Maintaining standards of care
AmeriHealth New Jersey Quality Management Program
The AmeriHealth New Jerseys 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.
- 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, and supporting Plan staff cultural humility and awareness of disparities, and supporting Plan staff cultural humility and awareness of disparities.
- Assess and address the satisfaction of members with their health care plan and services to support patient-centered system improvements.
The QM Program supports quality and performance improvement across all plans, investigating quality complaints and occurrences, implementing performance improvement initiatives, ensuring delegation oversight, credentialing compliance, and clinical services compliance. The QM program also employs resources to support an ongoing comprehensive program of continuous quality improvement throughout the organization. Specifically, it assures organizational practices and quality assessment and performance improvement efforts are reviewed in the appropriate quality committee meetings for feedback regarding performance and goals. It supports analysis of process and outcome measures to identify and prioritize opportunities to improve clinical care and service, member safety and member experience. 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, Pennsylvania, New Jersey, and other regulatory requirements.
- Reviewing and addressing member adverse occurrences, complaints, and concerns about the health care they have received*
- 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
The Population Health Management Strategy describes:
- Goals and populations targeted for each of the following four areas of focus:
- Keeping members healthy
- Managing members with emerging risk
- Addressing patient safety or outcomes across settings
- Managing multiple chronic illnesses
- Programs or services offered to members identified in the four areas of focus
- Activities that are not direct member interventions
- How member programs are coordinated
- How members are informed about available PHM programs
- How the organization promotes health equity
- 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 concern or complaint about the quality of care or service they received from a provider may call the Member Services number listed on back of the ID card and request filing a quality of care complaint.
NCQA 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.
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.
|Provider Type||Access Type||Appointment Availability Within|
(4 weeks for routine physical)
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.
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
Providers can view the Provider Manual for Participating Professional Providers, available through the Provider News Center, for additional information on appointment availability requirements, the minimum number of office hours per week and the maximum number of patients scheduled per hour per provider by practice and provider type.
Medical 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
- History and physicals
- Significant illnesses and medical conditions indicated on the problem list
- Documentation of medications – current and updated
- Prominent documentation of medication allergies and adverse reactions; if there are no known allergies or history of adverse reactions, this is appropriately noted
- Food and other allergies, such as shellfish or latex, which may affect medical management
- Past medical history (for patients seen three or more times), including serious accidents, operations, and illnesses; for children and adolescents (18 years and younger), past medical history relates to prenatal care, birth, operations, and childhood illnesses
- For patients 12 years and older, appropriate notations concerning use of cigarettes, alcohol, and 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
- Laboratory and other studies are ordered, as appropriate
- Unresolved problems from previous office visits are addressed in subsequent visits
- Documentation of clinical evaluation and findings for each visit
- Appropriate notations regarding the utilization of consultants
- No evidence that the patient is placed at inappropriate risk by a diagnostic or therapeutic procedure
- Documentation of preventive services and risk screening
- Immunization record for children is up to date or an appropriate history is made for adults
- Preventive services and risk screenings are offered and documented
- Records of hospital discharge summaries and emergency room/department visits
Medical record organization
- Each page in the record contains the patient’s name or ID number
- Personal/biographical data include address, employer, home and work telephone numbers, marital status, race, ethnicity, primary language, sexual orientation, and gender identity.
- All entries contain the author’s identification; author identification may be a handwritten signature, a unique electronic identifier, or initials
- All entries are dated
- The record is legible to someone other than the writer
Information filed in medical records
- All services provided directly by a primary care practitioner
- All ancillary services and diagnostic tests ordered by a practitioner
- All diagnostic and therapeutic services for which a member was referred by a practitioner (such as home health nursing reports, specialty physician reports, hospital discharge reports, and physical therapy reports)
- Laboratory and other studies ordered
- Encounter forms or notes have a notation, when indicated, regarding follow-up care, calls, or visits; the specific time of return is noted in weeks, months, or as needed
- If a consultation is requested, there is a note from the consultant in the record
- Specialty physician, other consultation, laboratory, and imaging reports filed in the chart are initialed by the practitioner who ordered them to signify review; review and signature by professionals other than the ordering practitioner do not meet this requirement
- If the reports are presented electronically, or by some other method, there is representation of review by the ordering practitioner.
- Consultation: abnormal lab and imaging study results have an explicit notation in the record of follow-up plans
- The existence of an Advance Directive is prominently documented in each adult (older than 18 years of age) member’s medical record; information as to whether the Advance Directive has been executed is also noted
Retrieving medical records
- Medical records are to be made available to the Plan as defined in the Professional Provider Agreement
- Medical records are organized and stored in a manner that allows easy retrieval
Confidentiality of medical records
- Protected Health Information (PHI) is protected against unauthorized or inadvertent disclosure
- Medical records are safeguarded against loss or destruction and are maintained according to state requirements.
- At a minimum, medical records must be maintained for at least ten (10) years, or age of majority plus six years, whichever is longer
- Records are stored securely and only authorized personnel have access to records
- Staff receive periodic training in member information confidentiality
Maintenance of records and audits
Providers must maintain all medical and other records in accordance with the terms of their Professional Provider Agreement and the Provider Manual for Participating Professional Providers. When requested by AmeriHealth 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 right to receive information about AmeriHealth, its benefits, services included or excluded from coverage, policies and procedures, participating practitioners/providers, and member rights and responsibilities. Written and Web-based information provided will be in a manner and format that is easily understood and readily accessible.
