Quality management

Maintaining standards of care

AmeriHealth New Jersey Quality Management Program

The AmeriHealth New Jersey’s 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.


Program goals

  • Assess and improve the safety of medical and behavioral health care and services provided to members.
  • Evaluate the sufficiency of the plan networks for members to access qualified providers for timely and appropriate care.
  • Ensure evidence-based, effective care is provided to members for their medical and behavior health conditions.
  • Promote efficient care and reduce health care waste through facilitating communication, continuity, and coordination of care among providers and 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.
  • Assess and address the satisfaction of members with their health care plan and services to support patient-centered system improvements.

Program activities

The QM program supports an ongoing comprehensive program of continuous quality improvement throughout the organization, monitoring the performance of our internal functional areas as well as the quality of care our members receive in our network. The program is based on comprehensive, integrated, and systematic processes driven by quality improvement principles and customer feedback. The QM team uses standardized measures of care and service quality to assess Plan performance and the performance of our network providers against our standards and goals. To identify and prioritize opportunities to improve clinical care and service, member safety, and member experience, the team supports analysis of process and outcome measures. The QM program convenes service and clinical quality committees monthly to assess performance, set goals, and develop performance improvement plans.

The QM program implements the Member Safety Program, facilitates the organizational Population Health Management Strategy, and assesses the adequacy of the network. It also ensures delegation oversight, credentialing compliance, and clinical services compliance. Finally, it implements policies and procedures to ensure plan compliance with established standards of practice, NCQA accreditation standards and CMS, PA, NJ, and other regulatory requirements.


Member safety

  • Reviewing and addressing member adverse occurrences, complaints, and concerns about the health care they have received¹
  • Reviewing claims data to identify potential safety and care quality issues, including medical and medication errors, for providers
  • Educating network providers about effective safety practices and resources and AmeriHealth New Jersey’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
  • Oversee processes for provider recognition in the provider directory for high quality care, e.g. the Blue Distinction Center program
  • Produce quality review reports to inform the Plan contracting process with providers
  • Working with regional coalitions to bring providers together through collaborative patient safety initiatives and information sharing

Population Health Management Strategy

  • Monitoring the health status and needs of our members, including identifying geographic and demographic differences in health factors
  • Monitoring and evaluating the care our members receive
  • Monitoring and facilitating care coordination capacity among providers and practitioners
  • Synthesizing the various components of population health management into a cohesive organizational strategy and coordinating across the organization to drive progress toward the Triple Aim
  • Evaluating the effectiveness of Plan programs and initiatives designed to improve the health outcomes, value of care, and experiences of our members, e.g. our preventive health outreach and condition management programs

Network adequacy

  • Evaluating the sufficiency of the plan networks for members to access qualified 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 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 and a report on progress, is available to members and providers, upon request. Provider requests, call 1-800-275-2583. Additional information about QM activities can also be found on our Provider News Center.

Members may request information about the QM program by calling the Member Services number listed on back of the ID card.

*Members who have a concerns 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 New Jersey’s accreditation statuses and other health care quality information on NCQA’s website at https://www.ncqa.org.

Access & availability standards

AmeriHealth New Jersey 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 New Jersey has established standards for the number and distribution of providers in our networks as well as timeliness of care. Each year, AmeriHealth New Jersey 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.

Access TypeAppointment Availability Within
Routine 2 weeks
(4 weeks for routine physical)
Urgent 24 hours

Office hours, patient scheduling, & 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 six. For most specialists, this number should not exceed four.

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 through the NaviNet® web portal (NaviNet Open), 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 Records 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 New Jersey has established standards for medical records to promote efficient and effective treatment by facilitating communication and the coordination and continuity of care.

The AmeriHealth New Jersey 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 New Jersey’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 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 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
  • 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 New Jersey 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 New Jersey 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.

Commercial member rights & responsibilities

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 & confidentiality

Protection of privacy in all settings

AmeriHealth New Jersey 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 annually receive 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 New Jersey 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 providers. AmeriHealth New Jersey does maintain records that contain personal health information as it relates to coverage. Upon a member’s request, we will provide a summary of any of his or her personally identifiable information maintained by us, such as telephone number, address, etc. At any time, a member may request that we modify, correct, change, or update his or her personally identifiable 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. Please be assured that we will only release information in accordance with applicable laws and regulations.

 

Right to approve release of information

Member information will only be released to qualified recipients and in accordance with applicable state and federal laws.

 

Use of measurement data

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

Utilization management decisions

It is the policy of AmeriHealth New Jersey 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 number on the back of your ID card.