like data, that are collected annually and sent to the New York State Department of Health (NYSDOH).
- Medicare Star Rating is consistent with CMS’ Quality Strategy of optimizing health outcomes by improving quality and transforming the health care system. CMS uses a Five Star Quality Rating System on a scale of 1 to 5, with 5 stars being the highest score a plan can receive, and 1 star being the lowest. CMS publishes star ratings in the fall each year, and the five-star rating system provides Medicare beneficiaries and their families a way to compare plan performance and quality.
- Quality Rating System (QRS) and Qualified Health Plan (QHP) Enrollee Experience Survey are a measure set comprised of clinical quality measures, including National Committee for Quality Assurance (NCQA), HEDIS® and a Pharmacy Quality Alliance (PQA) measure. The measure set also includes survey-based measures based on questions from the QHP Enrollee Survey that captures member experience and plan efficiency, affordability, and management. The quality ratings of Five Star rating scale is similar to Medicare Star Rating.
Population Health Management Strategy
A variety of clinically based programs are in place for addressing the needs of members across the continuum of care. These include health management programs to address members with complex health care needs, those with physical or developmental disabilities, multiple chronic conditions, and severe mental illness. These programs are designed to meet the care needs of the member population through identification, participation, engagement, and targeted interventions aimed at active engagements in health care services. The goal is to maintain or improve the physical and psychosocial well-being of individuals to address health disparities through cost-effective and tailored health solutions.
Delegation
Highmark adheres to the delegation requirements outlined by various regulatory bodies, including but not limited to: NCQA and the New York State Department of Health. The appropriate organization staff reviews all pre-assessments, annual assessments, medical necessity criteria and/or clinical guidelines, program documents (descriptions and evaluations) and performance reporting activities. Relevant information on delegated activities is also shared with oversight committees and the Board of Directors, as appropriate.
Annual Evaluation of QI Program
The effectiveness of the Quality Program is evaluated on an annual basis. The Program Evaluation addresses all aspects of the Quality Program process and activities as outlined in the Program Description/Action Plan. The Quality Program Evaluation is presented to the Quality Management Committee and the Board Directors for approval. Previously identified issues and ongoing projects are incorporated into the Action Plan for the subsequent year.
QI Work Plan
The Quality Work Plan is developed based on the outcomes and recommendations of the previous evaluation of the Quality Program. The Work Plan includes previously identified issues and Quality Program objectives for the upcoming year. Each objective is measurable and includes responsible parties and time frames for anticipated completion dates. The Work Plan will be updated on a regular basis throughout the year.
Highmark's Quality Management is responsible for evaluating member dissatisfactions, concerns, and issues related to clinical quality of care.
The Clinical Quality of Care Team of Quality Management becomes aware of potential issues/concerns and member dissatisfactions about clinical quality of care issues through information received from a variety of sources, including providers, members, and internal Highmark departments.
Important
Members are able to make clinical quality of care complaints to the health plan.
The Initial Review
A Clinical Quality Management Consultant (CQMC) completes the initial review of each case referred for potential quality of care issues. The CQMC, who is a registered nurse, reviews the case to determine whether there is potential for a quality issue referencing scientifically based standards of care.
- When this initial review determines that the concern does not have the potential for an adverse outcome, the case is closed and filed for trending purposes.
- If the potential for an adverse outcome is identified, medical records are requested from the provider or facility involved in the case.
A determination will be made if a clinical review is needed and applicable information is available (i.e., DOS, permission from member to use name, name and location of provider, HIPAA, if required) or if additional clarification is needed. The member concern is then forwarded to a CMQC who will request the medical record and a written response to the concerns from the provider. In New York, the medical record request will be accompanied by a request for a written response to the concerns from the provider.
Analysis of Medical Records
Once medical records are received, the CQMC performs an assessment of the case. If the assessment dispels any concern of potential for an adverse outcome, the case is closed and filed to track the provider for any future issues.