- The right to be treated with courtesy, consideration, respect, and be recognized for his or her dignity and right to privacy.
- The right to participate with practitioners in making decisions about his or her health care.
- The right to voice complaints or appeals about AmeriHealth or the care it provides and to receive a timely response about the disposition of the appeal/complaint and the right to further appeal, as appropriate.
- The right to make recommendations regarding our member rights and responsibilities policy by contacting Customer Service.
- The right to choose practitioners within the limits of covered benefits, availability, and participation within the AmeriHealth network.
- The right to confidential treatment of personally identifiable health/medical information. Members also have the right to have access to their medical record, and ask that it be amended or corrected, in accordance with applicable federal and state laws.
- The right to reasonable access to medical services.
- The right to receive health care services without discrimination based on race, ethnicity, age, mental or physical disability, health status, genetic information, color, religion, gender, sexual orientation, national origin, source of payment, utilization of medical or mental health services or supplies, or other unlawful basis including, without limitation, the filing by such member of any complaint, grievance, appeal or legal action against Professional Provider, a Group Practice Provider (if applicable), or AmeriHealth.
- The right to formulate and have advance directives implemented.
- The right to obtain a current directory of participating providers in the Plan’s network, upon request. The directory includes addresses, telephone numbers, and a listing of providers who speak languages other than English.
- The right to 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 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. A doctor cannot be penalized for filing a complaint or appeal on a member’s behalf.
- For members with chronic disabilities, the right to obtain assistance and referrals to providers with experience in treatment of their disabilities.
- The right to candid discussions of appropriate or medically necessary treatment options and alternatives for his or her conditions, regardless of cost or benefit coverage, in terms that the member understands, including an explanation of their complete medical condition, recommended treatment, risks of treatment, and expected results and reasonable medical alternatives. If the member is not capable of understanding this information, an explanation shall be provided to his or her next of kin or guardian and documented in the member’s medical record.
- The right to available and accessible services when medically necessary, including availability of care 24 hours a day, seven days a week for urgent and emergent conditions.
- The right to call 911 in a potentially life-threatening situation without prior approval from AmeriHealth and have AmeriHealth pay per contract for a medical screening evaluation in the emergency room to determine whether an emergency medical condition exists.
- The right to continue receiving services from a provider who has been terminated from the AmeriHealth network (without cause) in the timeframes as defined by the applicable state requirements of the member’s benefit plan. 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 participating providers for medically necessary services that were authorized or covered, except as permitted for copayments, coinsurance, and deductibles by contract.
- The right to be free from lifetime or yearly dollar limits on coverage of essential health benefits.
- The right to be free from unreasonable rate increases and to receive an explanation of rate increases of 15% or more before your premium is raised.
- The right to prompt notification of terminations or changes in benefits, services or provider network.
- The right to a choice of specialists among participating providers following an authorized referral, as applicable, subject to their availability to accept new patients.
- The right to choose an individual On-Exchange health plan rather than the one offered by an employer and to be protected from employer retaliation.
- The right to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation.
Commercial member responsibilities
- The responsibility to communicate, to the extent possible, information AmeriHealth and participating providers need in order to provide care.
- The responsibility to follow the plans and instructions for care that he or she has agreed on with his or her practitioners. This includes consideration of the possible consequences of failure to comply with recommended treatment.
- The responsibility to understand his or her health problems and participate in developing mutually agreed upon treatment goals, to the degree possible.
- The responsibility to review all benefits and membership materials carefully and to follow the rules pertaining to the health plan.
- The responsibility to ask questions to assure understanding of the explanations and instructions given.
- The responsibility to treat others with the same respect and courtesy expected for his or herself.
- The responsibility to keep scheduled appointments or 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.
- For point of service contracts, the responsibility to pay for charges that exceed what the plan determines as customary and reasonable (usual and customary, or usual, customary and reasonable, as appropriate) for services that are covered under the out-of-network component of the member’s benefit contract.
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 complete annual training regarding the importance of protecting member information. All contracted providers are required to maintain confidentiality of member information and records in accordance with applicable laws.
Access to medical records
AmeriHealth 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 designated record sets that contain personal health information as it relates to medical, enrollment, claims, and billing records as well as other records that we may use to make decisions about health care benefits. Upon a member’s request, we will provide a summary of any of his or her personal information maintained by us, such as telephone number, address, etc. At any time, a member may request that we modify, correct, change, or update his or her personal information that we maintain by contacting us by mail or telephone.
Inclusion in routine consent
In certain situations, it may be necessary for us to maintain and release a member’s records, claims related information, or health-related information to third parties for health care operations in accordance with applicable laws and regulations. Once enrolled with us, we may maintain and release member records to third-party vendors to ensure that quality health care coverage is provided to the member, to perform our contractual obligations, or to fulfill a regulatory mandate. 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. Members may request release of their personal information by completing the AmeriHealth Authorization Form.
Use of measurement data
At times we may use membership data to develop or enhance health benefits and services. 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.
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.