If the potential for an adverse outcome is identified, the case is forwarded to a Medical Director for review.
Medical Director Review Outcomes
When the Medical Director believes that a quality issue may be present, a written request for additional information is sent to the provider involved.
If it is determined that a quality issue is indeed present following the review of any additional information, a Level of Harm is determined by the Medical Director, and a corrective action plan is implemented if warranted.
In New York State, an acknowledgment letter of the decision regarding the clinical complaint/concern is sent to the member.
Provider Responsibilities
During the investigation of quality of care concerns, facility providers may be asked to supply any or all of the following:
- A copy of the member’s medical or behavioral health record
- A response from the administrator, or the administrator’s designee, to address a possible adverse outcome determined during the medical record review
- A corrective action plan (if warranted) if an adverse outcome is found during the medical record review
It is the provider's responsibility to supply all requested information. Professional agreements state no fees are to be imposed for medical records needed to investigate a Clinical Quality of Care concern.
Issues Leading to Corrective Action or Sanctioning
A provider or facility is placed under corrective action or sanctioning when a treatment, procedure, or service indicates a provider is not practicing in a manner that is consistent with the standards of Highmark and/or deviates from acceptable standards of care.
There are two issues when a provider can be placed under corrective action/sanctioning:
- Clinical quality of care – Occurs when an episode strays from accepted medical standards (e.g., actions or omissions resulting in an adverse effect on a patient’s well-being, medication errors, missed diagnosis, delaying treatment, unanticipated and unexplained death)
- Administrative non-compliance – Occurs when a provider’s behavior is not consistent with their agreement with Highmark contracts and guidelines (e.g., failure to comply with contractual obligations, medical record review deficiencies, and unauthorized billing for services)
Notification of Corrective Action
Once the Medical Director makes a determination to place the provider under corrective action, the provider will be notified in writing of:
- The reason for the corrective action
- What corrective action is needed and what it entails
- The period of time the provider will remain under the corrective action
The provider can either appeal the decision of the Medical Director, elect to abide by the corrective action plan, or make the necessary improvements (if applicable).
Appeal Hearing
If an appeal is requested, a hearing with the Network Quality and Credentials Committee (NQCC) will be made available. This committee will make the decision to either uphold or overturn the original decision by the Medical Director.
Sanctioning Possible
After the corrective action time period has expired, the provider will be re-evaluated by the Medical Director. If the Medical Director is satisfied that all stipulations are met, the corrective action will be lifted.
If the stipulations are not met, sanctioning of the provider could occur, which may result in a provider’s inability to participate in certain programs.
Preventive Guidelines
Preventive Health Guidelines, which are based on scientific evidence, are available for all Highmark providers to help them in their efforts to promote healthy lifestyles and disease prevention, while reducing risk factors in the following member (patient) populations.
- Prenatal/Perinatal Guidelines
- Children Ages 0-6 Guidelines
- Children Ages 7-18 Guidelines
- Adult Ages 19-64 Guidelines
- Adult 65 and Older Guidelines
- Women's Preventive Health Services Addendum
- Perinatal Depression Prevention Counseling Coding Guidelines
- PrEP Related Services Coding Guidelines
The Clinical Outcomes and Guidelines Quality team reviews and updates the Preventive Health Guidelines on an annual basis utilizing references such as the United States Preventive Services Task Force (USPSTF), CDC, National Institutes of Health (NIH), Centers for Medicare and Medicaid Services (CMS), etc. The Preventive Health Guidelines are placed on the applicable websites via the Provider Resource Center. A notice regarding the Preventive Schedule is made available via the member website.
The Preventive Health Guidelines, along with many other valuable clinical resources, are available on the Provider Resource Center. To access these materials, go to the Provider Resource Center and select Resources and Education from the main menu, then Clinical Quality and Education.
Condition Management Program
The Condition Management Program is designed to develop a collaborative working relationship between Highmark members, members’ providers, and Highmark clinicians to support the provider’s plan of care for members under their care. The purpose of the program is to identify members who are most at risk for significant care gaps and, therefore, a progression and/or worsening of their chronic condition. High-risk members are identified through a combination of inpatient and outpatient claims, pharmacy claims, and clinical risk scores that enable our clinicians to conduct outreach to those members by telephone.
Nurses providing condition management services by telephone are known as clinicians. Clinicians work collaboratively with the member and provider to establish realistic and attainable short and long-term goals and to encourage behavior and lifestyle changes that lead to better member self-management of their condition(s).
Members may be eligible to receive health coaching for these chronic conditions, such as, but not limited to, the following:
- Asthma
- COPD
- Depression
- Diabetes
- Heart Disease
- Heart Failure
- Hemophilia
- Hereditary Angioedema
- High-Risk Pregnancy
- HIV/AIDS
- Inflammatory Bowel Disease
- Mental Health Disorders
- Metabolic Syndrome
- Musculoskeletal Pain
- Obesity
- Substance Use Disorder
- Tobacco Use
For Federal Employee Program (FEP) members, one of the following rare disease cohorts may also apply:
- Amyotrophic Lateral Sclerosis (ALS)
- Crohn’s
- Cystic Fibrosis
- Hemophilia
- Lupus
- Multiple Sclerosis
- Myasthenia Gravis
- Myositis
- Parkinson’s disease
- Rheumatoid Arthritis
- Scleroderma
- Seizures
- Sickle Cell Anemia
Providers, members, and family members can learn about the program and refer to the program by calling the 24/7 health information line using the phone number on the back of their insurance card.
Continuity and Coordination of Care
Highmark recognizes the importance of coordination of care as part of the quality continuum. There are programs and policies in place to ensure coordination of medical, behavioral health, or other community support for members. This process enables Highmark to inform the membership of health care needs that require follow-up, training in self-care, and other measures to promote their health.
Highmark facilitates the continuity and coordination of medical care across the delivery system and collaborates with behavioral health practitioners to monitor and improve coordination between medical and behavioral health care. The communication between PCPs and behavioral health specialists is assessed as part of the Highmark Quality Program.
Network organizational providers such as hospitals, emergency facilities, ambulatory surgery centers, home health agencies, and skilled nursing facilities must promote continuity and coordination of care for network members by communicating with PCPs when care is delivered to their patients. PCPs should expect a written description of the care given to their patients any time services have been rendered by these providers.
Medical Record Review
Any Practitioner who provides care to our members
Medical record documentation can be assessed at any time using medical record documentation standards that are based on the most recent regulatory guidelines (CMS, NYSDOH, NCQA).
OB/GYN Providers
Medical record documentation will be assessed using the most recent NYSDOH prenatal guidelines. These standards will be used to evaluate compliance in appropriate prenatal medical care for pregnant women.
Purpose
Review of these medical records will improve continuity and quality of patient care by assuring timely, legible, accurate, and comprehensive documentation of patient-provider interaction. It will allow Highmark of Western and Northeastern New York to target areas of opportunity to provide education to practitioners on their documentation and areas where medical care can be improved.
Procedure
Medical record documentation standards are based on regulatory guidelines. The standards are reviewed for updates annually.
The medical records for review can be derived from any of the following sources:
- HEDIS/QARR/QRS Review: Healthcare Effectiveness Data and Information Set/Quality Assurance Reporting Requirements/Quality Rating System. Documentation submitted to address gaps in care serves as a valuable resource for discerning emergent trends that may necessitate further investigation.
- Quality of Care Concern Review: In response to member concerns with clinical quality of care, provider medical records may be requested for review.
- Internal Department Referrals: Records identified by Clinical Services, Credentialing, and Financial Investigations and Provider Review (FIPR), as needing Clinical Quality medical record review for clinical quality of care concern.
- Continuity and Coordination of Care: Designated projects will coordinate with medical record review to obtain medical records.
- Live Birth File: Records are identified for inclusion in the NYSDOH prenatal medical record review.
Patient Safety Program Activities
Highmark recognizes the importance of patient safety programs; therefore, the Highmark Patient Safety Program focuses on the development of activities which assess and improve the plan’s patient safety efforts.
Many activities have been developed to enhance patient safety, including development of patient-safety-focused, written educational offerings for member and provider communications.
Quality of Care Case Reviews
Clinical Quality – Quality of Care is responsible for evaluating member dissatisfactions, concerns, and issues related to clinical quality of care and for initiating appropriate action in response to them.
Clinical Quality – Quality of Care becomes aware of clinical quality of care dissatisfactions through information received from a number of sources, including providers and members as well as internal Highmark departments. Tracking mechanisms enable Clinical Quality – Quality of Care to monitor the information received over time and identify improvement opportunities.
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Who Does It? |
What Is Done?
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Step 1 |
Registered Nurse from Clinical Quality – Quality of Care |
Performs a preliminary review to determine whether there is potential for a quality issue. Decision made to either track the accepted case in a database of similar issues involving the provider; or requests and reviews medical records according to Clinical Quality – Quality of Care policy.
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Step 2 |
A Highmark Medical Director |
Performs a case review.
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Step 3 |
A Highmark Medical Director |
Reviews the case with any additional information provided by the involved provider.
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Step 4 |
Provider/Practitioner |
May choose to appeal (within 30 days) these actions before a subcommittee of the Highmark Network Quality and Credentials Committee. |
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Step 5 |
Clinical Quality – Quality of Care staff |
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HEDIS®
The Healthcare Effectiveness Data and Information Set (HEDIS®) is a set of standardized performance measures designed to ensure purchasers and consumers have the information they need to reliably compare the performance of all managed health care plans. Each participating plan reports data for the same measures, so you know you are making comparisons based on similar information.
To ensure these measures encompass data from the entire calendar year, health plans are asked to evaluate and report their results from the prior year. The Plan may be required to report on members from distinct product lines as required to meet and/or maintain National Committee for Quality Assurance (NCQA) accreditation, Centers for Medicare and Medicaid Services (CMS), and/or Office of Personnel Management (OPM) requirements, and/or the Pennsylvania and/or Delaware Department of Health and/or New York Department of Health (PA DOH, DE DOH, NYS DOH) requirements.
Understanding the categories in which plans are rated can help members make a choice based on what is important to them. HEDIS® determines quality and value by measuring success in the following areas:
- Effectiveness of Care: Assesses all types of care (preventive, early detection and screening, maternity, acute, chronic, and behavioral health as well as overuse and appropriateness of care) and populations (children, adolescents, adults, and seniors).
- Access/Availability of Care: Assesses our network providers’ accessibility and timeliness of care.
- Experience of Care: Assesses current members’ levels of satisfaction with the health plan.
- Utilization and Risk Adjustment Utilization: Assesses resource use, how efficiently care is provided, and whether needed services are being delivered.
- Health Plan Descriptive Information: Presents an overview of provider-related information and member demographics.
This reporting occurs annually and requires the use of administrative claims data, as well as supplemental data feeds through the use of electronic clinical data systems and medical record abstracted data.
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
Member Satisfaction Monitoring
Annual member satisfaction surveys are conducted, using a statistically valid sample of the membership, to ensure that the plan identifies potential areas for service quality improvements.
Results of the survey are reviewed by Clinical Services - Quality and internal ad-hoc workgroups. The findings are then reported to the Care Management and Quality Committee. Member satisfaction is also monitored through review of member dissatisfactions, complaints, and appeals.
CAHPS® and QHP EES Survey Results
Highmark contracts with SPH Analytics, an independent research firm certified by the National Committee for Quality Assurance (NCQA) and the Centers for Medicare and Medicaid Services (CMS), to conduct the annual Commercial and Medicare Advantage Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey and the Qualified Health Plan Enrollee Experience Survey (EES).
The surveys are used to gather information about the overall experiences of our members and to identify areas for improvement.
The CAHPS and QHP EES survey results are updated annually and are available on the Provider Resource Center's CAHPS/QHP EES Results page.
CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).
Shared Effort
Highmark considers the pursuit of quality improvement in health care to be a shared effort. While each facility must assess its own needs, establish meaningful goals, and monitor its own progress, Highmark can assist by providing data and opportunities for analysis. Highmark appreciates the cooperation of facilities in collecting data and making good use of it toward improvement of quality in health care services.
Medicare Advantage Quality Improvement Program
Highmark maintains a comprehensive Medicare Advantage Quality Improvement Program (QIP), which includes the mandatory Chronic Care Improvement Program (CCIP) as required by the Centers for Medicare and Medicaid Services (CMS). This program is designed to promote the effective management of chronic diseases across the Medicare Advantage plans. Annually, Highmark completes and attests to the effectiveness of its CCIP within the CMS Health Plan Management System (HPMS), demonstrating adherence to regulatory standards by submitting both a detailed Plan Section and an Annual Update on its progress.
Through its Quality Management teams, Highmark conducts systematic and ongoing follow-up on identified chronic conditions. For instance, a recent project focused on improving the percentage of diabetic members receiving annual diabetic retinal eye exams. This involved cross-functional teams performing quantitative and qualitative analyses, leading to targeted interventions aimed at enhancing health outcomes and participant engagement. This approach ensures continuous improvement in care delivery, aligning with CMS's objective of better health for our members.
Member Outreach Initiatives
The Clinical Outcomes and Guidelines team coordinates the development and implementation of member outreach and communication initiatives designed to promote evidence‑based preventive care, chronic disease management, and overall health improvement. Outreach activities include targeted mailings, educational materials, digital communications, and other engagement strategies that provide health information, reminders, and encouragement for recommended clinical services.
Member outreach initiatives are data-driven and prioritize populations with identified gaps in care, focusing on preventive health screenings such as breast, cervical, and colorectal cancer screenings, as well as other quality measures. Outreach strategies are tailored, when appropriate, to support accessibility, health literacy, language needs, and member preferences.
Health Care Disparities Activities
In support of reducing healthcare disparities, Highmark team collaborates with internal and external partners to identify and address inequities in access, utilization, and health outcomes across diverse member populations. Healthcare disparities activities utilize the Highmark Community Support tool to help identify members with social and community-based needs and connect them with available community resources and support services.
Member Health Care Education Materials
Highmark identified a need for Spanish-speaking members to have access to educational materials translated into their native language. Several of Highmark’s educational materials have been translated into Spanish and are available on the Provider Resource Center's Educational Resources – Member and Provider page.
Highmark is continuing to evaluate the need for other educational materials to be translated and will implement new translated materials as necessary.
Risk Adjustment Programs
Highmark has both prospective and retrospective coding programs in place to support correct risk scoring of its members. These programs are essential for ensuring the accuracy and completeness of each member's health record, allowing for appropriate risk adjustment. Highmark also provides resources and education to providers to facilitate accurate capture of ongoing conditions on an annual basis.
Goals of Risk Adjustment Programs:
- Support a complete and accurate health record
- Gap closure to engage members who may not be properly managing their chronic conditions
- Support providers to appropriately utilize Medicare Annual Wellness Visits and other encounters to complete health assessments and facilitate gap closure
- Support population health strategies
Provider documentation and coding information is available in the Clinical Quality and Education section of the Provider Resource Center.
Submitting Claims with More Than 36 Diagnosis Codes
Highmark can accept up to 36 diagnoses for a date of service. If you have more diagnosis codes than the system allows, Highmark has developed the following process to submit additional diagnosis codes:
- Submit first claim using applicable visit CPT code(s)
- Submit a second claim using 99499, $0.00. Include the additional diagnoses codes that went beyond the maximum codes allowed from the original claim on this new claim. Important: 99499 must be the only CPT code on this claim.
- If appropriate, submit remaining diagnoses using 99499 with modifier 25, $0.00 on an additional claim
Example: Billing system with a maximum amount of 12 diagnoses per claim:
- Submit first 12 diagnoses using actual visit CPT code(s)
- Submit 13 – 24 diagnoses using 99499, $0.00
- Submit 25 – 36 diagnoses using 99499 with modifier 25, $0.00
If you wish to submit additional diagnosis codes beyond the count of 24 by utilizing 99499 on another separate claim, a modifier 25 must be affixed to the procedure code along with a claim charge of $0.00 to avoid a duplicate claim.
- Highmark classifies 99499 as an eligible procedure code for risk adjustment within the encounter data processing system (EDPS). EDPS filtering is set by CMS, and the government agency lists only 99499 for the submission of additional diagnosis as eligible for risk adjustment. A claim only needs to have one line with an eligible procedure code in order for the entire claim, and all of its diagnosis codes, to be deemed eligible for risk adjustment. However, if 99499 is billed as a separate claim with a $0.00 charge, the diagnosis code(s) would be eligible for risk adjustment, but the separate $0.00 claim will be denied/rejected for payment as no payment can be made due to the $0 charge.
- Affix a claim charge amount of $0.00 to the procedure code. This must be the amount recorded.
Note: A denial message will show on the EOB stating that this line item could not be processed because a charge amount was not attached. Even though this line item is denied, Highmark will still capture the diagnosis codes affiliated with this procedure code. If a diagnosis code of value was omitted from the original billing, Availity® will allow you to submit the additional codes using 99499 on eligible 1500 claims.
Protected Activities
Activities of the Highmark Quality Program, including activities of the staff, medical directors, and the Network Quality and Credentials Committee, may be afforded protections as peer review activities under state and federal law. Such protected activities include:
- Evaluating and improving the quality of health care rendered;
- Reducing morbidity and mortality;
- Evaluation by health care professionals of the quality and efficiency of services ordered or performed by other health care professionals (including inpatient hospital and extended care facility utilization review and ambulatory care review); and
- Actions or recommendations of a professional review body, based on the competence or professional conduct of a physician, which could adversely affect the health or welfare of a patient, and which could affect the clinical privileges or plan membership of the physician.
Accordingly, network providers and other peer review bodies (such as hospital quality review committees) may furnish information requested by the Highmark Quality Program and the confidentiality of such information will be maintained and protected pursuant to applicable state and federal laws.
The following entities, which serve the noted regions, are independent licensees of the Blue Cross Blue Shield Association: Western and Northeastern PA: Highmark Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Choice Company, Highmark Health Insurance Company, Highmark Coverage Advantage Inc., Highmark Benefits Group Inc., First Priority Health, First Priority Life, Highmark Care Benefits Inc., or Highmark Senior Health Company. Central and Southeastern PA: Highmark Inc. d/b/a Highmark Blue Shield, Highmark Benefits Group Inc., Highmark Health Insurance Company, Highmark Choice Company or Highmark Senior Health Company. Delaware: Highmark BCBSD Inc. d/b/a Highmark Blue Cross Blue Shield. West Virginia: Highmark West Virginia Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Health Insurance Company or Highmark Senior Solutions Company. Western NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Cross Blue Shield. Northeastern NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Shield.
All references to “Highmark” in this document are references to the Highmark company that is providing the member’s health benefits or health benefit administration and/or to one or more of its affiliated Blue companies.
All revisions to this Highmark Provider Manual (the “manual” or “Highmark Provider Manual”) are controlled electronically. All paper copies and screen prints are considered uncontrolled and should not be relied upon for any purpose.
